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Statewide Summary Report Including Review of Statewide Leadership
and Overview of Major Services
Report of the 2nd Court Appointed Expert
Lippert v. Godinez

October 2018

Prepared by the Medical Investigation Team
Mike Puisis DO
Jack Raba, MD
Madie LaMarre MN, FNP-BC
Catherine M. Knox RN, MN, CCHP-RN
Jay Shulman, DMD, MSPH

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Table of Contents
Background ........................................................................................................................... 2
Methodology......................................................................................................................... 2
IDOC Prisons Overview .......................................................................................................... 6
Key Findings .......................................................................................................................... 9
Statewide Medical Operations............................................................................................. 12
Leadership, Staffing, and Custody Functions............................................................................ 12
Wexford Provider Staffing and Physician Credentialing ........................................................... 21
Statewide Use of University of Illinois ...................................................................................... 31
Statewide Overview of Major Services ................................................................................. 32
Clinical Space and Equipment ................................................................................................... 32
Medical Records........................................................................................................................ 37
Medical Reception .................................................................................................................... 42
Intrasystem Transfer ................................................................................................................. 45
Nursing Sick Call ........................................................................................................................ 48
Chronic Care .............................................................................................................................. 52
Urgent/Emergent Care.............................................................................................................. 59
Specialty Consultations ............................................................................................................. 62
Infirmary Care ........................................................................................................................... 69
Pharmacy and Medication Administration ............................................................................... 77
Infection Control ....................................................................................................................... 84
Mortality Reviews ..................................................................................................................... 91
Dental Program ....................................................................................................................... 103
Internal Monitoring and Quality Improvement ...................................................................... 118
Recommendations ............................................................................................................ 121
Key Recommendations of Second Court Expert ..................................................................... 121
Organizational Structure, Facility Leadership, and Custody Functions .................................. 122
Clinic Space and Equipment.................................................................................................... 124
Medical Records...................................................................................................................... 126
Medical Reception .................................................................................................................. 127
Intrasystem Transfer ............................................................................................................... 129
Nursing Sick Call ...................................................................................................................... 129
Chronic Care ............................................................................................................................ 131
Urgent/Emergent Care............................................................................................................ 133
Specialty Consultations ........................................................................................................... 135
Infirmary Care ......................................................................................................................... 137
Pharmacy and Medication Administration ............................................................................. 138
Infection Control ..................................................................................................................... 140
Mortality Reviews ................................................................................................................... 146
Dental Program ....................................................................................................................... 147
Internal Monitoring and Quality Improvement ...................................................................... 150
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Background
This report is produced for the United States District Court for the Northern District of Illinois
Eastern Division with respect to the litigation Don Lippert, et al. v. John Baldwin, et al. No. 10cv-4603. The Court has asked for the Expert to:
“Assist the Court in determining whether the Illinois Department of Corrections (“IDOC”)
is providing health care services to the offenders in its custody that meet the minimum
constitutional standards of adequacy.”1
The Court gave further direction. The Court asked the Expert to determine primarily whether
any of the systemic deficiencies identified by the First Court Expert as reported in December of
2014 currently exist. The Court asked the current Expert, in the course of the evaluation, to
identify any additional systemic deficiencies. Finally, the Court asked for assistance in forming
recommendations to correct identified deficiencies. The Court asked the current Expert to
consider the solutions proposed by the First Court Expert or to suggest alternate solutions. For
newly identified deficiencies, the Court asked for new recommendations.
In order to form our opinion to answer these questions, the Expert, Michael Puisis DO, formed
an investigative team consisting of Jack Raba MD, nurse practitioner Madie LaMarre MN, FNPBC, Catherine Knox MN, RN, CCHP-RN, and dentist Jay Shulman DMD, MSPH.

Methodology
The current Court Expert met with parties on December 18, 2017 to discuss his methodology
and plan. The methodology explained to parties was one typically used by correctional experts
in answering questions regarding adequacy of medical care in correctional settings. We
interview staff and patients. We observe delivery of care as it occurs for selected processes. We
review Administrative Directives, policies, and other documents such as budgets, staffing
documents, quality improvement meeting minutes, and reports, etc. We tour facilities’ areas
where care is provided and observe the setting of care to determine the adequacy of resources
that support care. Lastly, we review a sample of health records, including death records. From
these interviews, tours, document reviews, and record reviews, we form our opinions and
recommendations.
During our five site visits we reviewed 362 medical records and 363 dental records.2 In addition,
we reviewed 33 death records. Dr. Puisis performed all mortality reviews. Findings in site visit
record reviews corroborated findings in death reviews. Charts for urgent care, specialty care,
and hospital care record review were chosen based on having an ambulatory care-sensitive
Second Order Appointing Expert, United States District Court for the Northern District of Illinois Eastern Division, No. 10-cv4603 filed 12/8/17.
2 A table with details of record reviews is found at the end of this report as an appendix.
1

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condition.3 For all other site visit medical record reviews, records were chosen of patients that
had an actual or potential serious medical needs. In the case of chronic illness,4 records were
chosen randomly by type of disease (e.g., diabetes, autoimmune, HIV, etc.) For nursing sick call,
we selected records nursing sick call logs of patients with potentially serious medical needs
such as shortness of breath or chest pain instead of persons complaining of athlete’s foot or
wanting a low bunk.
For mortality reviews, there were 174 deaths in 2016 and 2017. We asked for 89 records but
only reviewed 33 records due to the truncated investigation. We excluded from selection nine
suicide deaths, three overdose deaths, and one death from injury. Record selection was
somewhat limited by the availability of records. We asked for death records when the Expert
first met with the attorneys in December of 2017. We started receiving records on March 7,
2018. Initially we reviewed six records,5 as they were the only records we had available.
Twenty-one records were then chosen from sites we were visiting.6 We then randomly chose
two records from sites that the First Court Expert had visited.7 The remaining four records were
chosen at random from sites that neither Expert visited. The only information available at the
time of record selection was the name, date of death, age, facility, and cause of death. The
cause of death was not provided for all patients; some patients had “natural causes,” “cardiac
arrest,” or “unknown” listed as the cause of death. Autopsies were not available for all deaths;
even when an autopsy was done it was not consistently available. We randomly chose more
records from facilities we were visiting intending to allow for a comparison with observed care
during site visits. We reviewed one to two years of documentation of care in these records.
Our mortality review consisted of describing episodes of care, and for each episode we
identified errors using a classification of 18 different error types. This allowed us to identify
common and systemic problems within the health program. Error types were summarized as an
appendix in the mortality review document. We summarized the mortality reviews in a
narrative summary, but also provided the spreadsheets used to document each individual
episode of care reviewed so that reviewers can see the specific instances of care that formed
our opinion in the narrative. The mortality reviews are integral to our opinion and should be
reviewed. These documents are provided as an appendix.
For dental records, the chart selection methodology is described in each element of the dental
program.
The IDOC, in their comments on our report, asserted that the report “relies primarily on a
subjective review of the health record” and failed to use “objective clinical measurements such
Ambulatory care sensitive conditions (ACSC) are conditions that can be managed in an outpatient setting. HEDIS, the Agency
for Healthcare Research and Quality (AHRQ) and quality improvement programs use ACSC to select records to review to assess
whether hospitalization might be preventable or whether care reveals quality or systemic issues. For more information see the
Prevention Quality Indicator Overview at https://www.qualityindicators.ahrq.gov/modules/pqi_overview.aspx.
4 We presume that all patients with chronic illness have a potential or actual serious medical illness.
5 Patients #1, 2, 3, 4, 5, and 6.
6 Patients #7 through 27 inclusive.
7 Patients #30 and 31; Pontiac had no deaths.
3

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as those found with the Healthcare Effectiveness Data and Information Set (“HEDIS”8)
guidelines or critical process assessments.”9 The IDOC does not participate in HEDIS
measurement so there was no IDOC data to review with respect to HEDIS measures.10
Moreover, quality improvement reports did not include objective data measures similar to
HEDIS that might have informed us. IDOC lacks useable data for analysis of clinical care, which is
evident in their quality improvement efforts. The First Court Expert in his analysis of the quality
improvement program also identified this problem.11
In their comments on our reports, the IDOC asserted that we believed that prison health care
systems should provide care “significantly in excess of what is available in the community” and
that our report “takes the position that inmates are entitled to a perfect healthcare delivery
system.” We do not agree with those assertions. The benchmarks we use are community and
correctional standards of care,12 not a hypothetical standard “in excess of what is available in
the community.”
8 The Healthcare Effectiveness Data and Information Set (HEDIS) is a performance measurement system managed by the
National Committee for Quality Assurance (NCQA). There are over 90 HEDIS measures over six domains including safety,
effectiveness, patient-centered, timely, efficient, and equitable. Large health maintenance organizations and practices use
HEDIS to measure their performance. Data submission used for HEDIS reporting is strictly controlled and defined. These
measures are a useful comparator between managed care organizations and other health organizations. These measures do
not address acute or emergency care, access to specialty services, access to hospital care, access to an appropriate provider,
timely access to a professional opinion and evaluation, access to medication, or many other areas specific to the correctional
setting. These performance measures are useful but are not designed for correctional health care programs
9 Letter via email from John Hayes and Michael Arnold, Office of the Attorney General to Dr. Puisis: Re: Lippert v. Baldwin, No.
10-cv-4603 – Defendants’ comments to the Draft Report of the 2nd Court Appointed Expert, dated September 10, 2018.
10 Although IDOC does not track HEDIS measures or participate in HEDIS, we made comments on and/or reviewed care in
multiple areas that correspond to HEDIS measures. Our report documents record reviews or other investigations that identified
quality of care and/or systemic issues in all of the following HEDIS measurement areas: Adult BMI assessment; Colorectal
cancer screening; Care for older adults; Use of spirometry testing in the assessment and diagnosis of chronic obstructive
pulmonary disease; Statin therapy for patients with cardiovascular disease and diabetes; Comprehensive diabetes care; Followup after emergency department visit for people with multiple high-risk chronic conditions; Medication management in the
elderly; Fall risk management; Management of urinary incontinence in older adults; Influenza and pneumococcal vaccination
status for older adults; Hospitalizations for potentially preventable complications; Acute hospitalization utilization; and
Emergency Department utilization.
11 On page 44 of the First Court Expert’s summary report he states, “although some data was collected it was never used to
measure performance against standards and therefore was not part of an effort to measure the quality of performance.”
12 As examples of references reflecting community standards of care, we utilized the U.S. Preventive Services Task Force
Recommendations for Primary Care Practice; CDC Recommended Immunization Schedule for Adults Aged 19 Years or Older,
United States, 2018; MMWR (2006) Prevention and Control of Tuberculosis in Correctional and Detention Facilities; Standards
of Medical Care in Diabetes by the American Diabetes Association; 2013 American College of Cardiology/American Heart
Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults; Global
Initiative for Chronic Obstructive Lung Disease updated 2016; American College of Cardiology/American Heart Association
Guidelines for the Management of Patients With Unstable Angina and Non-ST-Elevation Myocardial Infarction; Evidence-Based
Guideline for the Management of High Blood Pressure in Adults, Report from the Panel Members Appointed to the Eighth Joint
National Committee (JNC 8): Centers for Disease Control and Prevention; HIV Testing Implementation Guidance for Correctional
Settings. 2009; National Commission on Correctional Health Care, 2014 Standards for Health Services in Prisons; HCV Guidance:
Recommendations for Testing, Managing, and Treating Hepatitis C, Last Updated May 24, 2018; American Association for the
Study of Liver Diseases and Infectious Diseases Society of America; Occupational Safety and Health Standards – Toxic and
Hazardous substances. 29 CFR 1910.1096(e)(3)(i); Guidelines for Infection Control in Dental Health-Care Settings--2003.
MMWR, December 19, 2003/52(RR17):1:16; Stefanac SJ. Information Gathering and Diagnosis Development; American Dental
Hygiene Association Standards for Clinical Dental Hygiene Practice Revised 2016; Makrides, N. S., Costa, J. N., Hickey, D. J.,
Woods, P. D., & Bajuscak, R. (2006); Correctional Dental Services. In M. Puisis (Ed.), Clinical Practice in Correctional Medicine
(2nd edition); Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure.

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In addition to record reviews, we toured five facilities: Northern Reception Center (NRC),
Stateville Correctional Center (SCC), Dixon Correctional Center (Dixon), Logan Correctional
Center (LCC), and Menard Correctional Center (MCC). Four Experts visited each site; two
doctors, a dentist, and a nurse. During each facility visit, we:
• Met with leadership of custody and medical
• Toured the medical services areas and housing units
• Talked with health care staff
• Reviewed health records and other documents
• Interviewed inmates
The First Court Expert mentioned in his report that the State provided comments that the
Investigative Team should utilize standards from the National Commission on Correctional
Health Care (NCCHC) or the American Correctional Association (ACA) as the basis for their
investigation. We agree with the First Court Expert’s response that NCCHC standards are useful
as a basis to evaluate IDOC Administrative Directives and certain processes of care. We do use
the NCCHC standards for that purpose and mention this in this report. However, the request of
the Court is to determine adequacy of care for serious medical needs. In order to do that, one
must do more than evaluate whether Administrative Directives meet NCCHC standards.
Adherence to NCCHC standards does not verify that quality of clinical care is adequate, which is
arguably the most important aspect of determining adequacy of care. The limitations of the
NCCHC standards as a sole measure for constitutional adequacy require additional investigative
measures to answer the Court’s request. Observation of actual practices at the facilities form
the basis for evaluation of actual care as it is delivered, and review of records forms the basis
for evaluation of clinical care.
To facilitate comparison with the First Court Expert’s report, we have utilized similar headings
of major services reviewed. We agree with the First Court Expert’s organization of topics of
study as presented in his table of contents. One change we made was to combine laboratory
functions and clinic space and sanitation, and to include other diagnostic testing available
onsite. These items are all support functions and were combined for that reason. We have
added a section in the summary document discussing the statewide operations of the IDOC,
UIC, and Wexford, the medical vendor, including a section on credentialing of physicians on a
statewide basis. We also included a brief summary describing the statewide monitoring effort
of the current medical contract.
The Second Order Appointing Expert gave authority to perform tours of eight facilities that had
been reviewed by the First Court Expert. The Court’s Order gave the Expert discretion to decline
visiting any of the facilities if determined to be unnecessary. The Court’s Order required the
Expert to meet parties after the first 120 days of the investigation to establish a plan and
timeline for concluding the review in a timely and cost-effective manner.

American Dental Association and U.S. Food and Drug Administration, 2012. For items for which there is no standard of care, we
utilized information as found in Up-To-Date, an online medical reference.

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We started this project intending to review eight facilities. At the 120 day meeting, the Expert
discussed preliminary findings and announced that it was his opinion that review of the eight
facilities was not necessary. The findings were consistently similar facility to facility and
confirmed by the First Court Expert’s findings. Review of death records from 12 facilities
demonstrated consistently poor care and the evidence was so overwhelming that the Expert
found it unnecessary to continue visiting the full complement of eight facilities. The Expert
strongly believes that further visits would not add to our opinions, except for site-specific
recommendations. We terminated visits after five facilities were visited. These included: NRC,
SCC, Dixon, LCC, and MCC. It is our opinion that this complement of facilities is adequate to
form an opinion of statewide services. The sample includes the main male and female reception
centers, the center used to house geriatric patients, two of the three maximum security
prisons, the largest IDOC facility (Menard Correctional Center), and facilities from Northern,
Central and Southern areas of the state. We are confident that review of this group of facilities
gives a representative sample of the IDOC health care system.
With respect to this report, for each section in which the First Court Expert had findings, we
summarize his findings in a paragraph and make a subsequent statement whether his findings
were still present or have been resolved. We then present our own findings. With respect to
recommendations, we do the same. We list, verbatim, the First Court Expert’s
Recommendations and document whether we agree or not. If we disagree or had additional
comments we add those. When we comment on the First Court Expert’s Recommendations we
do so in italics so our comments can be distinguished from the First Court Expert’s comments.

IDOC Prisons Overview
The Illinois Department of Corrections was established in 1970 to administer and operate state
prisons, juvenile centers, and juvenile and adult parole services. In 2006, the Illinois
Department of Juvenile Justice was formed, which separated the adult and juvenile correctional
systems. In 1970, the IDOC operated seven adult prisons. Currently, the IDOC operates 25 adult
prisons,13 a facility for housing the severely mentally ill (Joliet Treatment Center), and four
transition centers.14 The population of Illinois prisons has increased from approximately 6000
inmates in 1974 to approximately 49,000 inmates in 2015,15 an eight-fold increase in
population. The most recent information given to us by the IDOC is that the correctional center
population as of November 30, 2017 is 41,376.16
Illinois prisons are overcrowded. The latest data from 2015 comparing prisons nationwide show
that, based on design capacity, Illinois is the second most overcrowded prison system in the
NRC and SCC are considered one facility for custody purposes, but NRC and SCC now have separate medical programs.
Therefore, for purposes of this report there are 26 facilities. When we refer to prisons with respect to the medical programs we
will refer to 26 prisons.
14 Agency Overview on the IDOC website found on December 16, 2017 at
https://www.illinois.gov/idoc/aboutus/Pages/IDOCOverview.aspx.
15 Illinois Prison Overview, Illinois State Commission on Criminal Justice and Sentencing Reform, 2015, as found at
http://www.icjia.org/cjreform2015/research/illinois-prison-overview.html.
16 180126 Presley Rated Capacity on November 30, 2017, provided to us by IDOC.
13

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nation. Alabama is the most overcrowded.17 That 2015 data showed that Illinois had a
population at 145% of capacity. Since 2015, the population has been reduced by several
thousand. Still, as of November 30, 2017, the IDOC is at 131% of rated capacity. It houses
41,376 inmates in facilities rated to hold 31,525 inmates.18
Many IDOC facilities are old and hard to maintain. The state, on several occasions, has
attempted to close some of these older facilities, including SCC, Pontiac, and Vandalia. In recent
years parts of the Stateville Correctional Center, including the old Roundhouse building, have
been closed. Of its 25 adult prisons, only four were opened in the 21st century, and two of these
facilities (Decatur and Sheridan) were older facilities that were rehabilitated. Thirty-eight
percent of inmates in IDOC reside in facilities built before 1981. Two of the facilities housing
approximately 11% of the IDOC population were built in the 19th century (MCC 1878 and
Pontiac 1871), and two facilities were built in the early 20th century (Vandalia 1921 and SCC
1925). All of the male maximum security beds in the IDOC are in structures built in the 19th
century or early 20th century (MCC 1878, Pontiac 1871, and SCC 1925). Maximum security
facilities house approximately 7500 inmates (approximately 17% of the IDOC population) who
spend more in-cell time. These structures make delivery of medical care more difficult and less
efficient, are difficult to maintain, and may negatively affect inmate health in a variety of ways.
These health-related effects include heat exposure issues, particularly at the Menard facility,
and potential for rodents and vermin. In addition, these facilities present challenges in health
care delivery, including access to care, medication administration, and providing ordered
medical care. As our reports show, we found some of these problems in the older facilities we
visited. We did note an additional egregious issue at NRC, where inmates are locked down 24
hours a day except for four hours per week. In some cells, inmates had no functioning lights for
weeks at a time, inhibiting nurses’ ability to properly identify inmates when administering
medications. These conditions are a serious obstacle to health care access.
With respect to IDOC health care costs, a 2017 study detailed costs of health care in state
prison systems between 2010 and 2015. 19 In 2015, the average per inmate per year health care
spending for persons in state prisons in the U.S. was $5,720. Illinois spent $3,619. This was 37%
below national average. Nationwide, per capita expenditures for health care for state prisoners
ranged from a low of $2,173 to a high of $19,796. Illinois ranked seventh lowest in the U.S. in
terms of per capita spending per inmate per year as noted in the table below.20 We were given
information from the IDOC Chief Financial Officer that for 2017 the annual spending per inmate
increased to approximately $4800 per inmate per year, but there is no comparable data for
17 Appendix Table 1, Prison facility capacity, custody population, and percent capacity, December 31, 2015, as found in
Prisoners in 2015, Bureau of Justice Statistics, US Department of Justice, December 2016, NCJ 250229 located on the web at
https://www.bjs.gov/content/pub/pdf/p15.pdf.
18 180126 Presley Rated Capacity on November 30, 2017, as provided by IDOC.
19 Data from Prison Health Care: Costs and Quality; a report from the PEW Charitable Trust, October 2017, as found at
http://www.pewtrusts.org/en/research-and-analysis/reports/2017/10/prison-health-care-costs-and-quality.
20 We note that the Kaiser Family Foundation reported that Illinois civilians had per capita health care expenditures of $8,262.
This can be compared to the $3,619 per capita health expenditures per inmate per year. Health Care Expenditures per Capita by
State of Residence for 2014 for the Illinois civilian population is found at https://www.kff.org/other/state-indicator/healthspending-per-capita/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

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other state prison systems nationwide.21 IDOC Spending in 2017 is still below the average 2015
spending of prisons nationwide.
Ten Lowest Per Capita Expenditures
for Health Care in US State Prison
Systems in 2015
State
Louisiana
Alabama
Indiana
Nevada
South Carolina
Arizona
Georgia
Illinois
Kentucky
Mississippi

Per Capita Annual
$2,173
$3,234
$3,246
$3,246
$3,478
$3,529
$3,610
$3,619
$3,763
$3,770

For most state systems, the number of employees, age, and percent of female population were
the largest drivers of cost of prison health programs. The Federal Bureau of Prisons assessed
that institutions with the highest percentages of aging inmates spent five times more per
inmate on medical care and 14 times more per inmate on medication than institutions with the
lowest percentage of aging inmates. The National Institute of Corrections estimates that
inmates over age 55 cost, on average, two to three times more than the expense for all other
inmates.22 Based on this same 2017 report, Illinois has the seventh lowest rate of persons over
age 55 (8.5%). As well, in 2015 IDOC had a female population of 5.8%, the ninth lowest rate of
females incarcerated in state prison systems. These two factors should lower the costs of care
somewhat, but are not so great as to account for the difference in IDOC cost from the mean
health expenditure of state prison systems.23
Staffing appears to be the biggest contributor to the low IDOC spending on health care. In fiscal
year 2015, Illinois has the second lowest number of full-time equivalent (FTE) health care
workers (19.3 per 1,000 inmates) of all 50 state prison systems. The range of FTEs per 1,000 in
the 50 state systems range from 18.6 FTEs per 1,000 inmates to 86.8 FTEs per 1,000 inmates.24
In his deposition, Mr. Brunk the Chief Financial Officer for the IDOC stated on pages 12-13 that the total expenditures on
health care in the IDOC were approximately $203 million. Using a population of approximately 42,000 the expenditures per
inmate per year would be approximately $4,800.
22 Prison Health Care: Costs and Quality; a report from the PEW Charitable Trust, October 2017 as found at
http://www.pewtrusts.org/en/research-and-analysis/reports/2017/10/prison-health-care-costs-and-quality.
23 Prison Health Care: Costs and Quality; a report from the PEW Charitable Trust, October 2017 as found at
http://www.pewtrusts.org/en/research-and-analysis/reports/2017/10/prison-health-care-costs-and-quality.
24 Prison Health Care: Costs and Quality; a report from the PEW Charitable Trust, October 2017 as found at
http://www.pewtrusts.org/en/research-and-analysis/reports/2017/10/prison-health-care-costs-and-quality.
21

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There is a direct correlation between the FTEs per 1,000 inmates and per-inmate annual
spending. A low number of staff can reflect a more efficient system of care or understaffing
with its attendant negative consequences for provision of health care. In our study, we found
that in 2018 there were 25 employees per 1,000 inmates, which still places Illinois
approximately in the lower 10% of state prison systems based on 2015 data. This will be
discussed later in this report.

Key Findings
Overall, the health program is not significantly improved since the First Court Expert’s report.
Based on record reviews, we found that clinical care was extremely poor and resulted in
preventable morbidity and mortality that appeared worse than that uncovered by the First
Court Expert.
Governance of the IDOC medical program is subordinated to custody leadership on a statewide
level and at the facility level. The subordination of health care to custody leadership has
resulted in a medical program that is not managed on sound medical principles and one that is
without medical leadership.
The existing IDOC system of care was established to have a more robust central office capable
of monitoring vendor activity. The IDOC central office has been progressively diminished over
the years to the point where it is incapable of effective monitoring.
The medical program does not have a separate budget. The IDOC could not provide to us a
document that included expenditures for medical care. Authorization and responsibility for
medical expenditures does not reside with the health authority.
IDOC Administrative Directives are inadequate policies for this state system. The IDOC medical
policies need to be refreshed, augmented, and address all National Commission on Correctional
Health Care (NCCHC) standards.
The IDOC does not have a staffing plan that is sufficient to implement IDOC policies and
procedures. The staffing plan does not incorporate a staff relief factor.
Custody staffing has also not been analyzed relative to health care delivery to determine if
there are sufficient custody staff to deliver adequate medical care.
Budgeted staffing was increased but vacancy rates were higher than noted in the First Court
Expert’s report. Staff vacancy rates are very high.

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The vendor, Wexford, fails to hire properly credentialed and privileged physicians. This appears
to be a major factor in preventable morbidity and mortality, and significantly increases risk of
harm to patients within the IDOC. This results from ineffective governance.
Wexford and the IDOC fail to monitor physician care in a manner that protects patient safety.
There is no meaningful monitoring of nurse quality of care. If care is provided it is presumed to
be adequate, when in fact it may not be adequate.
The inability to obtain consultation reports and hospital reports appears to be a long-standing
system wide problem. This is a significant patient safety issue.
The collegial review process of accessing specialty care is a patient safety hazard and should be
abandoned until patient safety is ensured.
Specialty care is not tracked with respect to whether it is timely. The Wexford system of
utilization management is ineffective and for many patients is a barrier to timely care. The use
of free care at UIC appears to have resulted in unacceptable delays. Waiting for unacceptable
time periods for free care when care needs to be performed timelier has harmed patients.
Patients are not consistently referred for specialty care when it is warranted. We view this as a
problem of hiring unqualified physicians and as a problem of the utilization process itself.
The paper medical record system creates significant barriers to delivery of safe health care,
including inaccessibility of prior reports and prior diagnostic tests. The current paper
medication administration records (MARs) are inconsistently filled out, filed, or able to be
viewed by clinicians. The paper record also makes monitoring health care processes exceedingly
difficult. An electronic medical record is needed.
Sanitation, maintenance, and equipping health care units is not standardized. Many clinical
areas are inadequately sanitized.
The reception process does not ensure a thorough initial medical evaluation that will correctly
identify all of a patient’s problems in order to develop an appropriate therapeutic plan.
Provider medical histories are inadequate. Follow up of abnormal findings is inconsistent.
Laboratory tests and other studies needed for an initial evaluation of a patient’s chronic
illnesses are inconsistently obtained. Tuberculosis (TB) screening is improperly performed due
to custody rules at NRC.
The chronic disease system promotes fragmentation of care and fails to adequately address all
of a patient’s problems from the perspective of the patient. Patient problems are lost to follow
up or are not addressed in the context of a patient’s complement of diseases.
The chronic care disease guidelines need to be updated. Alternatively, contemporary existing
guidelines by major specialty organizations should be used in lieu of IDOC-specific chronic care
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guidelines. These specialty organization guidelines are periodically updated and are based on
latest scientific evidence. For the Office of Health Services to attempt to duplicate these
guidelines is unrealistic.
The Administrative Directive for periodic examination 25 is inconsistent with current standards
of preventive care.26 Inmates are therefore not offered all preventive services that are typically
offered to individuals in the community. The most important missed preventive care is
colorectal cancer screening in individuals over 50 years of age.
Housing of the elderly and disabled is inadequate. The IDOC needs to perform an assessment of
its geriatric and disabled population to determine housing needs for this population. It is likely
that new or rehabilitated housing for this population is needed.
There is no active infection control program. Infection control practices lack guidance from a
physician with expertise in infection control practices. This is evident in HIV testing, TB
screening, and analysis of surveillance practices.
The quality improvement program operates on a legacy system of principles that no one any
longer understands or effectively implements. No one in the IDOC has experience or knowledge
of contemporary quality improvement methodology and practice. The quality improvement
program is ineffective statewide.
The quality improvement program does not have a means to identify problems for study and
does not associate identified problems with systemic processes.
Data for quality improvement is obtained by manually counting events. Logs tracking processes
of care are either not maintained or maintained in a manner such that the data is not easily
useable.
The methods of preparing and administering medications is not standardized across the system.
There are pervasive and systemic issues with respect to medication administration that place
inmates at risk of harm. When these occur, there is no system to identify or correct the
systemic problem.
Overall, the dental program has not improved since the First Expert Report. Dental care
continues to be below accepted professional standards and is not minimally adequate.
Examinations are inadequate and routine care is provided without intraoral x-rays, a
documented periodontal assessment, and a treatment plan. Periodontal disease is rarely
diagnosed and treated.

25
26

Offender Physical Examination; Illinois Department of Corrections Administrative Directive 04.03.101.
As exemplified by the US Preventive Services Task Force Recommendations.

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There is no systemwide capital replacement plan for dental equipment. As examples, the
panoramic x-rays taken at the R&C centers are inadequate and the x-ray devices are outdated.
IDOC has no dentist on the Medical Director’s staff and the clinical oversight of the dental
program is inadequate.
Dental staffing is insufficient to provide adequate and timely care.

Statewide Medical Operations
Leadership, Staffing, and Custody Functions
Methodology: We interviewed the Agency Medical Director, the Regional Coordinators, the
Regional Medical Coordinator, Chief of Programs and Support Services, the Wexford Vice
President of Operations, the Wexford Director of Operations, two Wexford Regional Managers,
and two Wexford Regional Medical Directors. We reviewed the table of organization, and
reviewed selected documents. We obtained and reviewed staffing documents. We reviewed
peer review documents and credentialing documents provided by Wexford.
First Court Expert Findings
The First Court Expert found that leadership was a problem at all facilities visited. Many
leadership positions were vacant. Some Wexford supervisory staff spent considerable time on
Wexford corporate duties rather than on the operational assignments they were being paid for.
Several physicians did not have primary care training and hiring of underqualified physicians
was a problem. Clinical quality was variable and compounded by lack of clinical oversight, peer
review, and access to electronic resources to access clinical information. Medical Directors
spent little time in reviewing clinical practice of other providers or engaging in important
administrative duties. Staffing deficiencies were present at several facilities but were facility
specific. Nurses other than registered nurses (RNs) were performing independent assessments,
which is not consistent with the State of Illinois Nurse Practice Act. The Office of Health Services
was under-resourced and unable to provide clinical oversight. The First Court Expert was
informed by State and vendor staff of problems [unspecified] with Wexford Regional Medical
Directors. Professional performance review, mortality review, and quality improvement were
described as extremely disappointing.
Current Findings
We agree with the findings of the First Court Expert and note that, with minor exceptions,
findings are the same. There have been staffing increases, particularly at NRC and SCC, but
vacancies are increased. Staffing is deficient, in our opinion, even if vacancies were filled. The
IDOC does not know how many staff are necessary because a staffing analysis has not been
performed, even for development of Schedule E staffing budgets for contract medical services.
There are fewer HCUA position vacancies. The HCUA leadership staff at all five facilities was
very good. Physician leadership, however, is worse. We had additional findings regarding the
governance of the health program, monitoring of clinical services, credentialing of physicians,
and policy concerns. There is no centralized medical health authority that develops the budget,
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determines recommended staffing levels, monitors the contract, and provides oversight of
clinical care. Because operational control of the medical program is under the authority of the
Wardens of individual facilities, processes can be established that are not consistent with
appropriate medical management practices.
Structure of Medical Services and IDOC Leadership
The organizational structure of the IDOC health program was established in the 1980s and early
1990s. The program was structured so that the IDOC staff would maintain administrative
control over the health program and have a variety of vendors provide physician staff and other
staff the state was unable to provide. Staffing of the facilities was provided by contract medical
vendors with a considerable number of state employees. Currently, dialysis services are
provided at three facilities by NaphCare. University of Illinois at Chicago provides laboratory
services statewide and statewide management of HIV and hepatitis C patients with anti-viral
medication via telemedicine. Wexford Health Sources provides the remaining medical, dental,
vision, and pharmacy services under the guidance of the IDOC Agency Medical Director and in
accordance with their contract.
Currently, the IDOC medical program table of organization is not organized on a medical model.
Governance of the IDOC medical program is subordinated to custody leadership on a statewide
level and at the facility level. The health authority27 is the Chief of Programs and Support
Services, and is an ex-warden. The IDOC medical program has no named responsible
physician,28 although in practice some aspects of this responsibility appear to reside with the
Agency Medical Director, who appears to be primarily a consultant. The budget of the health
program is not a separate budget. At a facility level, wardens are the Chief Administrative
Officer and are responsible for operations of the health program.
The health authority is not responsible for operational management of the statewide medical
program. Instead, authority and responsibility are diffuse. This results in gaps in management,
oversight, and monitoring, and leads to poor performance. The Office of Health Services is not
responsible for determining staffing levels, budget needs, equipment needs, or oversight of the
medical program.
The responsible health authority is the Chief of Program and Support Services, who reports to
the Director. This is a custody position. The current organizational structure does not require
that the health authority have health care education and training commensurate with the
requirements of the position. Requirements of the health authority position are not explicit in
the Office of Health Services policies. This position is currently filled by a licensed clinical
psychologist who was previously with the Department of Mental Health in Chester, Illinois and
recently was the Warden at Southwestern Illinois Correctional Center. She has ultimate
responsibility for oversight of medical care and ensuring that systems are in place to ensure
27 A health authority is a person responsible for health care services. This person arranges for all levels of health care and
ensures that all levels of service are provided, and that care is accessible, timely, and of good quality.
28 A responsible physician is a physician who has final authority regarding clinical issues.

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adequate care. We have concerns with the health authority being a custody person, particularly
because it can be filled with non-health care personnel without experience in managing a
clinical medical program. In an interview with the Chief of Program and Support Services, she
had minimal knowledge of operational features of the medical program, was not intimately
involved in the medical budget, was not responsible for the medical contract, and was not
involved in developing or managing staffing levels.
Custody personnel have considerable responsibilities over health care. In addition to the Chief
of Program and Support Services being the health authority, Wardens have authority over
medical operations on a facility level. An Assistant Director is responsible for implementation of
the electronic medical record. Another Deputy Director, who was previously a nurse, is
occasionally asked to develop staffing analyses of selected facility medical programs. This level
of custody authority and involvement over management of the health program is considerable.
Because oversight authority of the medical program is not medical staff, there is the risk that
medical autonomy will be lost and that clinical operational processes will be disadvantaged
with respect to custody processes and that clinical and operational independence will be lost.
This is contrary to two fundamental NCCHC standards which are critical to an adequate
correctional health care medical program.29 We did see evidence of this with respect to
medication administration and health request processes at several facilities. We also noted at
NRC that inmates were locked in their cells, except for brief periods, for 24 hours a day. This is
similar to a super-maximum prison and is excessive. This practice impaired the ability of nurses
to adequately pass medication, read TB skin tests, and to appropriately access medical care.
Despite this ongoing barrier to medical care as a result of this custody practice, there was no
evidence of medical advocating for ways to appropriately perform their work. Because the
Warden supervised the medical program, it is our opinion that medical staff were unlikely to
advocate for improved care.
The IDOC Agency Medical Director reports to the Chief of Program and Support Services. The
Agency Medical Director has limited responsibility with respect to the health program. He is
responsible for formulation of statewide health care policy and chronic care guidelines.
Through subordinates, he monitors and reviews medical services, but he has insufficient
physician staff to perform adequate monitoring, especially for physician care. He has no
authority to manage operations of the health program. He has no responsibility for the budget
except in a consultative role. He participates in scoring prospective vendors of the medical
contract and in reviewing staffing recommendations in the contract. But this is mostly an
advisory and consultative role. According to his job description and interview, he does not
function as the authority in establishing budgets, staffing levels, or equipment purchases.
Although he appears to be the final clinical medical decision maker, one has to infer this
responsibility because it is nowhere stated in his job description.

P-A-02 Responsible Health Authority and P-A-03 Medical Autonomy, Standards for Health Services in Prisons 2014; National
Commission on Correctional Health Care.

29

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Each facility is managed by a health care unit administrator (HCUA), which is a state position.
However, most facilities have a mix of state and Wexford employees. Because of coemployment rules,30 the mixed staff creates supervisory confusion between Wexford and IDOC
supervisors working under the HCUA. This is most evident at the NRC and SCC. The Wexford
staff are supervised by Wexford employees who are not under supervision of the HCUA.
Each HCUA reports to the assistant warden of programs of the facility. Each facility medical
program is therefore under the operational management responsibility of the Warden of the
facility, not the Agency Medical Director. This means that medication administration or access
to sick call, as examples, are under ultimate control of the Warden through the supervision of
the HCUA. Wardens have no knowledge of how to manage medical program operations. This
arrangement reduces the Office of Health Services to a consultative role as opposed to
operational control. The Office of Health Services needs to have final authority over health care
policies, not merely a consultative role.
The Office of Health Services has a staff of four employees assisting the Agency Medical
Director in his monitoring function: an Agency Medical Coordinator who is a nurse and three
Regional Coordinators who are also nurses. There is no dentist on staff. These individuals act
mostly as regional resources to facility staff with respect to interpretation and implementation
of the Administrative Directives and clinical guidelines. They also provide a monitoring function.
Because they do not have authority to change operational practices, their monitoring function
lacks the authority to direct operational changes, even if they disagree with how practices are
being managed.
The Agency Medical Director monitors and reviews care through contract monitoring reports31
and verbal reports of the Regional Coordinators. Contract monitoring reports are the
responsibility of the HCUA. In the absence of the HCUA, the Assistant Warden of Programs at
the facility is responsible for the contract monitoring report. The Agency Medical Director
monitors the quality of doctors through review of credentials at annual CQI meeting, review of
problematic peer reviews, and studies of the quality improvement meetings.32 However, the
credential reviews are inadequate, as will be described later in this report. The peer reviews are
performed by Wexford doctors on each other and are ineffective. And the quality improvement
studies do not monitor clinical quality of care.
Two of three of the Regional Coordinator positions are currently vacant and filled on an acting
basis by HCUAs who are still responsible for managing their facility. While an HCUA filling in as a
Regional Coordinator on short-term basis is reasonable, longer than 60-90 days is likely to result
in reduced effectiveness at the HCUA’s home facility. The Agency Medical Coordinator fills in
Co-employment is a relationship between two or more employers whereby each has legal responsibilities to the same
employee. In this case, line staff may be Wexford but have an IDOC supervisor and IDOC employees may have a Wexford
supervisor. This created problems at multiple facilities we visited. This is particularly problematic with respect to scheduling and
disciplinary issues.
31 Page 26 Dr. Meeks 30(b)(6) deposition on July 25, 2017.
32 Page 33 Dr. Meeks 30(b)(6) deposition on July 25, 2017.
30

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periodically for one of the HCUAs when she is performing as a Regional Coordinator. When
Regional Coordinators visit sites, they monitor clinical care but do not issue reports on their
work. Each Regional Coordinator has a monthly phone call with the Agency Medical Director,
Agency Medical Coordinator, and HCUAs, Assistant Wardens, and other staff in their region to
discuss any issues. The Regional Coordinators do not engage in direct review of nursing practice
at individual facilities that results in reports. We were told they occasionally review records of
nursing care. We found no evidence of formal reports of oversight over nursing practice on a
regional level. This includes oversight of nursing independent evaluations and medication
administration practices.
On a regional level, because Regional Coordinators and the Agency Medical Coordinator are
nurses, they are unable to monitor or review physician care, leaving a large gap in oversight of
the quality of medical care. The Regional Coordinators perform mortality reviews using a
structured format which result in reports, which were not made available to us. A Regional
Coordinator, who is a nurse, testified that he reviews deaths and complicated medical cases.33
In these reviews, he has never found care to be inadequate. We found many preventable
deaths and inadequate care on most death reviews we performed, even ones at the facility
supervised by the Regional Coordinator, who never found inadequate care. This work needs to
be done by a physician, not a nurse, but the only physician in the Office of Health Services is the
Agency Medical Director. The Agency Medical Director cannot monitor or review physician care
at 26 facilities. The Agency Medical Director does not perform any mortality reviews. It would
be difficult to impossible for him to review every death. The time allowed in his job description
for monitoring physicians is less than 15 hours a week, which is inadequate time to monitor all
physicians statewide. This task is not apparently performed by Wexford either. The Agency
Medical Director told us that he has not received any communications from Wexford Regional
Medical Directors with respect to problems identified in mortality review or peer review. As a
routine, the IDOC Agency Medical Director stated in deposition that he does not review
Wexford peer reviews except for isolated peer reviews for problematic providers.34 As a result,
oversight of facility physicians, including Medical Directors, is virtually non-existent. As this
program is currently staffed, the Agency Medical Director is unable to effectively act in
accordance with his job description, specifically to monitor medical care, especially physician
care. IDOC oversight is inadequate and has not identified physician practice problems largely
because of lack of physician oversight.
The IDOC has contracted with Wexford Health Sources Inc. for approximately 20 years. When
IDOC first contracted out its medical services in the 1980s, the IDOC managed the contract.
Sometime in the mid-2000s, the Illinois Department of Healthcare and Family Services (HFS)
became responsible for letting this contract, including monitoring and oversight of the contract.
The latest contract with Wexford was completed in 2011. Sometime after that contract was
awarded, responsibility for monitoring and managing the contract returned to IDOC. The
contract expired April 30, 2016 and provided for renewals of one or more years for a period of
33
34

Page 34 Joseph Ssenfuma deposition on September 28, 2017.
Page 33 Dr. Meeks 30(b)(6) deposition on July 25, 2017.

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five additional years through 2021. The latest renewal of this contract signed in April of 2016
was signed by IDOC. HFS is no longer involved in letting the contract, choosing the vendor, or in
monitoring the contract. This responsibility returned to the IDOC, which is not prepared to
monitor this contract.35
With respect to monitoring medical care including physician care, there is a large gap. In the
most recent contract with Wexford in 2011, the onsite Wexford Medical Director is assigned
responsibility for monitoring the performance of medical personnel and is to report deficiencies
to the HCUA.36 However, the onsite Medical Director is a Wexford employee and therefore
clinical monitoring is self-monitoring by the vendor, rather than independent monitoring by
IDOC. Moreover, about half of the Medical Directors do not have primary care training and are
unable to effectively give guidance on appropriate care. The IDOC is therefore depending on
the vendor to monitor itself with respect to clinical physician care, but the vendor has hired
persons who are not always trained sufficiently to understand what constitutes appropriate
care.
The contract monitoring on the part of the state is inadequate. Formal contract monitoring is
performed by HCUAs via the monthly contract monitoring reports.37 The HCUA is the only IDOC
staff that is specifically assigned for formal contract monitoring. HCUAs are provided a
spreadsheet to use for this purpose. There are five performance targets that are assessed. The
performance targets are:
• Whether all hours in the contract are fulfilled
• Whether all bills have been paid timely
• Whether there has been any Court finding of deliberate indifference
• Whether Administrative Directives have been complied with
• Whether Wexford met provisions of the contract.
We found no clinical quality of care items in contract monitoring reports of the five sites we
visited, even when we noted significant clinical issues during our site visits. This is a major
deficiency. No one is monitoring clinical care, particularly physician care. Even non-clinical
deficiencies are not monitored adequately. Most sites had performance issues with respect to
staffing and some Administrative Directive performance targets, yet the IDOC has never levied
penalties against Wexford based on these performance targets.38 Because of IDOC tardiness in
invoice payments to Wexford, it has been difficult for IDOC to penalize Wexford for its
infractions. While this has an element of fairness to the vendor, overall it contributes to lack of
enforcement of the contract as a result of budgetary realities.

1299433 Deposition of Jared Brunk Chief Financial Officer of the IDOC. In this deposition in January of 2018, Mr. Brunk
acknowledges that there was more than one person in the IDOC who thought that it would be useful to have additional
contract monitoring on pages 80-83. This Chief Financial Officer could not describe how the contract is monitored.
36 Item 2.2.2.21 Contract between Wexford Health Sources Inc. and IL Department of Healthcare & Family Services signed
5/6/11.
37 30(b)(6) deposition of Dr. Meeks on July 25, 2017 on page 26.
38 Deposition of Jared Brunk, Chief Financial Officer of the IDOC conducted January 31, 2018.
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The HCUA positions are filled by nurses. Nurses are not able to monitor clinical care of
physicians, including appropriateness of referral, chronic care, and infirmary care. Several of the
HCUAs remarked on their inability to monitor the clinical care of the Wexford physicians and
were unaware of quality issues, even when they existed.39 Because HCUAs cannot monitor
physician care, the contract monitoring is ineffective and incomplete. The only monitoring of
clinical performance of the physicians is Wexford peer review, in which Wexford physicians
monitor other Wexford physicians. Many of these physicians are unqualified to practice primary
care medicine. We found that these peer reviews are ineffective and fail to critically monitor
physician performance. Peer reviews will be discussed later in this report.
Wexford has a regional management structure that contributes to the fractured organizational
structure of the IDOC medical program. Administratively, there is a Wexford Director of
Operations and five Regional Managers. Each Regional Manager is responsible for five facilities,
with one Manager taking responsibility for six facilities. The clinical medical management
structure includes two Regional Medical Directors, each being responsible for 13 facilities. The
span of control of the two Wexford Regional Medical Directors is so large that it is very difficult
to spend meaningful time on site at any facility, and in our opinion not possible to effectively
supervise clinical care.
The Director of Operations and two of the five Regional Managers (50% of Wexford senior
administrative management staff) are ex-wardens and have no training in provision of medical
care. Because the IDOC HCUAs administratively manage operations at each facility, the Wexford
administrative managers have no role in managing operations at any of the IDOC facilities. The
Wexford view of duties and responsibilities40 of the Regional Managers include:
• Oversee leadership of Health Services Administrators (HSA)41 in the operation of facility
health care units.
• Provide HSAs with management guidance strategies for regional growth and operational
assistance.
• Oversee HSAs’ resolution of health care unit personnel issues.
• Supervise the performance of the HSA and department heads, conducting annual
evaluations.
• Instill a sense of accountability among the HSA team members through fair and
consistent oversight of individual and organization performance standards.
These duties and responsibilities appear inaccurate and not applicable to IDOC. The Regional
Managers do not oversee or supervise the HCUAs. The Regional Managers do not oversee
health care unit personnel issues except for Wexford employees. The Regional Managers
39 For example, we spoke to the HCUA at Dixon about a death. We found the death preventable. She was unaware that there
were problems with the death. No one from Wexford had brought up clinical issues with respect to this death with her even
though in our opinion problems were significant.
40 There is no job description for this position. There is a position summary listing duties and responsibilities on the Wexford
website which was advertising for a Regional Manager. This was provided to us as representative of a job description for the
Regional Manager. This is found at https://jobs.wexfordhealth.com/search/jobdetails/regional-manager/73d40fc0-c935-47d4b51f-b8095ad79af0?s_cid=ssEmail.
41 We understood the term Health Service Administrator to be the same as Health Care Unit Administrator (HCUA).

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appear to mainly act as intermediaries with respect to personnel issues, obtaining supplies and
equipment, and other similar issues related to adjusted service requests (ASRs). They also act as
customer relations functionaries. We were challenged in determining what they are actually
responsible for. They do not participate in CQI, analysis of operational issues at the sites,
resolution of operational issues, or other similar typical operational activity. They add little
value to the operational effectiveness of the IDOC management structure with the exception of
personnel issues of the Wexford staff.
The Regional Manager who was responsible for SCC, NRC, and Dixon Correctional Center told us
that he knew of no consistent problems at these facilities; yet we found serious operational
problems with medical records, medication administration, and evaluation of health requests.
Physician care, follow up of specialty care, and intake evaluations were also inadequate. To not
understand that there were problems is to be unengaged or indifferent to significant serious
issues. At Menard Correctional Center, where there were also serious operational problems,
the Regional Manager stated there were no problems and no areas of concern. These
responses were not in line with problems identified by the HCUA. Neither Regional Manager we
spoke with actively participates in quality improvement activities. One of the managers
perceived his role as administering the contract. Despite significant operational issues at all
sites we visited (e.g., lack of hospital and consultation reports, medication administration
issues, staffing concerns, problems with medical records, and supply issues), these Regional
Managers do not appear to be engaged in improving operations.
Based on interviews with HCUAs, neither the Regional Managers nor the Regional Medical
Directors spend much time at the facilities, nor do they participate in solving significant
problems. The most pressing problem of four of the five HCUAs was staffing and vacancies.
HCUAs were universally unhappy with the effort of Wexford on these issues.
The Wexford Regional Medical Directors are responsible for ensuring that direct patient care is
consistent with community standards and with contract requirements. They supervise the
facility Medical Directors and are responsible for peer reviews of Medical Directors, and must
ensure and/or conduct death reviews.42 Since there is inadequate oversight by the IDOC over
physicians, the supervision of Wexford Regional Medical Directors is the only oversight of
physicians. Wexford is thereby evaluating its own performance and does this extremely poorly.
Although the Wexford Regional Medical Directors have a clinical supervisory role over their
physicians, based on their job descriptions we could not verify that they perform this
adequately, as they perform no peer review, mortality review, or formal written review of
clinical work. According to the Agency Medical Director, he receives no formal communication
regarding clinical oversight of Wexford physicians, including Regional Medical Director initiated
peer review, mortality review, or other review of clinical care. There is no evidence we could
find that verifies their oversight of physicians except their statements that they review the work
of the physicians. Neither Regional Medical Director stated that clinical care review is on their
42

Regional Medical Director’s Responsibilities as provided by Wexford Health Sources.

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list of major responsibilities or tasks, except for addressing questions of the physician staff.
Because neither IDOC nor Wexford performs effective review of clinical care of physicians,
poorly performing physicians continue to perform poorly without apparent oversight. We noted
this on multiple chart reviews and mortality reviews.
Wexford Regional Medical Directors are also responsible for ensuring patient care is consistent
with community standards.43 Yet we found many examples of physicians providing care
inconsistent with current standards of care that appear to be systemic practices. For example,
IDOC does not provide colorectal cancer screening based on current standards of care and does
not appear to routinely screen patients with cirrhosis for varices or hepatocellular carcinoma.
Persons with chronic obstructive lung disease (COPD) are not provided pulmonary function
testing, which is a cornerstone of management of COPD. The current management of lipid
disorders is not in line with current standards or with the Office of Health Services treatment
guideline. We will discuss these later in the Chronic Disease section of this report. These
deficiencies need to be corrected because these deficiencies have caused morbidity and
mortality. There is no evidence of participation of the Wexford Regional Medical Team in
identifying these deficiencies to the IDOC or ensuring that their physicians are practicing based
on contemporary standards of care.
With respect to facility leadership, administrative supervision by HCUAs at individual facilities
has improved since the First Court Expert’s visit. The IDOC HCUAs are responsible for
administrative operational supervision of each facility. Of the 26 HCUA positions, all but one is
now filled. However, two of the HCUAs also serve as acting Regional Coordinators, making them
much less effective as HCUAs. Effectively, only 23 of 26 HCUA positions are filled. HCUAs were
all competent and were engaged in solving administrative problems, even though some
problems appeared unrecognized. This is one of the most significant and positive advances
since the First Court Expert’s report and is a strength that the program can build on.
Medical Directors are all Wexford positions. Of the 26 Medical Directors statewide, 8.5 (33%)
are vacant.44 This is an enormous vacancy rate for this key leadership position. Approximately
only half of physicians have training in primary care, which will be discussed later in this report.
This is a very small percentage of physicians trained in primary care. When a Medical Director is
not trained in primary care it is very difficult to be responsible for monitoring performance of
medical staff rendering direct patient care. An untrained physician is not likely to know how
that care is supposed to be provided. We found that onsite monitoring of clinical care was very
poor to nonexistent.
Director of Nursing (DON) positions can be either Wexford or IDOC. Fifteen (58%) of the DON
positions are staffed by Wexford. Eleven (42%) are staffed by the IDOC. Seven (27%) of DON
positions are vacant; four DON vacancies are Wexford positions and three DON vacancies are
Regional Medical Director’s Responsibilities as provided by Wexford Health Sources.
Illinois Medical Vacancy Report with ASRs as of 6/18/18 provided by the Attorney General’s Office from Wexford Health
Sources. This report gives staffing at all facilities as of 6/18/18.
43
44

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IDOC positions. Nursing staff can be either IDOC or Wexford, making it difficult, because of coemployment rules,45 to properly supervise line staff.
Of the 78 leadership positions (Medical Director, DON, and HCUA) at the 26 facilities, 16.5
(21%) are vacant. The vacant positions are compounded by co-employment issues46 and use of
two HCUAs as Regional Coordinators. The leadership vacancies are significant on a statewide
basis. The lack of Medical Directors is dramatic and is compounded by using physicians in these
positions who are, in our opinion, unqualified by virtue of not having primary care training.
In summary, administrative supervision by HCUAs is adequate but clinical-medical supervision
and management, particularly physician care, is inadequate and places patients at significant
risk of harm. The clinical supervision at the facility level is inadequate based on Medical
Director and DON vacancies, and poor qualifications of physicians.
IDOC Policy
The IDOC provides policy direction on clinical care through its Administrative Directives and
chronic care guidelines. The medical Administrative Directives are a part of the larger IDOC
Administrative Directives which include all custody policy. We will discuss the chronic disease
guidelines in the section on Chronic Disease and dental guidelines in the Dental section. The
Medical Administrative Directives are inadequate with respect to the breadth of guidance that
is necessary for a correctional medical program. The IDOC has only 18 Administrative Directives.
In comparison, the National Commission on Correctional Healthcare47 has 68 standards, which
is a minimum panel of policies for a large prison system. There are essential areas of service
that are not governed by Administrative Directives and thereby are not guided by policy and
not standardized statewide. Though each facility can have additional institutional policies and
procedures, the lack of statewide guidance means that practices are not standardized. The
Office of Health Services needs to be responsible for statewide policy guidance in all areas of
service, with local policy following statewide policy. The 18 medical Administrative Directives
are inadequate for this purpose. The National Commission on Correctional Health Care
standards are a reasonable guideline to determine the scope of processes of care that should
be governed by Administrative Directives.

Wexford Provider Staffing and Physician Credentialing
It is our opinion that the quality of physicians in the IDOC is the single most important variable
in preventable morbidity and mortality, which is substantial. The first step in provision of
quality of care is to ensure appropriately credentialed medical staff. In its response to the First
Co-employment means that there are two employers (IDOC and Wexford), each of whom has some legal responsibility for
the same employees.
46 When a State employee HCUA is responsible for managing the health care unit but staff are Wexford, there are some
limitations with respect to discipline and assignment as a result of union rules. When a DON is a Wexford employee and staff
nurses are state employees, the same occurs. These co-employment issues affect multiple facilities we visited.
47 The National Commission on Correctional Healthcare is the leading organization establishing standards for correctional health
programs.
45

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Court Expert’s report,48 on page 4 an attorney for the State states that, “More than 80% of
WHS’ [Wexford Health Services] physicians are either Board Certified in Family Practice or
Internal Medicine, or have more than 10 years of Family/Internal Medicine practice experience
or correctional medical experience.” This is a misleading statement that gives an inaccurate
representation of the credentials of physicians. Credentialing information provided by Wexford
shows that only six (20%) of the physicians are board certified in a primary care field. Because
physicians typically work alone in these facilities, experience alone is no guarantee that
performance will improve to be consistent with current standards of care. We document
multiple preventable deaths in the mortality review section of this report. It is our opinion that
poorly credentialed physicians contribute significantly to those preventable deaths.
Currently, there are 30 Wexford physicians working in IDOC facilities. Of these, only 16 (53%)
have completed training in primary care. Of the 16 that completed primary care training, only
six (20% of the 30) are board certified in primary care. Two doctors are obstetricians who work
at LCC doing women’s care, for which they are appropriately credentialed and privileged; one of
these is board certified. These doctors only provide obstetrical and gynecological care, not
primary care. Five physicians have an internship or a year or two of primary care training but
did not complete a residency.49 The remaining seven include:
• One anesthesiologist
• One doctor with two years of occupational medicine
• One doctor with some training in pathology
• One doctor with a year of physical medicine
• One surgeon
• Two radiologists, one of whom did not complete residency training.
Credentialing is a process whereby a physician’s qualifications are evaluated by reviewing their
education, training, experience, licensure, malpractice history, and professional competence
with respect to the work they will be expected to perform. Proper credentialing is the
foundation of protecting patient safety. Credentialing must ensure that a physician is properly
trained for the work they will be performing. Credentialing protects patient safety by
preventing incompetent, poorly trained, or impaired physicians from engaging in patient care.
In correctional facilities, the scope of practice required and the health care needs of patients
are mostly primary care, which requires physicians who have residency training in a primary
care field. However, the only requirement in the IDOC with respect to credentialing is to verify
that a physician has a license. A Regional Coordinator testified that the only review of
credentials is to verify that the doctor has a license, and that their training, board certification,
or disciplinary history is not part of credentialing review.50

Letter via email to Dr. Shansky, First Court Expert from William Barnes, representing the IDOC dated 11/3/14.
This information comes from items 42Z9081-42Z8845-Part 1; 42Z9082-42Z8845-Part 2; 42Z9085-42Z8845-Part 4; 42Z908842Z8845-Part 3; and 42Z9090-42Z8845-Part 5. This credentialing information was provided by Wexford Health Sources, Inc.
50 Deposition of Joseph Ssenfuma, Regional Coordinator, on September 28, 2017.
48
49

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Privileges are the services and procedures that a physician is qualified to perform based on
training and experience. The credentials and training of a physician determine what privileges
that physician should have. As an example, a doctor who is trained and credentialed in general
surgery can obtain privileges to perform appendectomies and cholecystectomies. A physician
trained and credentialed in obstetrics can obtain privileges to deliver babies. Physicians trained
and credentialed in internal medicine or family practice can obtain privileges to practice
primary care. Physicians trained and credentialed in internal medicine cannot obtain privileges
to deliver babies or perform appendectomies. And physicians trained and credentialed in
radiology or general surgery cannot obtain privileges to provide primary care. Because the
scope of practice and needs of the patients in a correctional medical program are primary care,
physicians should be credentialed and privileged in primary care. In IDOC, physicians are
credentialed to perform primary care even when they have no training in primary care. This is a
serious problem with the credentialing process. For this reason, we agree with the First Court
Expert that Medical Directors be board certified in a primary care specialty. Given the size of
the IDOC facilities, there is only one physician on staff at most facilities. When this physician is
not trained in primary care, there is no other available physician to care for the patient.
Because there are so many physicians who have not completed a primary care residency, the
level of supervision of their care should be at a higher level than for board certified physicians.
This is not the case. There is no special monitoring for this group. All physicians receive the
same type of peer review.
Peer review is a means to monitor the quality of physician and other provider care, and thereby
protects patient safety. Peer review of physicians in the community is typically of two types.
One type of peer review is done on a routine basis for all physicians and is done as a monitoring
device to ensure quality of care. This type of peer review is often called performance evaluation
program or PEP. A second type of peer review is done when a member of the medical staff may
have committed a serious gross or flagrantly unacceptable error or exhibits a serious character
or behavior problem and needs to be evaluated with respect to possible reduction of privileges
or referral to a medical board. The latter type of peer review is generally a formal quasi-legal
procedure that has significant implications for the physician’s employment and professional
status. We found that the first type of peer review is done for all physicians and mid-level
providers in the IDOC, but the second type of peer review does not appear to occur in IDOC,
based on information made available to us. As will be detailed later in the mortality review
section of this report, there were numerous grossly and flagrantly unacceptable episodes of
care that should have resulted in peer review but did not. Peer review in the IDOC is ineffective,
as physicians who commit repeated egregious medical errors continue to practice and continue
to harm patients.
The first type of peer review which is performed by Wexford is a structured questionnaire
performed by one Wexford physician on another Wexford physician. We noted at one facility
that a general surgeon performed the peer review of the primary care work of a nuclear
radiologist. It is our opinion that this type of performance evaluation is defective and unlikely to

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result in meaningful evaluation, as neither doctor is adequately trained to practice primary care
and would not be able to know when care was adequate.
Also, the peer review that is done is so poor that it is unlikely to identify problems. The Wexford
peer review consists of a review of 10 single episodes of care for five areas of service. For each
of these areas of service there are a series of questions ranging from 10 to 15. Some of the
questions are not relevant to clinical quality, such as:
• Is the handwriting legible?
• Is the signature with professional designation legible?
• Is the patient enrolled in all relevant clinics?
• Are all medications written on a script?
• Does the clinic include pertinent vital signs?
While it is important to write a legible note, legibility does not evidence clinical competence.
Many questions require an interpretation. For example, the question “Was treatment
appropriate for this visit” requires that a physician know the appropriate treatment. The
problem is that when only 20% of doctors are board certified and 23% have no training in
primary care, many doctors will not know the appropriate treatment. Doctors performing these
evaluations need to be expected to know what the appropriate treatment is, otherwise the test
will not perform as expected. Also, these episodes of care are picked at random and may not
include patients that have serious illness. When someone does not have a serious illness, it is
difficult to test the clinician, because it is very difficult to make an error if there is no decision to
make with respect to the treatment. Additionally, it appears that these reviews are not taken
seriously and appear to be done merely because these are requirements of the contract. For
these reasons, it is not surprising that almost all peer reviews were scored 100% adequate.
When we compare these results with death chart reviews we performed, there is dramatic
discrepancy. Most chart reviews we performed contained many errors. We reviewed the care
provided over two years prior to the death. Of 33 death charts we reviewed, there were over
1700 errors. Many had serious errors. Some had egregious errors that resulted in death. We
noted the same level of medical error in chart reviews we performed on site visits. The Wexford
methodology of peer review does not appear to accurately review physician practice, based on
a comparison to our record review of clinical care. This process is not working as intended.
The First Court Expert opined that Wexford hired underqualified physicians, and recommended
that facility Medical Directors be trained in primary care and be board certified. We agree with
this finding, based on the credentialing information above, and we agree with his
recommendation.
In reviewing the Defendants’ comments to the First Court Expert’s Draft Report,51 the
Defendants challenged the assertion of the First Court Expert that Wexford Health Services has
hired “underqualified clinicians.” In their attempt to refute that assertion, the Defendants
51 Re: Lippert v. Godinez – Defendants’ comments regarding Confidential Draft Report via email dated November 3, 2014,
authored by William Barnes.

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stated that, “The community standard, as espoused by the American Medical Association,
requires physicians to possess only a license to practice medicine.” This is misleading and
inaccurate. This statement implies that the current community standard of medicine is for
physicians to only have a license to practice medicine, presumably in any field. We disagree. It
is our opinion that the community standard in the U.S. is for physicians working in primary care
to have residency training in a primary care field. One would never see a pathologist delivering
babies. The Defendants’ statement also implies that the American Medical Association (AMA)
endorses their position. This statement of Defendants is neither the community standard nor is
it a standard we could identify as espoused by the AMA.
It is true that it is legal for a doctor without residency training to open a private practice in the
community and practice primary care medicine without any training in primary care. However,
it is becoming increasingly uncommon, and particularly in urban areas, it is now extremely
uncommon to find doctors without residency training in primary care who work in general
practice. The standard in the community is for physicians in organized medical practices to
undergo credentialing and privileging, and to have residency training consistent with their
scope of practice.
With respect to the recommendation to hire board certified physicians, the State’s response
said,
“This recommendation, along with any recommendations dictating specific training or
certification for licensed correctional physicians, lacks any justification or support in state
law and community, ACA, AMA, and NCCHC standards. Accordingly, this recommendation
exceeds minimum constitutional standards of adequacy” [my emphasis].52
With respect to the assertion that use of board certified primary care physicians exceeds
minimum constitutional standards of adequacy, we note as an example that there has been
Federal Court intervention requiring use of primary care trained physicians when that training
was necessary to protect inmate-patients. For years, the California Department of Corrections
and Rehabilitation (CDCR) had poorly credentialed physicians, which resembled the current
situation in the IDOC. In 2004, in the California prison system, many physicians were not trained
in primary care; instead, they had training in surgery, radiology, gynecology, pathology, etc.,
similar to the IDOC situation in 2018. Many physicians had prior or current sanctions of their
licenses and evidence of clinical incompetence by virtue of malpractice claims, which we were
unable to evaluate for Wexford physicians. It was the opinion of the Court in California that the
lack of qualified physicians resulted in increased morbidity and preventable death. We believe
that the situation in California is similar to the situation in the IDOC. In California, as a result of
that situation, the Federal Court issued an order53 requiring the use of physicians who were
Letter via email to Dr. Shansky, First Court Expert from William Barnes, representing the IDOC dated 11/3/14.
Proposed Stipulated Order Re: Quality of Patient Care and Staffing; Marciano Plata, et al., v. Arnold Schwarzenegger, et al.;
United States District Court Northern District of California No. C-01-1351 T.E.H., originally filed 9/17/04. In that order, the Court
stated: “As of January 15, 2005, defendants shall not hire independent contractor primary care physicians who are not boardeligible or board certified in internal medicine or family practice.” p. 3.
52
53

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board certified or board eligible54 in internal medicine or family practice.55 We note that in the
California prison system in 2007, there were 18 preventable and 48 potentially preventable
deaths, and in 2017, when all physicians were required to be board certified, there were 0
preventable deaths and 18 potentially preventable deaths.56 Although there were other
systemic improvements that helped reduce the number of preventable deaths, improvements
in physician credentialing played the major role. Improving credentials of physicians and
removal of unqualified physicians has been shown to reduce mortality.57
We have learned that in the mid-1980s, approximately 12 IDOC prison facilities were accredited
by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). At that time,
the Agency Medical Director approved all facility Medical Directors and his requirement was
that Medical Directors completed primary care training. Accreditation by JCAHO required
privileging based on appropriate credentials. At that time, the IDOC placed into its
Administrative Directives the requirement that all physicians have one-time primary source
verification of their credentials, which was a requirement to verify training. The IDOC ended
their accreditation with JCAHO but kept in the Administrative Directives the requirement of
primary source verification. Over the years this practice was ignored and currently the HCUAs
we interviewed do not even know what primary source verification is. The only credentialing
review is to ensure at the annual CQI meeting that every physician has a license.
Physician Staffing
Physician staffing in IDOC is very poor. The Vice President of Operations for Wexford could not
remember the last time there was a full physician staff. She thought in 2014 there was only one
vacancy, but that was as close to full staffing as the program got. We noted earlier in this report
that IDOC lacks adequately trained physicians. This is compounded by vacancies in physician
positions. Persistent and ongoing vacancies in the Medical Director position title contribute
significantly to physician staffing deficiencies. In addition to vacancies of Medical Directors, all
five facilities we visited were missing a physician. Two facilities had replaced a physician
position with a nurse practitioner because of the inability to fill physician positions. Statewide,
the total days of missing Medical Directors totaled 22% of total days these positions were
supposed to be filled,58 an unacceptable vacancy rate.
Because of vacancies, physicians are moved from site to site as “Traveling Medical Directors.”
One of the facilities we investigated, NRC, had a Traveling Medical Director. This individual did

54 Board eligible is a term used to describe a physician who has completed a residency training in a field and is therefore
qualified to take a board certification test for that specialty. For example, a board eligible internist is one who has completed a
residency in internal medicine and is qualified to take the board certification test but has not yet done so.
55 Since this order, the California Department of Corrections and Rehabilitation, through the Receiver’s office, requires board
certification in family practice or internal medicine.
56 Based on annual analyses of inmate deaths as reported by Dr. Imai, consultant to the medical receiver in California as found
under the heading of Death Review at https://cchcs.ca.gov/reports/.
57 Terry Hill, Peter Martello, Julie Kuo; A case for revisiting peer review: Implications for professional self-regulation and quality
improvement. Plos One at https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0199961&type=printable.
58 Document 42P5621-IDOC Facilities lacking permanent medical directors 7-1-15 to 11-26-17 Bates number 550.

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not participate meaningfully in quality improvement, did not show any evidence of oversight of
the medical program, and had clinical issues.
The turnover of Wexford physicians is also very high. Of 33 physicians listed on a 9/19/14
report59 by Wexford, only 18 (54%) are still working three and a half years later. The inability of
Wexford to hire and retain qualified physicians is a serious problem and was mentioned as a
significant problem by every HCUA we spoke with. There has been no formal analysis of this
that we could find. The Vice President of Operations for Wexford told us that it was harder to
recruit to corrections because of the impression that if you worked in corrections, you were a
bad doctor. We disagree. In our opinion and from experience, recruitment in corrections
depends on establishing conditions of work that are professional and foster a sense of
providing a worthwhile service. When that occurs and when doctors are properly supported,
qualified doctors can be found and retained in correctional environments and elsewhere.
At the five sites we visited, none had a long-tenured Medical Director. LCC had a Medical
Director who had the longest tenure of the five facilities we inspected. She had been Medical
Director since May of 2016. The Medical Director at Dixon started in October of 2017. The
Medical Director at MCC has been in his position since June of 2017. One Medical Director was
at Dixon for a short period of time before being moved to NRC. After several months at NRC, he
was moved to SCC. About two months after being moved to SCC, he resigned. His position at
NRC was filled in coverage by the ex-Medical Director at Hill, who the First Court Expert stated
had identified clinical issues. This musical chairs rearrangement of Medical Director
assignments is demonstration of the failure to create an environment likely to attract qualified
physicians. The IDOC needs to determine why it is that their vendor cannot recruit and retain
qualified physicians.
Physician leadership was not improved based on the First Court Expert’s comment that,
“the Medical Directors were functioning in primarily clinical roles and spent little if any time
reviewing the clinical practice of other providers or engaging in other important
administrative duties.”60
Several of the HCUAs spoke about poor physician quality as an issue. Two of the Medical
Director positions were vacant. A coverage physician at one facility with a vacant Medical
Director position did not participate meaningfully in quality work or in providing clinical
leadership. In two of the remaining three facilities we visited, the HCUA spoke of having
problems with the Medical Director. One was described as only doing chart reviews, not
wanting to see patients, not reviewing deaths, and having to be urged to see patients. When
leadership and quality of physicians is inadequate, patients are placed at risk because poor
quality will not be identified or corrected.

59
60

40C0134- IL Physicians Report 9 19 14 Key Produced by Wexford Health Services.
Final Report of the Court Appointed Expert, Lippert v. Godinez December 2014 p. 7.

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Non-Physician Staffing
On a statewide basis, exclusive of dialysis and the HIV and hepatitis C telemedicine program,
there are 1119.6 medical staff in the IDOC program, with an inmate population at mid-year
2017 of 43,075. This amounts to 26 staff per 1000 inmates, which places IDOC approximately in
the lowest 10% of state prison systems in the country61 with respect to staffing numbers based
on 2015 data. Of the 1119.6 staff, 401 (36%) are employed by IDOC and 718.6 (64%) are
employed by Wexford Health Sources. Of the 1119.6 medical staff, there are 245.8 (22%)
vacancies, not including leave of absences, which would increase this number a few points.
Wexford has an 18% vacancy rate for its 718.6 employees and IDOC had a 29% vacancy rate for
its 401 employees. These are very high vacancy rates and compound a very low staffing level,
making staffing a critical problem statewide. This was confirmed by HCUAs at sites we visited.
We compared facility staffing for mutually visited facilities. In 2014, the First Court Expert
determined that for the five facilities we visited there were 303.41 budgeted positions, an 18%
vacancy rate, and 25 staff per 1000 inmates.
Positions, Vacancies, and Positions per 1000; First Court Expert’s 2014 visit62
Facility

Positions

Vacancies

% Vacancy

Population

Staff per 1000

SCC & NRC

73.90

23

31%

4078

18

LCC

62.21

4

6%

1997

31

Dixon

66.30

18

27%

2349

28

MCC

101

9

9%

3750

27

Total

303.41

54

18%

12174

25

For the same five sites we visited, there were 405.05 budgeted positions. There were 99
(23.5%) vacancies. This is a very large vacancy rate, which makes it difficult to effectively
operate a health program.63 Four of the five facilities we visited had unacceptable vacancy
rates.64 We note several key differences in the staffing differences between 2014 and 2018. The
population in the five facilities we reviewed decreased by 2177 (18%). The number of positions
61 Prison Health Care: Costs and Quality, Pew Charitable Trusts, October 2017. We note that the staffing levels given in the Pew
study reflect 2015 numbers. However, these 2018 IDOC staffing numbers still would rank Illinois in the lowest 10% of state
prison systems comparing IDOC 2018 staffing to nationwide 2015 numbers.
62 This table is constructed from data taken from tables presented in the First Court Expert’s report.
63 In Defendants’ comments on our report they noted that there is a national nursing shortage and cite a survey of readily
available health care facilities in the United States in January 2018 by Nursing Solutions, Inc. a recruitment firm. Defendants
note that over 25% of the hospitals in this country who responded to the survey have Registered Nurse (RN) vacancy rates of
greater than 10%. This same study reported that the average vacancy rate for Registered Nurses is 8.2%. In either case, nursing
vacancies in the IDOC facilities we visited exceeded the average from this survey and were much more than the maximum of
12.5% used in the study.
64 Except for LCC, all IDOC facilities had vacancy rates of 20% or greater. These vacancy rates are much higher than Federal
Bureau of Prisons policy that establishes that vacancy rates not exceed 10% during any 18-month period (Program Statement
P3000.03:
Human
Resources
Management
Manual,
Chapter
3,
page
11
obtained
at
https://www.bop.gov/PublicInfo/execute/policysearch#. There are no published reports comparing vacancy rates amongst
health care providers working in state prison settings.

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increased by 101.64 (33%).65 The staff per 1000 inmates increased by 16 (64%). But the vacancy
rate increased from 18% to 23.5%, a 30% increase.
Positions, Vacancies, and Positions per 1000 Inmates; 2018 visits
Facility

Wexford and
IDOC staff

Vacancies

% Vacancy

Population

Staff per 1000

98.00
69.00
53.15
93.80
91.10
405.05

24
29
1
19
26
99

24%
42%
2%
20%
29%
23.5%

1183
1681
1806
2298
3029
9997

83
41
29
41
30
41

SCC
NRC
LCC
Dixon
MCC
Total

While budgeted staffing increased at three of five facilities we visited, it decreased at two of
five facilities. There are 44 additional staff working at these facilities than there were when the
2014 report was written.
Four of five facilities we visited had significant vacancy rates, as high as 42%, which are mostly
nursing staff. Almost every HCUA told us that there were insufficient nursing staff. This was
confirmed in the deposition of the Agency Medical Coordinator, who noted that over the past
several years there have been nursing shortages at SCC, Pontiac, Decatur, Graham,
Southwestern, and MCC.66
Most HCUAs told us that if all their positions were filled they believed that there would be
adequate staff. We do not agree. The IDOC has not performed a staffing analysis based on
expectations of the Administrative Directives and special care needs, including infirmaries and
geriatric care. Relief factors have not been included in staffing considerations and budgeted
staffing numbers do not appear to be adequate. In our opinion, despite increased nurse
budgeted staffing and even when vacancies are filled, there will still be nursing shortages. The
IDOC, in their comments on our report, assert that the IDOC in the current fiscal year and
Wexford in the past year spent a total of $8,283,718 on overtime wages. We acknowledge that
this is a significant expenditure. Based on our investigation, overtime is used to cover some but
not all vacant shifts. However, reliance on overtime contributes to staff fatigue, increased
errors, staff dissatisfaction and turnover as well as higher incidence of poor patient outcomes.67
While we did not evaluate working conditions for staff, we did find ample evidence of error and
Dixon appears to have had a significant increase in staffing, but as the HCUA related to us, this is artefactual, as 22 nurses
were moved from the mental health program to the medical program but still had assignments in mental health. Their
reassignments did not create increased staffing for the medical program, but gave the impression that there had been a large
increase in staffing. If these 22 nurses are removed from the Dixon staffing, the actual increase in staffing would be 79.64
positions or a 26% increase, not a 33% increase.
66 Deposition of Kim Hugo, Agency Medical Coordinator pp. 25-31, April 11, 2018.
67 Institute of Medicine (2004) Keeping Patients Safe: Transforming the Work Environment of Nurses. National Academies Press,
Washington, D.C., Stanton, M. (2004). Hospital nurse staffing and quality of care. Agency for Healthcare Research and Quality.
Research in Action, Issue 14.
65

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poor patient outcomes in our review of health care provided to IDOC prisoners. The use of
overtime does not change our opinion that a staffing analysis is needed or that there is lack of
adequate staffing.
The Wexford component of staffing is memorialized in a contract document called a Schedule
E. Based on interviews with senior leadership of Wexford and IDOC, we could not determine
who is responsible for developing staffing levels found in the Schedule E. The Wexford Vice
President of Operations told us that the Schedule E staffing is the recommended staffing of the
IDOC to which the vendor can make suggestions. Mr. Brunk, the Chief Financial Officer, told us
that the Schedule E is developed by the Wexford Regional Manager and reviewed by the IDOC
Office of Health Services. The Agency Medical Director told us that he had input into the
Schedule E for new facilities but otherwise had no input into the Schedule E, and that Mr. Brunk
or Wexford developed the Schedule E, which the Office of Health Services approved. The Chief
of Programs and Support Services, who is the health authority, told us that the Agency Medical
Director was responsible for development of the Schedule E. Development of the Schedule E is
not in the job description of the Agency Medical Director. The lack of a central health authority,
we believe, contributes to this confusion. Furthermore, the Schedule E as represented in the
current contract does not include input from HCUAs, Regional Coordinators, or even the Agency
Medical Director in addressing clinical needs in their facilities. Given these responses, it is our
opinion that the Schedule E does not reflect actual staffing need, as it does not appear based on
any staffing analysis we could identify after discussions with health leadership who we thought
would be responsible for this document.
No one we spoke with has responsibility for determining if total staff (state and Wexford) is
adequate. The IDOC Agency Medical Director and the Agency Medical Coordinator told us that
an Assistant Warden of Programs (AWP) from Sheridan, who also was a nurse, was engaged in
analyzing staffing at various sites, but the extent of this analysis was not known to the Agency
Medical Director. The Illinois Nursing Association (INA) is the union for the registered nurses in
the IDOC. The Agency Medical Coordinator participates on an INA standing committee that
meets monthly to discuss INA related nursing issues. The INA has raised issues with respect to
staffing at certain facilities. When this occurs, the AWP from Sheridan performs a staffing
analysis, brings it to the standing committee, which then considers staffing recommendations,
and forwards them the Agency Medical Director for review. Other than this effort, we could
identify no analysis of staffing need state wide.
Based on conversations with senior IDOC leadership, staffing increases at NRC and SCC were a
result of union negotiations. Senior IDOC Office of Health Services staff were not involved in
this decision,68 although a Regional Coordinator gave recommendations on how many nurses
were needed. These increases were not based on a thorough staffing analysis, as relief factors
were not used and because no positions other than RN positions were considered. At no facility
has there been an analysis of staffing need based on adherence to the Administrative
Directives. This creates a gap between clinical need and staffing levels that affects all facilities.
68

See pages 14-16 of deposition of Kim Hugo, Agency Medical Coordinator, April 11, 2018.

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Because we only visited a small number of facilities, the true staffing deficiency is unknown.
The program should undertake a staffing analysis, considering all job classifications with relief
factors. This was a recommendation of the First Court Expert and we agree with that
recommendation. This analysis should not be performed by a custody person and probably
should be performed by an outside expert.
We noted at four sites there were inadequate supervisory nurses. At MCC, SCC, Dixon, and LCC,
we felt that budgeted supervisory nurse positions were inadequate. At Dixon, SCC, and LCC, the
HCUA provides some nursing supervision due to vacancies.
Custody staffing was not addressed by the First Court Expert. At several facilities we visited,
there were issues related to insufficient officer staffing to properly accompany nurses in
medication administration or to escort patients for scheduled appointments. While we did not
study this in depth and lack the ability to review officer staffing, the numbers of officers need to
be sufficient to ensure that medical services can be timely and appropriately provided. For this
reason, we believe that officer staffing with respect to medical services needs to be studied and
additional officers hired as indicated.

Statewide Use of University of Illinois
Current Findings
The First Court Expert did not address services provided by University of Illinois at Chicago
(UIC). UIC provides laboratory services statewide. We found no problems with laboratory
services at any facility we visited. UIC also provides HIV and some hepatitis C services via
telemedicine statewide. Everyone we spoke with commented on the high quality of these
services. All patients with HIV are scheduled for care by UIC clinicians. The First Court Expert
found that coordination of care between UIC and IDOC providers could be improved. We agree,
but found that overall when patients are referred, care was of very good quality.
For hepatitis C, IDOC physicians evaluate patients with hepatitis C in a hepatitis C chronic clinic.
We found that these clinics were not performing well. When patients reached a level of fibrosis
that is equivalent to stage 3 fibrosis, the IDOC physician refers the patient to a Wexford
internist, who evaluates whether the patient should be referred to UIC and whether any other
testing needs to occur. In our opinion, this process only serves to delay access to hepatitis C
care and we found multiple cases of delayed hepatitis C care that caused harm.
Furthermore, because IDOC physicians lack primary care training, they appear to not know how
to manage cirrhosis. There is no evidence that patients with cirrhosis from hepatitis C obtain
timely baseline esophagogastroduodenoscopy (EGD) to screen for varices or every six month
ultrasound screening for hepatocellular carcinoma, which is a standard of care. We noted on
death reviews a patient who died of bleeding varices who never had an EGD to screen for this
condition.

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As a result of these problems with referral for hepatitis C, it is our opinion that fewer people are
treated than who should be treated based on barriers to referral for care. Once engaged at UIC,
care appeared appropriate.
What was clear in reviewing the program at UIC was that credentialing of physicians is part of
the hiring process at UIC and all physicians are qualified. Progress notes are reasonable and
clinically adequate. Referrals are appropriate. There were no identified errors. The UIC medical
school correctional program is a significant resource that has potential to provide qualified
physicians to the IDOC correctional medical program. The UIC School of Medicine has a
subsidiary school of medicine in Rockford which has a significant primary care program. The
Southern Illinois School of Medicine is also a potential significant resource which is close to
many of the southern Illinois prisons. As we will discuss later in the recommendations, we
believe that the UIC program or some combination of state affiliated medical school programs
can be the basis for improving physician quality in the IDOC system of care. This needs to be
carefully explored. The UIC program also has potential to provide dialysis services. Telemedicine
services can include specialty care some of which can reduce but not eliminate the need for
transportation of inmates for offsite encounters. We believe that an affiliation with a university
based program like UIC can reduce some costs by use of 340B pricing discounts.69 The IDOC
would be remiss in not exploring these options.
We note the UIC and SIU both have dental schools, which is a potential resource for oversight
functions and possibly for direct service provision.

Statewide Overview of Major Services
Clinical Space and Equipment
First Court Expert Findings
In the final report, the First Court Expert noted that clinical space, sanitation, and equipment
were problematic at virtually every facility. The report noted facilities that lacked designated
space to conduct sick call in the housing units, did not have the clinical equipment needed to
perform adequate examination and screening, and had examination areas that did not allow
sufficient privacy or confidentiality during clinical encounters. There were nurse sick call and
provider clinical spaces that did not have examination tables. In housing units without
designated sick call rooms, nurses performed sick call duties at the cell doors without any
potential for confidentiality and no opportunity to perform an adequate physical examination if
so warranted.
System wide deficiencies in sanitation were identified. In many facilities, examination tables
and stools, infirmary mattresses, and stretchers had cracked or torn impervious outer covers
69

340B pricing is a government sponsored price discount on pharmaceuticals that can be provided to disproportionate share
hospitals that provide care to underserved populations. 340B pricing is currently used for the HIV/hepatitis C telemedicine
program.

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which did not allow proper cleaning and sanitation. Many facilities were not using paper
barriers on exam tables which could be changed between patients nor, alternatively, was there
evidence that the tables were cleaned with a sanitizing solution after each patient use. Some
clinical examination rooms lacked handwashing sinks.
Current Findings
The experts inspected the physical plants and equipment in the medical care areas at the NRC,
SCC, Dixon, LCC, and MCC. Overall, we found problems with nurse sick call rooms, infirmary
spaces, and examination rooms in all facilities we visited. The dialysis unit at SCC is inadequate
and needs renovation. These problems detracted from the ability to provide care.
Nurse Sick Call Rooms
The nurse sick call rooms in three of the five facilities have been situated in the housing units to
increase access to care. In two facilities, the sick call rooms are located in a centralized health
care building.
NRC has established nurse sick call rooms on the first floor of each of the three tiered cell
houses. These rooms are also used by providers to perform intake physical examinations that
were deferred during the intake process. Nurses commonly do sick call interviews cell by cell
through closed doors, moving some patients to the sick call rooms, which have a few plastic
chairs or four bolted metal chairs with shackles. The sick call rooms do not have examination
tables or desks, and all clinical equipment is carried in the during sick call session. Not all rooms
have sinks or soap and paper towels. The sinks were dirty and the floors poorly scrubbed. In this
condition, these rooms are unacceptable for the performance of nurse sick call or provider
intake physical examinations.
SCC established nurse sick call rooms in the all six housing units. The rooms are adequately
sized and equipped, having examination tables with paper rolls. The oto-ophthalmoscopes in
two of the six rooms were not functioning. These rooms were generally clean and organized.
One room did not have a sink but sanitizing hand gel was available for hand cleaning.
Dixon primarily provides nurse sick call in two dedicated and two part-time rooms in the
centralized health care unit (HCU). (There were two additional satellite sick call rooms in the
distant disciplinary segregation building). One nurse sick call room in the HCU had two desks
and two exam tables; this room lacked any auditory and visual privacy. The other three rooms
did not have examination tables. Only two of the four rooms had sinks. Having two exam tables
in one room and none in the other three is a barrier to the delivery of care and does not allow
for adequate privacy and confidentiality.
LCC provides nurse sick call in the ambulatory care wing of centralized health care building. Two
exam rooms and occasionally a third room were utilized for nurse sick call; all had sinks and
were adequately equipped. The exam tables had small tears in the upholstery and one otoophthalmoscope was not functional. Due to the need to share the examination rooms with the

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provider staff, there were times when there were not enough exam rooms to meet the nurse
sick call needs of the women at LCC.
MCC has established seven clinical examination areas in the facility’s cell houses that are used
for daily nurse and intermittent provider sick call and chronic care. In cell houses with only a
single examination room, nurse sick call and provider clinics cannot be provided simultaneously
and have to be separately scheduled so as not to overlap. The condition of these satellite clinics
varied from cell house to cell house. Some rooms were well maintained, others had cracked
and peeling paint, uncovered electrical outlets and ceiling vents, boxes cluttering the exam
area, and records and supplies stacked on exam tables during clinical sessions. One of the exam
areas did not have a sink. Not all of the areas were properly equipped; some lacked otoophthalmoscopes, oximeters, peak flow testing mouthpieces, blood sugar testing devices,
automated external defibrillators, and other supplies. One of the exam rooms in the East cell
house was cramped by the presence of correctional items, including three large file cabinets,
water damaged cardboard boxes, and an ancient refrigerator with a totally rusted door
Unsealed emergency bags were found in a number of the clinical spaces.
Infirmary Space
NRC opened a 12-bed medical infirmary in 2016. The nursing station is in a converted storage
closet with no sink, no electrical outlets, no phone, no computer, and only one desk for two to
three nurses. The size and condition of this nurse station hampers the efficiency of the
infirmary nursing staff. There were functioning patient nurse call devices at each infirmary bed.
The monitoring panel in one of the two negative pressure isolation rooms was not operational.
Even though the majority of the patients housed in the medical infirmary were chronically ill,
and had clinical issues including frailty, disability, ambulation deficits, inability to provide selfcare, or bladder or bowel incontinence, there were no adjustable hospital beds with safety rails
in the infirmary. Many of the mattresses had torn covers and could not be properly sanitized.
One patient with urinary incontinence had an uncovered porous foam egg crate cushion in lieu
of a mattress that was odiferous, dirty, and could not be cleaned and sanitized. The weekly
supply of clean linens was insufficient to meet the needs of the infirmary patient population of
incontinent, diapered patients who frequently soil their sheets. The medical infirmary rooms
were shabby and unacceptably dirty.
The SCC infirmary’s nursing station’s design does not allow direct line of sight of any of the 32
patient beds. Functional nurse call devices were in all of the two-bed rooms but not in the
single bed medical rooms. The HEPA filters and negative pressure units in both the isolation
rooms were non-functional; its filters and vents were clogged with dust. Low, fixed position
beds were not suitable to allow appropriate examination or to meet the clinical needs of the
patients housed on the infirmary. The head and leg sections could not be raised or lowered,
beds had broken wire springs, and safety railings were broken. The condition of the infirmary
beds created a safety hazard for the staff and patients. The tub room had large cracks in the
floor and no safety grab bars, rendering it unusable. The rooms were inadequately cleaned. The
cleanliness of the room varied based on the ability of the individual patients to assist with
cleaning their rooms. Elderly, physically and mentally impaired individuals who were unable to
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assist with cleaning their rooms had unacceptably dirty rooms. Only a single room with two
more physically fit patients was judged to be adequately clean. Flies, gnats, and cockroaches
were noted in patient rooms and in the corridor.
Dixon’s second and third floors contain the infirmary, ADA housing unit, and the geriatric
housing unit. The building’s two elevators were broken; one had been disabled for a long time
and the other had become non-operational on the day before the expert’s visit. The
malfunctioning of elevators created a major potential safety threat to the expeditious
evacuation of these floors, given the clinical condition (elderly, frail, bedridden, physically
ambulation impaired, etc.) of the patients housed on the health care building’s upper floors.
Most of the infirmary beds were functional, second-hand hospital beds with intact mattresses
and adjustable sections. However, one patient with dementia had a broken bed with a middle
section that sagged nearly to the floor. The infirmary rooms had nurse call devices and the
negative pressure unit in the isolation room was functional. The ADA and geriatric units have
fixed metal frame beds without adjustable sections with metal wire mattress supports. The
wire mattress supports were commonly broken and replaced with strips of sagging tied bed
sheets. The fixed metal beds must be replaced with more suitable beds; these beds are
inadequate and put the safety and health of the geriatric patients at risk. Peeling paint, cracked
wall plaster, rusted, dusty vents, and poorly ventilated showers were noted on both floors. As
throughout the entire health care building, floor tiles are cracked and loose; this is major safety
hazard for staff and the at-high-risk-for-fall patient population.
LCC’s infirmary occupies one wing of the health care building. Relatively new hospital beds in
excellent condition with adjustable height and head and leg sections were in all of the single
(non-crisis) and double bed rooms. There were nurse call devices next to all the medical beds.
The unit was clean and well organized. Both of the negative pressure units and the monitor at
the nurse station were not functional, even though the nursing logs had previously indicated
that they were operational.
MCC’s infirmary is located on the third floor of the centralized health care building and can be
reached by stairs or a single elevator. Overall, the infirmary was clean and in good repair. The
heavy doors to the patient rooms are kept locked with individual padlocks. This is a safety
hazard because emergency evacuation of the infirmary would be significantly delayed due to
correctional staff having to open each of the padlocks. These padlocked rooms are also a safety
hazard because there are no nurse call devices in any of the infirmary rooms; patients who are
able to ambulate have to bang on the doors to get medical attention. Patients unable to
ambulate have to call for help. The nurse station is in an enclosed room that is not within sight
or sound of the patient rooms. Twenty three of the 26 beds were low, fixed-position metal beds
without safety railings or adjustable heights and head and leg sections. The low to the ground
fixed position beds made it difficult and even unsafe for the staff to properly examine and
transfer patients into and out of bed. One patient with risk for falls slept on a mattress on the
floor because there were no available beds with safety railings. The negative pressure units
were operational, but the anterooms in these isolation rooms were cluttered and had
overflowing waste bins. The shower room used by the infirmary’s chronically and acutely ill
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patients did not have safety grab bars; the ceiling vent in the shower rooms was clogged with
lint and dirt.
Health Care Unit Space
The NRC health care unit did not have a sufficient number of exam rooms to accommodate the
facility’s four providers and the monthly UIC telemedicine specialty team. There are sessions
when one provider has to be shifted into a cluttered interview/storage room without an
examination table or clinical equipment. This is inappropriate for the use by clinical providers.
Two additional examination rooms are needed to assure that access to clinical care is not
hampered by the lack of examination space. The three exam rooms have non-adjustable exam
tables and none had paper rolls. Sinks in all the rooms were crusted with mineral deposits, and
uncovered paper memos were taped on the walls, creating a fire safety hazard. The wall
mounted oto-ophthalmoscopes were non-functional in every exam room and in the treatment
room. One portable scope was shared by the providers. Even though many infirmary and
general population patients have physical disabilities, there was not a single adjustable exam
table or an electric table in the clinic.
SCC’s health care unit was reasonably clean and organized. The unit had two provider exam
rooms and a telehealth room; if needed, the adjacent treatment room was used as a third
provider room. The four-chair hemodialysis suite was in deplorable condition, with peeling
paint; dirty, unbuffed floors; standing water on the floor of the deionization room; and an
uncovered waste container. The front of refrigerator door was totally rusted and impossible to
sanitize. The suite, deionization room, and the storage areas were cluttered, creating a safety
and fire hazard. The space of the suite did not allow for the required separation of the hepatitis
B infected dialysis patients. A very few of these egregious deficiencies had been noted on
Monthly Safety and Sanitation reports, but no action had been taken by IDOC, Wexford, or the
dialysis vendor to expeditiously correct these problems. The Hemodialysis Unit does not meet
the community standards of care or the CDC guidelines for prevention of the infections in
dialysis units (Reference CDC, Recommendations for Preventing the Transmission of Infections
among Chronic Dialysis Patients). The Hemodialysis Unit should be closed until all these
deficiencies in the physical plants and practice have been corrected; these conditions would not
be tolerated in community dialysis centers.
Dixon’s health care unit on the first floor of the health care building had three adequately
equipped provider examination rooms with an additional telehealth room. There were
sufficient exam rooms to accommodate all three providers at the same time. One of the
examination tables did not have a paper roll. The provider offices in an adjacent corridor were
reportedly to allow access to electronic medical references. The HCU was generally clean and
well maintained; however, as in the entire health building, there were cracked and missing floor
tiles throughout the first floor. This is a safety, sanitation, and infection control concern for
patients and staff.
LCC’s ambulatory health care unit occupied one wing of the health care building. Provider
chronic care clinics, provider sick call, and OB-gynecology specialist clinics, along with nurse sick
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call, are co-located in this area. The five examination rooms are not adequate to accommodate
the 7.5 budgeted full-time equivalent providers and nurses assigned to provider and nurse
clinical sessions. All of the examination rooms are adequately equipped; one otoophthalmoscope was not operational. One room did not have a sink, two of the five rooms did
not have a paper barrier on the exam table. Emergency jump bags are kept in the health care
unit and in a car used to transport nurses to distant cell houses on this large campus; these bags
were noted to be unsealed. The facility’s failure to restock and reseal the emergency bag after
every use jeopardizes the next response to an emergency on the campus.
MCC’s health care building’s first and second floor houses radiology services, telehealth room,
nurse staffed treatment room, dental suite, optometry, physical therapy, and support and
administration offices. Nurse and provider sick call and chronic care clinics formerly provided in
the four exam rooms on the first floor have been relocated to the cell houses. With the
exception of the telehealth room, the examination rooms are not well maintained; examination
tables and chairs have torn upholstery, oto-ophthalmoscopes were not functional, one of the
rooms was cluttered with supplies. These rooms are used intermittently for nurse sick call and
treatment room overflow, and should be kept in operational condition.

Medical Records
Methodology: We toured medical record areas, interviewed medical records personnel, and
reviewed medical records.
First Court Expert Findings
The First Court Expert found the quality of medical records poor at most facilities visited. This
included problem lists not updated and cluttered with redundant, irrelevant information. MARs
were incompletely filled out. “Drop filing” occurred mostly at NRC and LCC. The IDOC fails to file
health requests in the medical record. Progress notes often contain no information with respect
to history, examination, or clinical decision making. Illegible handwriting made many notes
unreadable and unusable, except by the author.
Current Findings
LCC has corrected the problems with drop filing. With that exception, there has been no
improvement. We found several additional significant problems. These include:
• With the exception of MCC, charts are so large that they frequently come apart, making
the record extremely difficult to use. This promotes loss of documents.
• Record rooms are too small to accommodate all records. Therefore, additional storage
space is necessary, making finding an older document extremely cumbersome.
• Record rooms are not secure and therefore violate Administrative Directives and fail to
follow Illinois Department of Human Services guidelines on protection of the medical
record.
• There is not a standardized tracking system in place to sign out a record.

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•
•
•
•
•

Any staff member can access the records room and pull and re-file records. This
promotes loss of records and does not safeguard confidentiality or use by unauthorized
persons.
Access to a medical record for use during clinical encounters is not universal.
Data for use in quality improvement is obtained manually. This makes measurement of
health care processes extremely cumbersome.
We noted inability of the IDOC to find all documents in mortality records sent to us.
Records of on-site dialysis are maintained separately from the IDOC medical records and
the medical record fails to contain updated information about what is occurring in
dialysis.

At the time of the First Court Expert visits in 2014, the IDOC was in the process of implementing
an electronic medical record. This effort started at LCC and Decatur, the only two female
facilities. The record was incompletely implemented; the electronic MAR was not implemented.
After part of the electronic record was implemented at LCC and Decatur, the electronic record
project was aborted. We did note on our review at LCC that there were some serious problems
with the electronic record. This record defaults vital signs from the last vital signs obtained. The
record will automatically present vitals in a note from months previous if no more recent vital
signs were done. This is dangerous and should be stopped, as it is a patient safety issue.
The IDOC is considering implementation of a different electronic record. The IDOC has placed a
custody Deputy Director in charge of the project to implement an electronic medical record. It
is our opinion that someone with medical expertise and medical record expertise should head
this effort, not custody personnel. No funding has been provided for this project.
A correctional health program generates large volumes of paper. Infirmaries, mental health
units, the health request process, and administration of medication are hospital-like with
respect to the volume of paperwork that is generated. As a result, inmates who remain
incarcerated for a long period of time generate massive paper medical records. Three problems
ensue. One problem is that there is no place to store all the paper record volumes so that they
are easily accessible. A second problem is that the paper record comes apart, making use of the
documents contained therein extremely cumbersome. The third problem is that the current
volume of documents often does not contain all of the documents necessary to provide care.
This can result in physicians acting without complete information about the patient. This is
particularly true because of the frequency of changes in physician staff.
Almost all inmates with chronic illness or with mental health problems have multiple volume
files, easily in the thousands of pages per inmate. Record rooms in the prison facilities do not
have the capacity to store all volumes of the record. As a result, most of the volumes of records
are placed in storage someplace on the grounds of the facility, but not always close to the
medical unit. The most current volume of a record often does not contain a key test result,
consultation report, hospital summary, or diagnostic test result that is necessary to understand
the progress of the patient. In our own review of records, we had to frequently ask for
additional volumes of the record. When this occurs, clerks have to go to the storage unit to find
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the document. This delay is not workable if a provider is with the patient. The entire patient
record should be available for use, but this would be exceedingly impractical using a paper
record.
Also, the paper medical records frequently come apart. All paper documents are two-hole
punched and held together by a plastic binding clip. The plastic clip is glued to a pressboard
binder that is used for covers of the record. These covers are expandable. The thinning process
is standardized except for when to initiate the thinning process. By IDOC rules, certain
documents are carried forward to the current volume. The carry-forward documents often do
not include critical test reports, consultation reports, or other clinical information that is critical
to understanding the patient’s diagnosis or therapeutic plan. Other than MCC, the IDOC has no
rule on when to thin the record. Several facilities allowed records to expand well beyond two
inches. One facility told us they could not afford to purchase the pressboard covers, so charts
were not thinned when they should have been.
There are major problems with this process. Medical record volumes that may contain
important information are not easily accessible. A newly thinned record may have insufficient
medical record documents to properly care for the patient. Medical record volumes that are
not thinned come apart. The plastic clips come undone and the clinician is left with a pile of
paper that can easily become misplaced in the medical record. This promotes poor care.
None of the facilities we visited had a completely secure record room. Medical records are
considered confidential and must be secure. The Illinois Department of Human Services
guidelines for providers in maintaining a medical record state that medical records must be
maintained in accordance with accepted medical standards which require confidentiality,
secured by lock when not in use, and safeguarded against loss or use by unauthorized
personnel.70 Typically, when paper records are used, staff maintaining the record must keep the
records in a locked room to which no one except authorized medical record employees have
access. Records are pulled by medical records staff only. When a record is pulled, a placeholder
is inserted into the space where the record was, containing information on where the record is.
After-hours record use is strictly managed so that only authorized persons are permitted in the
records room. None of the facilities we visited ensured that this happened at all times and in all
circumstances.
The NRC record room was the worst of all facilities. Everyone had access to the record room.
Any staff member could pull and refile records they used. Paper documents were not in a
pressboard folder and sometimes were merely stapled together or in piles. When a pile of
record documents was removed from the room, there was no indication where the record was.
In chart reviews we conducted, it appeared that many documents were missing.71 This
arrangement is a patient safety hazard and needs to be corrected as soon as possible. We were
Illinois Department of Human Services website as found at http://www.dhs.state.il.us/page.aspx?item=40657.
We noted on four mortality records that there were parts of the record that were missing that made it impossible to evaluate
the death. These records included Mortality Review Patient #11 from SCC/NRC; Mortality Review Patient #12 SCC/NRC;
Mortality Review Patient #16 SCC/NRC; and Mortality Review Patient #31 Illinois River.
70

71

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told that the State had funded additional clerical positions for this unit. However, the room size
is so small that we do not believe that the room can accommodate any additional employees.
This process will require significant work to remedy.
Some patient encounters occur without a medical record; this mostly pertains to nursing sick
call at MCC and NRC. All patients need to be seen with a medical record. When patients are
seen without a medical record, nurses write their note on a blank progress note without benefit
of review of the patient’s current problems, medications, or other significant information. The
progress notes are filed later. This is inappropriate medical care and is likely to lead to mistakes,
placing patients at risk of harm. All nursing and provider evaluations must occur with a medical
record.
Some of the First Court Expert’s findings are a result of use of a paper medical record and some
are staffing and practice issues as well as medical record issues. The First Court Expert found
deficiencies with problem lists. Problem lists are easier to maintain in an electronic record than
in a paper record. However, in both electronic and paper records, the quality of the problem list
is directly related to medical staff participation in maintaining it. The failure to maintain the
problem lists in IDOC is a failure on multiple levels. Leadership has not instituted standardized
practices with respect to who can enter a problem on the problem list. When providers do not
work to place accurate problems in a standardized methodology on the list, the list also
becomes inaccurate. While this problem is easier to correct with an electronic record, it is a
matter of leadership, supervision, and practice, and is related to personnel and practice issues
rather than medical record issues.
Incomplete MARs can be a staffing or process problem. When there are insufficient nurses to
administer medications, the records can be incompletely filled out. Also, the practice of
recording medication administration hours after medication has actually been administered,
which occurs at several sites we visited, will result in inaccurate entries. This appears to be a
staffing issue and a process issue. We believe that the burden of using, filing, and reviewing
paper MARs is so great that it alone is a compelling argument for implementation of an
electronic medical record. If paper records are to be continued in the IDOC, significant root
cause analysis and process work needs to be done to discover what the problems are so that
they can be fixed.
Paper requests for health care contain the patient’s written complaint that nurses address in
the sick call process. In our opinion, these written complaints are health record documents, as
they describe the patient’s problem. The IDOC does not include these in the medical record and
discards them. These documents need to be included in the paper record or scanned to the
electronic medical record.
The issue brought up by the First Court Expert that many practitioners fail to document a
history, physical examination, or therapeutic plan is not a medical record problem in our
opinion. This is a problem of physician quality. As an example, we noted one physician at SCC
who was a surgeon and not primary care trained who, for six months, was following an
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infirmary patient who had dementia. His entire note for 19 consecutive patient evaluations
consisted of the statement, “No specific complain, no change, dementia, continue same care.”
The patient was ultimately hospitalized for a cardiopulmonary condition but because the doctor
failed to evaluate the hospital record it wasn’t clear why the patient was hospitalized.
Ultimately, the patient developed metastatic colon cancer not diagnosed until the patient had
advanced disease. For almost a year following hospitalization, the doctor wrote the following
note repeatedly, “No specific complaint, no change, dementia, post colectomy for metastatic ca
[cancer]. Continue same care.”
This repeated note was written during a time when the patient experienced falling repeatedly,
developed incontinence, developed pustular otitis, and severe malnutrition and dehydration.
This was negligence and incompetence of the provider and not a result of the medical record.
Many notes failed to contain adequate history, physical examination, assessments, or
development of therapeutic plans. In review of 33 death records, we found 276 episodes of
care with inadequate history; 249 episodes of inadequate examination; and 228 episodes in
which a therapeutic plan was inadequate. In our opinion, this is not a problem with the medical
record, but is a problem of physician quality.
Illegible handwriting is an individual problem which is extremely difficult to correct with a paper
medical record system. We noted problems with legibility at all sites except at LCC, where an
electronic record is used.
We also note that use of a paper record means that accessing data from the record for the
purpose of measuring performance must be done manually. This is extremely cumbersome and
discourages quality investigations. An electronic record can significantly improve data use.
Dialysis is provided by a vendor. Even though dialysis occurs onsite at IDOC facilities, the
records of dialysis are not incorporated in the medical record. We noted at SCC that the
nephrologist will occasionally write a few comments on a referral form but these are not
thorough or fully inform the status of the patient’s condition or treatment. These dialysis
records should either be incorporated into the record or a reasonable complete summary of
the patient’s status and treatment should be provided on a regular basis to update the medical
record.
In summary, there were many problems with use of the paper record that will be difficult to
correct. These include storage of important information due to excessive chart size,
documentation on the MAR, ensuring confidentiality of the record, legibility, and functionality.
It is our recommendation to implement an electronic medical record statewide to include
electronic medication administration functions. The system should be designed and acquired so
that the IDOC has easily accessible data for use in measuring performance. Data analysts who
are expert in obtaining data from the electronic record for quality purposes should be
employed.

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Medical Reception
The medical reception evaluation and treatment plan establishes a baseline for the patient’s
medical, mental health, and dental conditions, and serves as a blueprint for the patient’s care
following transfer to the patient’s parent institution. Failure to identify and treat serious
medical conditions at intake increases the risk of harm to patients and liability to IDOC. Our
review showed that the medical reception process generally occurs timelier since the First
Court Expert report; however, there are persistent issues related to the reliability of various
processes (e.g., TB skin testing) and quality of medical reception evaluations. There are also
issues related to the timeliness of follow-up of serious medical conditions. Our report
confirmed findings of the previous report and identified previously undescribed problems.
First Court Expert Findings
The First Court Expert reviewed three reception centers, noting that the purpose of the medical
reception process is to identify and treat acute and chronic medical and mental health
problems, including communicable diseases, and to identify any special medical needs. The
Court Expert found the following problems:
• IDOC forms do not elicit current symptoms (all facilities).
• Nurse screenings being performed in areas that were noisy and did not provide
adequate privacy (LCC).
• Significant delays in performance of clinician history and physical examinations of newly
arriving inmates, sometimes for more than a month (NRC).
• Lack of integration of TB and laboratory test results into the history and physical
examination so that all medical conditions are timely diagnosed with an accompanying
treatment plan for each condition and documentation on the problem list (NRC,
Menard).
• Medical record disorganization that impeded clinicians’ ability to identify and utilize
clinical information to timely diagnose and treat patients appropriately (NRC).
• Delays in follow-up and treatment of chronic diseases and other medical conditions
(NRC, MCC, LCC).
Current Findings
This review showed that improvements have taken place with respect to the timeliness of
completion of the medical reception process at some facilities (NRC and LCC) but not uniformly
across the system (MCC).
Record review showed that county jails forwarded medical transfer information that was
available to health care staff at the time of arrival. However, NRC providers did not document
that they reviewed the information and, in some cases, missed important medical diagnoses
(e.g., prostate cancer, pancreatic cancer, pulmonic valve regurgitation) or medications for high
blood pressure (e.g., hydrochlorothiazide). One such error resulted in death.
We noted two cases in mortality reviews that included significant problems with failing to
review transfer information or to take an adequate history. In one case, a provider failed to
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take an adequate history of a patient in the midst of getting valve replacement for a congenital
anomaly.72 The provider made the wrong diagnosis, failed to contact the patient’s civilian
doctor, and even failed to read a letter in the IDOC medical record from the patient’s civilian
doctor. As a result of this failure, the patient’s planned surgery was never done, his condition
was unrecognized in IDOC for six months, and the patient died from complications of his heart
condition without having obtained surgery. Another patient from LCC was at Cook County Jail
and was sent to Stroger Hospital for a pancreatic mass. A biopsy was non-diagnostic but the
mass was strongly suggestive of pancreatic cancer and follow up was recommended.73 The
doctor at LCC presumed that the patient had a benign pancreatic mass and no follow up was
initiated for five months. Pain medication history was also not taken and the patient was placed
on inadequate doses of pain medication and suffered in pain over the last five months of her
life.
Medical reception was conducted in clinic examination rooms that were not standardized with
respect to medical equipment and supplies. There was no microscope available at LCC to the
provider to diagnose vaginal infections.
Clinic examination room furniture was often in disrepair (e.g., torn exam table covers) and
needs to be repaired or replaced. Exam tables did not have paper to use as a barrier between
patients and there was no schedule of sanitation and disinfection activities. Exam rooms were
dirty, and in some cases filthy. At NRC, the lack of a water softening system at the facility
(reportedly due to budget issues) results in mineral deposit buildup on sinks and faucets,
making disinfection difficult, if not impossible. At LCC, the nurse and clinician conduct the
medical reception process in rooms that are small and difficult to clean. These conditions
present a risk of infection to patients.
On the day of patient arrival, nurses perform a medical history, TB symptom screen, height and
weight, vital signs, visual acuity, and plant a tuberculin skin test. Phlebotomists draw labs
including hepatitis C and HIV opt out testing. At NRC we found that the scales were not
calibrated.74 Nurses incorrectly measured visual acuity by having the patient sit in a chair to
read the visual acuity chart approximately 10 feet away instead of having the patient stand 20
feet away and testing visual acuity for each eye separately. NRC nurses incorrectly read
tuberculin skin tests by having the patient show his arm in the cell window rather than
palpating the patient’s arm for induration. Tuberculin skin test results were not consistently
documented in the health record. At LCC, nurses did not document urine pregnancy testing on
all patients of childbearing age upon arrival.
Lab tests performed as part of intake screening routinely include serum chemistry, syphilis, and
opt-out hepatitis C and HIV testing. Although HIV is supposed to be opt-out,75 the
72

Mortality Review Patient #2.
Mortality Review Patient #20.
74 One of the experts stepped on two scales which gave a 10 pound discrepancy between the scales.
75 Opt-out testing means that testing will be performed unless the patient refuses the test. Opt-in testing means that the
patient is offered testing and is performed only upon patient consent.
73

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Administrative Directive (AD) requires that consent be obtained before drawing blood for HIV,
which essentially renders the process as opt-in.76 Opt-out testing is recommended by the
Centers for Disease Control because it supports early identification and treatment. Data shows
that significantly fewer inmates are being tested for HIV than hepatitis C infection.
A nurse performs the medical history. The IDOC Offender Medical History form is limited with
respect to chronic diseases and does not include COPD, thyroid, kidney, liver, autoimmune
diseases, or cancer. Importantly, as noted in the previous Court Expert report, the form also
does not include a section for review of systems (e.g., chest pain, shortness of breath,
abdominal pain, blood in stool, difficulty with urination, etc.) that are typically included in a
comprehensive history and physical examination. This poses a risk that important medical
diagnoses or symptoms of serious illness will be missed and not medically evaluated, increasing
risk of harm to the patient.
The IDOC Offender Physical Examination form (DOC 0099, Rev. 11/20/12) includes a section for
substance abuse, risk factors for blood borne infections (e.g., HIV and HCV), and TB symptoms,
but does not include a section for chronic disease pertinent review of systems (e.g., chest pain,
SOB, polyuria, polydipsia, neuropathy, etc.), which contributes to the assessment of disease
control.
The timeliness of clinician history and physical examinations has generally improved. At NRC
and LCC, a medical provider saw patients with acute or chronic diseases within 24 hours of
arrival. At MCC, only 60% of examinations took place in seven days or less. Although timeliness
of physical examinations has generally improved, clinicians did not consistently elaborate on
positive findings noted by the nurse,77 and the history and physical examinations were often
cursory and lacking in quality. Because nurses complete the patient history, providers generally
do not complete a thorough history leaving a gap of information about the patient’s illnesses. In
many cases, NRC clinicians simply noted the patient’s diagnosis rather than perform a medical
history, review of systems, and assess the patient’s disease control. At LCC, record review
shows a physician assistant was conscientious and did an excellent job.
Providers wrote orders to enroll patients into the chronic disease program in 30 days and
assigned patients low bunk/gallery status as clinically indicated. At NRC, providers also ordered
diagnostic tests (e.g., chest x-ray, EKG) and labs for some chronic diseases (e.g., thyroid,
anticoagulation), but did not order HbA1C for any diabetics. At NRC, medical provider orders
(EKG, chest x-ray, blood pressure monitoring, etc.) were not consistently implemented by
nurses.
Clinicians usually ordered medications on the day of arrival; however, in some cases they did
not provide continuity of care with respect to patients’ chronic disease medications, either
omitting or changing medications (e.g., insulin types) without documenting a clinical indication.
76
77

Administrative Directive 04.03.11 Section5 II. F. 5. D.
MCC Medical Reception Patients #12, 13 & 14.

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MARs did not consistently reflect that the patients received the medications. At NRC, nurses
gave some patients blister-packed medications from stock supplies but did not create a MAR
and document that it was given to the patient. In some cases, nurses documented giving
medication to the patient on the physician order form, but in other cases there was no
documentation that the patient received the medication.
A clinical concern is that at NRC, three patients were being treated for heroin withdrawal at the
time of admission, but the provider did not order Clinical Opiate Withdrawal Scale (COWS)
monitoring to assess whether the patients’ symptoms were improving or worsening, and that
may have required changes in medication withdrawal regimens.
We observed a NRC dentist perform dental screening examinations without changing gloves
between patients (See Dental Section).
With respect to follow-up, medical providers did not timely address abnormal lab test results
and did not complete the initial chronic disease form when seeing patients at the first follow-up
visit.
There are no mechanisms in place to monitor timeliness of the intake process or to evaluate
the quality of intake screening, the health history, or physical examination. There were no CQI
studies provided that indicate the intake screening is monitored for quality or timeliness. This is
a high volume, high-risk area of health care delivery in the correctional setting and should be
regularly reviewed as part of the CQI program.78

Intrasystem Transfer
Our report confirmed findings of the previous Court Expert report and identified previously
undescribed problems. Overall, we find that the timeliness of medical screening following
transfer has improved, but there continue to be problems with the completeness of the forms
and continuity of care following transfer. We also found that the CQI program does not
consistently address continuity of care provided following intrasystem transfer.
First Court Expert Findings
The previous Court Expert found problems with the intrasystem transfer process at almost
every facility resulting in discontinuity of care (e.g., medications, chronic disease follow-up). At
Dixon, the process was so broken that despite having a special medical mission, nurses did not
perform the process for two to three weeks after patients’ arrival, resulting in discontinuity of
care. The Court Expert also found that continuity of care following intrasystem transfer is not
studied to identify and correct problems.
Current Findings

78

National Commission on Correctional Health Care. 2014. Standards for Health Services in Prisons. Pp. 13-14.

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IDOC Administrative Directive 04.03.103, Offender Health Care Services, does not include a
policy and procedure for how custody and health care staff are to conduct the intrasystem
transfer process. SCC Operations Policies and Procedures includes a Transfer Screening policy
that is consistent with NCCHC Standards for Health Care Services in Prisons (P-E-03). However,
the policy is not site-specific with respect to how custody notifies health care staff of inmates
who are transferring into and out of the facility, which health care staff performs medical
screening, how patients are to be enrolled into the chronic disease program, and the procedure
for providing continuity of medications.
We found that institutions did not use a tracking log to document completion of required
services following transfer into the facility (e.g., enrollment into the chronic disease program,
periodic health assessments, etc.).
NRC does not receive a large volume of patients transferring into the facility. Inmates who
transfer into NRC are typically scheduled to go out to court or receive specialized medical
services in the Cook County area. At the time of our review there were 29 inmates at the facility
for greater than 90 days. Of this number, 12 were for medical reasons, 12 were for parole
board hearings, two were boot campers, two were pending WRITS and one was for discharge. A
review of five records showed that all patients were timely seen upon arrival, but one of three
eligible patients was not timely enrolled into the chronic disease program.
Transfers to SCC average less than 50 per month. Inmates received on transfer are brought to
urgent care in the health care area for nurse screening before placement in population. The
nurse reviews the sending facility transfer form and inquires if the inmate is currently receiving
treatment or has any other immediate need for medical attention. The nurse then schedules
the inmate for subsequent health care (i.e., enrollment in a chronic care clinic, initiation of
medications, etc.) as needed. The nurse also provides a verbal explanation and handout about
how to access health care at the facility.
SCC does not keep a log, list, or other method to track inmates received on transfer. A sample
of 12 records was obtained from other sources. Ten of these inmates had health care
requirements that needed continuation at SCC. The transfer process was complete in seven of
the 10 charts reviewed of inmates with ongoing health care needs. One transfer summary did
not list psychotropic medications that were prescribed, but these were identified by the nurse
upon review of the chart and continued.79 In another, there was no transfer summary for an
inmate with diabetes and hypertension. The nurse who reviewed the chart noted his medical
history, enrolled him in chronic care and ensured that his medications were continued.80 In
another chart reviewed, an inmate on prescribed psychiatric medications was not scheduled to
see a provider urgently and no other attempt was made to continue medication upon his arrival
at SCC.81 Transfer screening at SCC has improved since 2014. However, record review revealed
SCC Intrasystem Transfer Patient #11.
SCC Intrasystem Transfer Patient #12.
81 SCC Intrasystem Transfer Patient #10.
79
80

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that for 30% of the inmates requiring continuity of care, transfer information was incomplete or
care was not provided as prescribed. Continuity of care upon transfer needs to be more
reliable. At SCC, the First Court Expert recommended that the CQI program address the
intrasystem transfer process with respect to continuity of care. However, CQI minutes and
related material for the calendar year 2017 showed no reports monitoring the continuity of
care following transfer.
At Dixon, the process has improved since the previous Court Expert’s report. All transferred
inmates are brought to the dispensary upon arrival at DCC. Registered nurses review the
transfer summary, take vital signs, and conduct a brief screening interview to identify any
immediate medical needs and reconcile prescribed medications so that treatment can be
continued. Each inmate receives an individual explanation from the nurse about how to request
health care attention for urgent and routine medical needs. The next day these inmates are
seen again by nurses, who complete a lengthier interview using the intake screening questions
and review the medical record. At this encounter, the nurse ensures the problem list is up to
date, completes any screening not done at intake, and identifies any pending referrals or
appointments. Inmates who have chronic diseases are enrolled in chronic care clinic, and
medication, treatments, and labs are ordered. At this second encounter, the nurse answers any
questions and confirms the inmates’ understanding of how to request care, procedures to
receive KOP and pill line medications, and obtain refills.
A review of eight records showed opportunities for improvement. In two cases, the transfer
summary did not include the name of the sending facility and information on TB screening.82 In
two cases, the inmate was not scheduled for a chronic care appointment within 30 days of
arrival for an initial evaluation.83 Five patients had medications which were provided without
dose interruption when received at DCC.84 However, one of these ran out two weeks after the
transfer and was not reordered.85 It was a KOP medication. It was not possible to ascertain if
the discontinuity was because the inmate did not know how to request a refill, or the patient
was lost to follow up. Two others were not taking medication at the time of transfer but were
referred to a provider who ordered medication that was within 24 hours.86
Our review showed that timeliness of intrasystem transfer has improved since the First Court
Expert report. However, the completeness of these evaluations, as well as continuity of care
following arrival, needs improvement. Given the number of errors and omissions found in the
chart review that affect patient care, we recommend that health care leadership establish a
process to monitor and provide feedback as part of the CQI program. When facilities send
inaccurate or incomplete information on the intrasystem transfer form, the receiving facility
should provide feedback to the sending facility. Errors and omissions should be subject to
focused study to improve the accuracy of transfer information and continuity of patient care.
DCC Intrasystem Transfer Patients #1 & 2.
DCC Intrasystem Transfer Patients #2 & 3.
84 DCC Intrasystem Transfer Patients #1, 2, 5, 6, 7, & 8.
85 DCC Intrasystem Transfer Patient #1.
86 DCC Intrasystem Transfer Patients #3 & 4.
82
83

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Nursing Sick Call
Our report confirmed findings of the previous Court Expert report and identified previously
undescribed problems. Overall, we find that IDOC lacks an adequate system for access to care
through nursing sick call, creating a systemic risk of harm to patients. The findings at NRC were
particularly egregious, in part due to lockdown of the population 24 hours a day, and warrants
immediate attention.
First Court Expert Findings
The previous Court Expert found that nursing sick call ranged from problematic to significantly
broken throughout the system, in that one or more of the elements required of a professional
sick call encounter are missing. These elements are:
• Sick call request forms are available to inmates.
• Completed requests are placed directly by the inmate into a locked box or handed
directly to a health care staff member.
• Completed requests are collected by a health care staff member.
• There is identified clinic space.
• The clinic space is appropriately equipped.
• The space provides patient privacy and confidentiality.
• Sick call, including paper triage, is conducted by a licensed RN whose education,
licensure, and scope of practice permit independent assessments.
• Sick call is conducted pursuant to IDOC policies and procedures with regard to the use of
approved treatment protocols at each encounter, use of over-the-counter (OTC)
medication dosages only, and referrals follow-up as needed.
• A sick call system must ensure confidentiality from request to treatment.
• A sick call system which addresses all a patient’s complaints or, at a minimum,
prioritizes the complaints.
• A sick call log and tracking system has been developed and maintained.
Particularly problematic was that the sick call process permitted non-registered nurses to
conduct sick call at many facilities. The Illinois Nurse Practice Act does not permit LPNs to
perform independent nursing assessments, which is being done in IDOC. Moreover, in
segregation units, nurses did not conduct meaningful assessments but rather talked to the
patient through a solid steel door. There was no immediate review by an RN or physician to
ensure that the LPN conducted an appropriate assessment. At Stateville and Pontiac, there was
frequent and arbitrary canceling of sick call by custody staff. At Dixon, inmates were permitted
to raise only one complaint per sick call visit. At NRC and Dixon, there was no sick call log. Hill
Correctional Center’s sick call system did have many of the required elements.
Current Findings
IDOC Administrative Directive Offender Health Care Services 04.03.103 6. (a-c) addresses
review of sick call requests. However, the policy provides insufficient operational guidance to
staff regarding how to implement the sick call program. For example, the policy does not
address what sick call request forms are to be used, how they are ordered, which staff is
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responsible for ensuring that health care request forms are available to inmates, how inmates
are to submit their requests to protect confidentiality, etc. The policy does not address where
sick call is to be performed, by what level of staff, or the disposition of written health requests
(i.e., scanning into the health record). Thus, the policy is inadequate. In addition, the policy is
not consistent with NCCHC standards.
The previous Court Expert found standardization with respect to how inmates access nurse sick
call; through submission of written health requests that nurses collected, triaged, and assigned
a priority to be seen. We found lack of standardization in how inmates access health care in
IDOC, with some institutions using a written health request process that is consistent with IDOC
Administrative Directives and some institutions using a daily sign up system, which is not
consistent with current Administrative Directives. The sign-up system (which does not include
the nature of the patient’s complaint), does not allow nurses to prioritize which patients should
be seen first based upon the urgency of their complaint and does not result in scanning of the
patient’s complaint into the medical record. At LCC, staff retain sign-up sheets, which are the
only record that the patient has requested to be seen; however, we found that multiple sign-up
sheets were missing. This is a concern because then there is no medical-legal documentation
that the patient requested health care.
In IDOC facilities, both RNs and LPNs perform sick call using Treatment Protocols. In the State of
Illinois, LPNs are to practice “under the guidance of a registered professional nurse, or an
advanced practice registered nurse, or as directed by a physician assistant, physician…to
include conducting a focused nursing assessment and contributing to the ongoing assessment of
the patient performed by the registered professional nurse.” LPN’s may also collaborate in the
development and modifications of the RN or advanced practice registered nurse’s (APRN) plan
of care, implement aspects of the plan of care, participate in health teaching and counseling,
and serve as an advocate for the patient by communicating and collaborating with other health
service personnel.87 However, Illinois scope of practice does not permit LPNs to perform
assessments independent of an RN or higher level professional, as is currently being done in
IDOC. Neither does the scope of practice permit LPNs to perform independent assessments
according to protocols. LPNs do not have requisite education and training, including physical
assessment skills, needed to perform independent assessments.88 Thus, some IDOC patients do
not receive evaluations by health care staff licensed to perform independent assessments. This
increases the risk of harm to patients. In addition, we found that nurse to provider referrals are
not made when clinically indicated, and when made are not timely performed.
Although we found some improvements in nursing sick call relative to the previous Court
Experts report, these improvements were uneven across the system, with some facilities
demonstrating significant improvement with access to care and others none at all.

Illinois LPN Scope of Practice. Section 55-30.
NCCHC defines Qualified Health Care Professionals to include nurses without distinguishing between registered and licensed
practical nurses. However, RN and LPN practice must remain within their education, training, and scope of practice for their
respective state.

87
88

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The findings at NRC were the most egregious and warrant special mention. At NRC, there is no
functional sick call system that provides timely access to care. Inmates are not provided
approved health request forms to submit their requests; therefore, inmates write their
requests on small scraps of paper or generic Offender Request forms. Inmates may or may not
have pens or pencils to write their health requests. Staff reported that inmates could borrow a
pen from another inmate, but an officer commented to a court expert: “Yes, but it will cost
them a lunch tray.”
Inmates cannot submit their requests confidentially by placing them in a locked box accessible
only by health care staff. Instead, they place the piece of paper in a crack in the door that could
be picked up by anyone walking by, even inmate porters on the unit. Sometimes officers pick up
the forms and place them in open folders to be picked up later by a nurse. Even if there were
sick call boxes on each unit, inmates cannot submit their forms because throughout NRC
inmates are locked down 24 hours a day except for four hours per week.89 Thus, the institutional
practice to lock offenders down 24 hours per day is a serious obstacle to access to care.
At NRC, health care staff does not collect health request forms on a daily basis. Staff does not
date, time, and sign when health requests are received. Nurses do not triage patient health
requests within 24 hours, nor do nurses document the urgency of the disposition (e.g. urgent,
routine) on the request. The Director of Nurses reported that some nurses did not see patients
and threw the health request away rather than file the request in the health record. For
example, if a CMT/LPN triaging the request noted the patient had not yet had a physical
examination, the request would be thrown away under the assumption that the complaint
would be addressed at the time of the physical. Likewise, if the CMT/LPN noted that a provider
saw the patient in the last day or two, the request would be thrown away under the
assumption that the complaint had been addressed. Nurses do not assess patients with
symptoms within 24 hours of triage according to IDOC administrative directives. Nurses are to
have the health record available to them for a sick call encounter but during our tour, a nurse
reported she was only able to locate three of 10 health records of patients she was scheduled
to see. Nurses conduct sick call in inadequately equipped and supplied rooms in housing units
without access to a sink for handwashing. This contributed to inadequate patient assessments.
Nurses did not consistently refer patients to providers when clinically indicated and when
made, referrals to providers did not timely take place.
At other facilities we found that some of the problems identified in the previous Court Expert’s
report had been resolved but other problems persisted.
• At SCC, access to sick call is through a combination of a written health request and signup system. Problems related to the frequency of sick call clinics and custody’s failure to
escort patients to clinic exam rooms have been resolved. Improvements were noted
with the standardization of exam room equipment and supplies, and availability of the
medical record at nursing encounters. However, issues persist with respect to LPNs
conducting sick call; inadequate health assessments; inadequate privacy in segregation;
89

This information was confirmed by correctional officers on the units and the Superintendent.

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and failure of nurses to refer patients to providers in accordance with IDOC treatment
protocols or to document the urgency of referrals (i.e., routine, urgent).
•

At Dixon, access to nurse sick call is through a written health request. Problems related
to confidentiality of sick call request forms have been resolved through installation of
sick call boxes on the housing units. RNs are assigned to perform sick call, but LPNs are
assigned when there are insufficient RNs available, exceeding their scope of practice.
Dixon has implemented a sick call log that is used to monitor the timeliness and
appropriateness of nursing decisions. Persistent problems from the previous report
include health requests not being filed in the health record; inadequately equipped and
supplied examination rooms; inadequate nurse assessments; lack of access to health
records in X-house; nurses not triaging patients with dental pain; and patients not being
timely seen by a provider or dentist in accordance with IDOC treatment protocols.

•

At LCC, our review showed some improvement from the previous Court Expert’s report
but other issues persist. To access sick call, inmates sign up for sick call on a sheet of
paper in the housing unit rather than submitting a written request with the nature of
the complaint. Patients are supposed to be seen the following day; however, in a sample
of records reviewed, 31% of patients were not seen due to no show, refusal, or
lockdown. This is a concern because if nurses cannot see all patients within 24 hours,
they need to be able to triage patients according to the urgency of their complaint.
However, this is not possible because inmates do not document the nature of the
complaint on the sign-up sheet. This is a serious disadvantage of the sign-up system
versus the written request system, which also provides documentation in the medical
record of the patient’s complaint. Sick call tracking logs show extraordinarily high noshow or refusal rates, in some cases exceeding 50%. In X-building, where segregated
inmates are housed, correctional officers do not escort inmates to a clinic area and
nurses still perform cell-front assessments. An RN is assigned to perform sick call, but
records also show that LPNs also performed sick call. Record review showed that some
patients who require a medical diagnosis are assessed only by a nurse and not medically
evaluated by a provider and/or do not receive ordered medical treatment.

•

At MCC, our review found that some of the problems with sick call described in the
previous Court Expert’s report have been resolved while other problems persisted.
Positively, the rooms used by nursing staff to conduct sick call are uniformly equipped
and supplied. Many of the exam rooms have a Plexiglas door which ensures auditory
privacy during the sick call encounter. However, we found that LPNs also performed
independent assessments, nurses did not have the patient’s record when performing
patient assessments, assessments were inadequate, and referrals to providers were not
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Chronic Care
First Court Expert Findings
The First Court Expert found variable provider quality with respect to provision of medical care
and that there was lack of oversight of the providers. He also found deficiencies in chronic care
guidelines and policy. The First Court Expert’s Report raised concerns about the organizational
approach to the delivery of chronic care in the IDOC; patients were predominantly seen in
single disease clinics that arbitrarily dictated that patients were seen only two to three times a
year regardless of the their disease control. The First Court Expert found patients with poorly
controlled chronic illnesses who went many months without active management of their
disease as they awaited the next disease specific clinic that were only scheduled for two-three
months out of the year. This process created a fragmented and inefficient system of care for
patients with chronic illnesses. The report also found fault with the lack of involvement of the
primary care providers with monitoring the condition of patients with human
immunodeficiency virus (HIV) between their intermittent telehealth visits with UIC specialists,
the failure to define whether diabetic patients had type I or II diabetes, and the failure to
synchronize the delivery of insulin with meal times. The First Court Expert found that the IDOC
guidelines did not clearly define when Pap smear screening could be discontinued, when
mammograms should be performed more frequently, and the need for increased Pap smear
screening in women with HIV infection. The First Court Expert also noted that chronic
obstructive pulmonary disease (COPD) and asthma were treated identically which is
inappropriate. There were no guidelines for treatment of COPD. He noted that they found
discontinuity of medication without anyone noticing, compounded by physicians evaluating
patients in clinic without having access to the MAR. He also noted that patients frequently
missed their HIV medications without any chronic care monitoring.
Current Findings
We found that the IDOC now uses a UIC HIV chronic care guideline. Aside from this there have
been no improvements based on the First Court Expert’s findings.
The poor training and qualifications of physicians was the most important deficiency that
resulted in significant morbidity and mortality with respect to managing chronic illness. The
deficiencies of many providers based on record reviews included not understanding how to
diagnose or manage certain chronic illnesses, failure to timely or appropriately manage patients
whose disease was not well controlled, failure to monitor key tests or other variables with
respect to disease management, failure to identify or properly manage red-flag or other critical
abnormalities involving chronic illness, failure to consistently document the rationale for clinical
decisions and diagnoses in the chronic care patient progress notes, failure to document
adequate histories, physical examinations or therapeutic treatment plans, failure to incorporate
specialty recommendations with respect to management of chronic illness into a unified
therapeutic treatment plan, failure to refer for specialty care when indicated, and failure to
monitor medication management is a safe manner. Chronic disease guidelines, chronic disease
procedure, schedules, forms, or other processes appear to fail to overcome the deficiencies of
provider quality with respect to managing chronic care conditions in the IDOC.
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A chronic medical condition is an illness that typically lasts longer than three months and
requires medical management on a continuous basis. Typically, a primary care physician will
address all of a patient’s chronic illnesses at each visit. In IDOC the primary care physician will
only manage a single disease at each chronic care visit. Typically, when a primary care physician
encounters a condition they are incapable of managing they refer that patient to a specialist
who knows how to manage the condition. In IDOC this often does not occur and patients are
frequently not referred for specialty care when it appears indicated. Typically, when a specialist
evaluates a patient, a primary care doctor will integrate the specialist’s recommendations and
findings into the care plan of the patient. In IDOC, the primary care doctors often do not even
obtain specialty care reports and do not appear to consistently review or integrate specialty
findings or recommendations into the patient’s therapeutic plan. In IDOC, primary care
physicians are poorly trained and do not appear to know how to diagnose or manage many
chronic illnesses. Many illnesses appear to not be followed in chronic clinics and some
conditions are not managed. The result is fragmented care that fails to address all of a patient’s
problems.
Four years ago, the First Court Expert found that most of the IDOC chronic care clinics
addressed only a single disease and were conducted every four to six months. We found
chronic care clinic schedules were unchanged. With the exception of a few multiple illness
clinics (MIC) for a select group of conditions at Dixon and MCC, patients with multiple chronic
illnesses continue to have their illnesses addressed in single disease clinics spread over the
course of a year. The non-baseline chronic care clinics (asthma, cardiac/hypertension, diabetes,
hepatitis C, high risk/HIV, seizure) are silos in which only a single disease is managed. The
schedule for these clinics is inflexible and not based on the degree of control of a patient’s
illness.90
Failure to manage patients based on the degree of control of their illness has the potential to
harm patients, as patients are evaluated on a fixed schedule irrespective of the degree of
control of their illness. Therefore, persons who need greater attention because their disease is
poorly controlled may not receive it. We view this as inefficient, wasteful, and potentially
harmful. Patients should be evaluated as frequently as is necessary to establish disease control
and not based on an inflexible schedule. Primary care doctors also need to coordinate care for
the patient integrating treatment for all of the patient’s conditions. When specialists manage a
single illness, they typically list all of the patient’s other medical conditions and medications,
and consider the implication of all diseases on the condition being monitored. In the IDOC,
every single disease is managed as if it is the only disease the patient has. Diseases are often
interrelated, such as metabolic syndrome. Drug-drug interactions need to be considered in the
90 IDOC’s chronic care clinic annual schedule is generally, with some site variation, as follows: asthma (January and July,)
diabetes (April, August, and December), cardiac/hypertension (A-L March and September; M-Z April and October), general
medicine (May and November), hepatitis C (June and December), high risk/HIV (monthly), seizure (February and August), and
TB (monthly, annual evaluation). LCC has combined two conditions, diabetes/lipids and diabetes/hypertension, for
simultaneous evaluation in the initial baseline clinic but not in the follow-up chronic care clinic sessions. Dixon and Menard
have created a limited number of multiple illness clinics that combine the treatment of diabetics with a few other chronic
illnesses.

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management of medications. Some illnesses have an effect on other illnesses. When IDOC
providers evaluate patients in individual chronic care clinics, they do not list the patient’s other
illnesses and do not address any other conditions, even when a condition may not be in control
or may have an impact on the condition being treated. There has been limited movement since
the First Court Expert’s Report to develop chronic care clinics that consolidate the evaluation of
multiple illnesses in a single visit. Dixon and MCC have established a few combined illness clinics
called MIC (multiple illness clinics); these clinics generally address diabetes and one or two
other chronic illnesses. There was no evidence or communication during the site visits that
combined illness clinics would continue to expand at Dixon or MCC or would be initiated at any
other sites.
A single chronic disease clinic (General Medicine Clinic) is used as a vehicle to manage all
diseases other than disease specific chronic illness clinics. But we found that there are many
diseases that are not managed in IDOC chronic clinics and therefore are unmonitored. This
included patients with cirrhosis, cancer, heart failure, substance abuse, and rheumatoid
arthritis as examples. This is consistent with deficient problem lists. We found that problem lists
were incomplete indicating that providers were unaware of all of the patient’s problems. When
patients were seen in either chronic clinics, routine provider clinics, or on an emergency basis, a
complete list of problems was not documented and at no clinics did all of a patient’s diseases
receive monitoring.
Also, some diseases are monitored in a clinic that is inappropriate for their condition. As an
example, COPD is a common respiratory condition affecting about five percent of the
population and is the third-ranked cause of death in the United States.91 IDOC treats COPD in
the asthma clinic and utilizes identical forms and nomenclature for control and management as
if COPD were the same disease as asthma. They are not the same disease even though there
can be an overlap syndrome. Diagnosis, staging, and management of these two conditions are
different. Yet in IDOC they appear to be treated the same. The First Court Expert commented
on this but there has been no modification to guidelines, forms, or management practices
based on our findings.
Some illnesses are managed in specialty clinics. All individuals with HIV and eligible patients
cleared for treatment with hepatitis C are managed via telehealth by the UIC infectious disease
telehealth clinic. UIC HIV telehealth clinics are held monthly. A monthly telehealth renal clinic
staffed by a consulting nephrologist is scheduled as needed. Dialysis patients are seen monthly
by a NaphCare nephrologist even though the nephrologist does not document his notes in the
medical record. Hepatitis C is managed in the hepatitis C chronic clinic. When IDOC physicians
deem a patient is a candidate for treatment the patient is referred to a Wexford corporate
doctor who makes a decision on referral to UIC. This system has become a barrier to access to
care for hepatitis C.

91

UpToDate, Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging.

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There are currently 2,500 active hepatitis C patients in the IDOC. Even though effective, shortcourse regimens of medications that result in a high percentage of cures have been developed
and are in common use in the community, only 345 patients (3%) of the nearly 10,500 hepatitis
C patients incarcerated in the IDOC between 2010 and 2016 were offered and received
treatment.92 An additional 125 patients have completed treatment from 2017 through June
2018.93 At the present time, only 10 hepatitis C patients are currently receiving treatment. The
low rates of treatment are primarily due to a restrictive screening protocol that limits patients’
eligibility for treatment which was developed, in no small part, to control the costs of the
medications. These eligibility restrictions limit hepatitis C treatment to patients who have
developed advanced stages of liver fibrosis (cirrhosis). The failure to aggressively treat hepatitis
C in the IDOC has negative public health and health care cost impacts, both in the IDOC and
ultimately in the non-incarcerated communities of the Illinois. We support more aggressive
treatment of hepatitis C and elimination of barriers to access to the UIC program.
Patients with uncontrolled or partially controlled chronic illnesses were not consistently well
managed. When medications for chronic conditions were modified in chronic care clinics there
was no follow up on the impact of this treatment adjustment until the next chronic care clinic
which could be four to six months later. We noted some patients who were not followed up
appropriately after a modification in the treatment plan.94 Some patients whose chronic
illnesses were complicated and difficult to control were not appropriately or timely referred to
medical specialists for consultation.95 The care of many diabetics was found to be flawed and
put patients at risk for hypo and hyperglycemia, and ultimately for end organ damage.96
Patients on Vitamin K antagonist anticoagulation medication (warfarin) were rarely well
controlled. The adjustment of anticoagulation medication to attain a therapeutic level of
anticoagulation was often not aggressively pursued, leaving the patient at risk for repeated clot
formation. The logistics of testing and adjusting warfarin dosages placed a number of patients
at risk.97 IDOC should consider placing patients requiring long term anticoagulation on direct
factor Xa inhibitor anticoagulants that do not require ongoing testing and dose adjustment. The
current prescribing of warfarin puts patients and the institution at risk and we noted one death
in a patient on warfarin who was not being properly monitored.98 Providers virtually never
documented in the chronic care progress notes that they had reviewed patients’ MARs or
communicated with nursing staff to assess the frequency of medication administration and
patient compliance.99 The failure of the chronic care providers to routinely monitor patient
compliance with prescribed medication put the patient at notable risk for overprescribing and
needlessly increasing medications dosages. Weights of patients were recorded with vital signs
Email communication 12/28/2016 from DOC.
UIC Liver Telemed Treatment Analytics.
94 NRC Chronic Care Patients #1, 2, 10.
95 NRC Chronic Care Patient #9; SCC Chronic Care Patients #7, 13; Dixon Chronic Care Patient #14; LCC Chronic Care Patients #4,
6; MCC Chronic Care Patient #2.
96 Dixon Chronic Care Patient #13; LCC Chronic Care Patient #6; MCC Chronic Care Patient #9.
97 SCC Chronic Care Patient #12; Dixon Chronic Care Patients #7, 10; MCC Chronic Care Patient #11.
98 Patient #30 Death Review Records.
99 NRC Chronic Care Patient #3; SCC Chronic Care Patients #6, 8; Dixon Chronic Care Patient #6; LCC Chronic Care Patient #10;
MCC Chronic Care Patients #2, 8.
92
93

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at most clinical encounters, but the chronic care providers seldom documented that they had
reviewed weights for significant gains or losses. Weight loss in correctional settings is an
ominous sign; patients with weight loss need to be aggressively evaluated for an underlying
cause, which may include cancer, uncontrolled diabetes, hyperthyroidism, and other etiologies.
The failure of chronic care, infirmary, and sick call clinical teams to monitor and address
changes in patient weights can result in significant delays in the diagnosis of treatable medical
conditions and illness in IDOC patients.100
The First Court Expert had significant concerns about the care provided to diabetics in the IDOC.
The system wide failure of the providers to differentiate treatment differences between type I
or type II diabetes and the IDOC universal practice of treating all diabetics on insulin with the
same regimen of medications is not consistent with the level of care provided in the community
and, in some circumstances, puts the patient at risk for hypoglycemic episodes. Type 1 and type
2 diabetes are different metabolic diseases and require different management. Type 1 diabetes
occurs in patients who fail to produce sufficient insulin. These patients have an insulin
deficiency. Type 2 diabetes is a metabolic condition of excess weight causing insulin resistance.
The body fails to respond appropriately to insulin causing glucose levels in the blood to
increase. The IDOC does not appear to differentiate these conditions with respect to use of
insulin therapy. Every patient taking insulin prior to incarceration is automatically placed on a
twice daily regimen of an injectable long acting insulin (either NPH or Humulin 70/30 insulin
which combines a long and short acting insulin in a single injection) and a sliding scale short
acting insulin. The standard of care is not to use pre-mixed insulins (70/30) in the treatment of
type 1 diabetes. Use of pre-mixed insulins in type 2 diabetics is also not preferable if normal
blood sugars are desired.101 The sliding scale dosage is based on the results of capillary blood
glucose (CBG) finger stick testing that is performed before every breakfast and dinner meal on
all insulin using diabetics. This practice is inherently flawed.
Most type I diabetics will require three or four, not two, times per day CBG testing to determine
the quantity of short acting insulin that is needed to be administered before meals. Most type II
diabetics who cannot be adequately controlled on oral medication alone are typically placed a
variety of long acting insulins, some of which are given once a day, others twice a day. Although
some Type II diabetics will require the addition of pre-meal short acting insulin, most do not.
Type II diabetics, even if they are on insulin, generally require intermittent but not twice a day
CBG testing. Placing patients on unnecessary pre-meal CBG testing is not without risks. Short
acting insulin alone or in combinations should be administered in close timing with meals to
minimize the risk of a sudden drop in blood sugar. The timing of insulin administration and meal
delivery in IDOC’s large correctional facilities is consistently poorly coordinated and puts
diabetics on short acting insulin at heightened risk of hypoglycemic attacks. IDOC exacerbates
this risk by placing many insulin-using diabetics on 70/30 insulin, which contains a combination
that is 70% long acting and 30% short acting. For example, a patient on 40 units of 70/30 insulin
will receive 28 units of long acting and 12 units of short acting insulin with each injection.
100
101

Dixon Chronic Care Patients #1, 10; Dixon Infirmary Patient #1; LCC Infirmary Patients #1, 4.
See UpToDate® section on premixed insulins in General Principles of Insulin Therapy in Diabetes Mellitus.

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Adding an additional sliding scale-determined two to eight or more units of rapid acting regular
insulin to the patient’s dose because the pre-meal CBG is elevated further increases the risk of
sudden drops in blood sugar. This practice endangers the health of IDOC diabetics and should
be reevaluated. IDOC should consult with an endocrinologist/diabetologist to review its current
prescribing of insulin and the frequency of CBG testing.
The experts also noted that there was varying provider compliance with national diabetes
standards of care concerning testing of urine protein and microalbuminuria, and the prescribing
of medications to diminish the risk or progression of chronic kidney disease; annual eye
evaluations for diabetic retinopathy; examination for diabetics’ feet to prevent foot ulcers;
sensory testing of lower extremities; administration of pneumococcal 23 vaccination; and the
appropriate initiation of HMG CoA reductase inhibitors (statin) to minimize a diabetic’s risk of
cardiovascular disease. The care of diabetes in the IDOC does not consistently meet the
standard of care provided to diabetics in the community.
The IDOC annual or biannual examinations fail to provide a number of nationally recommended
preventive and screening interventions that are designed to prevent certain chronic illnesses.
All patients with chronic illnesses including diabetes, asthma, COPD, chronic kidney disease,
congestive heart failure, HIV infection, and other chronic conditions are to be vaccinated with
the pneumococcal-23 vaccine.102 A review of the medical records of 52 patients with chronic
illnesses revealed that only eight (15.4%) had received the pneumococcal 23 vaccine. All adults
65 years of age and older are to be administered both the pneumococcal 23 and 13
vaccinations. Only three (14.3%) of 21 patients 65 years of age or older had been administered
pneumococcal-23 and not a single one (0%) of these elderly individuals had been offered the
pneumococcal 13 vaccine.103 All HIV patients are also to receive the pneumococcal 13 and
meningococcal disease vaccines. None (0%) of the 12 charts of patients with HIV had
documentation that either pneumococcal 13 or meningococcal vaccines had been
administered. The IDOC is putting its patients and staff at risk for preventable infections by not
providing basic adult immunizations to its at-risk patients. This does not meet the community
standard of care. IDOC is administratively negligent by not purchasing either pneumococcal 13
or meningococcal vaccines for use in its correctional facilities.
It is a national recommendation that all adults (men and women) 50 years of age or older are to
be screened for colon cancer.104 The charts of 50 IDOC patients with chronic illnesses who were
50 years of age or older were reviewed; none (0%) of these patients had been electively
screened for colon cancer using any of the acceptable screening methodologies (colonoscopy,
fecal immunochemical test, stool guaiac cards, flexible sigmoidoscopy with stool guaiac cards).
IDOC is grossly negligent in not providing nationally recommended colon cancer screening to
the incarcerated men and women 50 years of age or older in their facilities; this is resulting in
preventable deaths and avoidable morbidity in the IDOC.
CDC, Recommended Vaccination Schedule Adults 18 Years or Older, United State 2018 and IDOC Office of Health Services,
Chronic Illness treatment Guidelines, Diabetes, Asthma March 2016.
103 CDC, Recommended Vaccination Schedule Adults 18 Years or Older, United State 2018.
104United States Preventive Service Task Force, Colorectal Cancer Screening, June 2016.
102

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Women at LCC are generally being appropriately screened for cervical and breast cancer on a
regular basis. The medical charts of 14 (93%) of 15 women had received a cervical cancer
screening (Pap smear) in the last three years as per IDOC policy. However, the IDOC practice
guidelines failed to note that women with HIV are to have annual Pap smears until three
consecutive annual negative smears have been documented, and thereafter cervical cancer
screening can be performed at three year intervals. One HIV patient was found have only one
negative Pap smear and, as of three years later, had not received a repeat test. HIV patients are
at high risk for cervical cancer; this woman was not being properly screened for cervical cancer.
Four (80%) of five women over 45 years of age had received a mammogram in the last two
years in accord with IDOC protocols.
A large number of patients assigned to chronic care clinics are at risk for or already have had a
stroke, heart attack, or peripheral vascular disease. National105 and IDOC standards106
recommend that all at-risk patients over a certain age and patients with diabetes, high blood
pressure, hyperlipidemia, other selective conditions have their 10-year risk of arteriosclerotic
cardiovascular (ASCVD) calculated. If their risk is 7.5% or higher or they already had suffered a
cerebral-cardiovascular event, they are to be prescribed a high dosage of a high intensity HMG
CoA reductase inhibitor (statin) medication. Forty-eight medical records of chronic clinic
patients over 50 years of age and others with a history of arteriosclerotic disease, diabetes,
hypertension, hyperlipidemia, etc., were reviewed. IDOC providers had not calculated the 10year ASCVD risk on any of these 48 patients. We assessed the 10-year risk for these 48 patients
and noted that 46 of the 48 patients’ scores exceeded the percentage that indicated that a high
dosage of a high intensity statin be prescribed; only one of those patients whose risk was 7.5%
or higher had been prescribed a high intensity statin, but it was not at the recommended level
of intensity dosage. IDOC is failing to meet the national and its own standard of care by not
calculating at risk patient’s ASCVD 10-year risk and not prescribing the appropriate HMG CoA
reductase inhibitor (statin) medication to minimize patients’ future risk of heart attack, stroke,
and peripheral arterial vascular disease.
Chronic care, provider sick call, and infirmary progress notes frequently lacked useful clinical
information about the patient’s clinical status. Providers rarely listed an alternative diagnosis
that was being considered as a reason for a change in the patient’s conditions or symptoms. We
noted earlier that lack of training affected the ability of IDOC physicians to diagnose and
manage chronic illnesses. This is compounded by lack of access to current electronic medical
reference services that might assist them with the care of routine and complex patients. IDOC
providers failed to consistently or appropriately seek the assistance of specialists in many
patients whose complexity warranted additional advice which resulted in delays in diagnosing
or initiating appropriate testing and treatment. Providers whose primary care skills are limited

Stone NJ, Robinson JG, Lichtenstein AH, et al; 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines; Circulation Nov 2013, 129 S1-S45 as found at
https://www.ahajournals.org/doi/abs/10.1161/01.cir.0000437738.63853.7a.
106 Office of Health Services, Chronic Illness Treatment Guidelines, Hyperlipidemia Guidelines March 2016.
105

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would be expected and should be encouraged to more readily request consultation with
specialists when they are unsure of a patient’s diagnosis or treatment.

Urgent/Emergent Care
The IDOC requires that all facilities be prepared and equipped to respond to medical
emergencies in a timely and orderly fashion. This includes the ability to provide first aid and
cardiopulmonary resuscitation by trained correctional staff until medical personnel arrive.
Emergency response drills are to be conducted on each shift at least semi-annually, one of
which must involve multiple casualties.107 The IDOC-Wexford contract requires the vendor to
provide emergency treatment procedures that include the provision of in-service training on
first aid and emergency response, policies and procedures for emergency transfer and
transport, 24-hour coverage by a physician and psychiatrist, immediate transfer capability,
automatic external defibrillators (AED), and emergency response. The vendor is required to
report all referrals for emergency services monthly.108
First Court Expert Findings
Findings of the First Court Expert for this service were that nurses and clinicians failed to
identify when patients required emergency room services and/or hospitalization. Other findings
were that patients were not assessed by nurses upon return from the emergency department
or hospital, and that the record of offsite care was not obtained. Finally, some patients were
not appropriately followed up by a primary care clinician. Unscheduled services were not
tracked, and performance was not monitored.
The key criteria for the adequacy of unscheduled services defined by the First Court Expert
include:
1. A nurse performs an initial assessment of any patient with an urgent or emergent need
for health care attention.
2. The nurse contacts the appropriate clinician to discuss the findings and obtain direction
for subsequent care.
3. If the patient is sent offsite, they are brought back to the medical unit with a report
from the offsite provider, and seen by a nurse.
4. The nurse reviews the recommendations from the offsite provider and obtains orders as
necessary. If no report accompanies the patient’s return, the nurse contacts the offsite
provider to obtain the report and treatment recommendations.
5. The nurse also assesses the patient, including vital signs, and determines if the patient
can be discharged to population or, if unstable, the patient is admitted to the infirmary
or another location where the patient can be cared for appropriately.
6. The patient is seen by a primary care physician for follow-up within the next few days.
7. A log of all unscheduled services is kept, and used to monitor and improve performance.

107
108

IDOC Administrative Directive 04.03.108 Response to Medical Emergencies dated 9/1/2017.
IDOC Wexford Contract 2.2.3.12, 2.2.3.19.1, 2.9.3.2.1.3.

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Current Findings
Our findings are unchanged from those of the First Court Expert. Among charts reviewed that
were obtained from lists of patients sent to the ED, seen in sick call, chronic care clinics,
specialty care, and hospitalizations, we found numerous instances of incomplete nursing
assessments and failure to contact a higher-level clinician,109 patients returning without records
from the offsite provider,110 failure to assess patients upon their return from offsite care,111 and
lack of appropriate follow up by the primary care provider.112 Here are a few recent examples:
•

On 1/22/18, a 51-year-old woman with a history of asthma, hypertension, and chronic
hepatitis C infection was seen urgently for burning in the center of her chest radiating to
her throat, and vomiting.113 The chest pain protocol instructed the nurse to call the
provider urgently for patients with a history of hypertension. The LPN did not refer the
patient to a provider, but instead ordered Pepcid. On 2/17/18, an LPN responded to an
emergency called on the same woman. The patient was found sitting on the floor stating
that she was dizzy. The nurse did not perform any cardiovascular review of systems
(e.g., chest pain, SOB). The patient’s vital signs were normal. The nurse determined that
the patient should rest in her cell and did not contact a provider. Two days later the
woman had another episode of chest pain and dizziness. The LPN who saw her urgently
performed no cardiovascular review of systems. Vital signs were normal, but the
patient’s last EKG showed nonspecific T-wave abnormality. The LPN did not contact a
provider. On three occasions LPNs responded to this patient’s complaints of chest pain
and never contacted a provider. The independent decisions made by the LPNs in this
case are well beyond their scope of practice. The use of unqualified personnel, failure to
conform to written direction and the failure to consult a higher-level clinician placed this
woman at risk of harm from a cardiovascular emergency that could be avoided with
appropriate and responsive clinical care.

•

A nurse saw a patient on 4/16/2018 for a boil on his buttocks that had been present for
one and a half weeks. The nursing assessment was incomplete. The nurse referred the
patient to see the provider the next day. However, he was not seen for five days, at
which point an antibiotic was ordered. No labs or wound care was ordered. The provider
did order a follow-up appointment in four to five days. The patient was not seen for
eight days and at this encounter was sent to the ED because he was having lower
abdominal pain. There is an outbound note, but it contains minimal information. Upon
his return, the inbound note documents the medications and dressing change
recommendations that were on the patient discharge summary from the ED visit. He did
not see a provider for another two days. The nursing assessment of this patient’s

109 Dixon Urgent/Emergent Patients #1-3; MCC Urgent/Emergent Patient #1; Sick Call Patients #1-2; Specialty Consultations and
Hospitalization Patient #6.
110 SCC Urgent/Emergent Patient #1; DCC Urgent/Emergent Patient #2; MCC Urgent/Emergent Patient #1; Specialty
Consultations and Hospitalization Patients #6-9.
111 SCC Urgent/Emergent Patients #1-3; DCC Urgent/Emergent Patients #2-3.
112 SCC Urgent/Emergent Patients #1, 3, 5-7; Dixon Urgent/Emergent Patient #2; MCC Urgent/Emergent Patient #1; Sick Call
Patient #4; Specialty Consultations and Hospitalization Patients #6-7.
113 LCC Urgent/Emergent Patient #3.

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condition was incomplete, access to definitive care was delayed, and he was treated
symptomatically with antibiotics without a thorough evaluation. Documentation of the
ED visit was not obtained from the hospital and he was not seen promptly upon his
return to the facility. This is a patient whose condition deteriorated because it was not
managed in a timely and clinically appropriate manner by nurses and providers.
•

A patient with shortness of breath, dehydration, renal failure, and anemia was
hospitalized for nearly a month.114 When he returned to the facility on 11/19/17, the
nurse who admitted him to the infirmary assessed his condition visually but did not
examine him or take vital signs. The nurse also did not review the patient discharge
instructions that accompanied him or contact the facility physician for orders. The
patient was seen the next day by a physician. While much of the hospital record was
available, the physician only listed diagnostic possibilities and was not clear about the
plan of care. The treatment plan consisted of monitoring and comfort care only. There is
no documentation that the patient was seen by a physician for the next seven days. In
the meantime, nurses documented clear signs that the patient’s condition was
worsening, including bloody stools, diminished lung sounds, pitting edema of the legs,
poor oxygenation, and low blood pressure (98/62). When the provider was contacted,
the nurses were instructed to continue monitoring the patient and report if his
condition worsens.
On 11/27/17 the physician documented in an encounter that the patient needed to be
more compliant; the patient was demanding a change in his diet. Vital signs are
described as stable; also, that he had better aeration and his lower legs seemed
improved. The provider took no steps to definitively treat the patient; instead continued
monitoring and comfort care. There is no documentation that the patient agreed to
palliative or hospice care. The patient was not seen by a provider the next day, even
though he was bleeding from the mouth and had petechia on his trunk and upper
extremities. The following day, 11/29/17, the provider saw the patient and mused about
whether the dose of anticoagulant medication was correct. Ultimately, he ordered the
patient transferred to the local emergency room. There is an outbound note written by
a nurse, but it does not contain all the information relevant to the patient’s ongoing
care and there is no specific statement of the reason higher level care was being sought.
The patient was admitted to the hospital from the ED and died 20 days later.

The review of 33 deaths corroborates the findings from the review of records of patients seen
for urgent or emergent conditions. Errors made in urgent/emergent services provided to
patients who later died included the failure by nurses to refer to a higher-level clinician,115
failure to recognize patient instability and the need for hospitalization,116 patients who were
returned to the facility for whom the record of offsite care was never obtained or reviewed,117
Dixon Urgent/Emergent Patient #1.
See Mortality Review Patients #1, 7, 14, 15, 18, 23, 25 and 30.
116 See Mortality Review Patients #7-9, 13, 17-19, 21-23, 25, 28-29, 32-33.
117 See Mortality Review Patients #6, 9, 17, 21, 28.
114
115

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and patients who did not receive adequate follow up and implementation of
recommendations.118
Emergency equipment and supplies vary greatly from site to site. There are no standardized
expectations for the type and amount of emergency response equipment that is to be available
at each facility. All facilities had emergency response bags that are taken by responding health
care providers to the site of an emergency. At Dixon, the contents and their location in the
emergency response bags were standardized and listed on the outside. These bags were sealed
with a numbered, breakable seal to signify that the bag was ready to use. This was not the case
at any of the other facilities. At MCC, the contents of the bags are standardized but they are not
sealed to indicate readiness for use. At SCC and NRC, the contents of the emergency response
bags are poorly organized, poorly kept, and unsealed. All facilities except NRC check that the
emergency response equipment is available and functional. At NRC, the AED had expired
electrodes; at the other facilities, emergency equipment was checked and found functional.
Mass disaster bags were available at NRC and MCC, but in both cases were dusty, dirty, and
contained outdated supplies. These bags are not checked by health care staff regularly.
Facilities also have first aid kits available in the housing units and program areas. We found that
these were not always current and stocked.
Facilities varied in compliance with the IDOC requirement for emergency response drills. NRC
had not conducted a drill for the eight months prior to our visit in January 2018; all other
facilities were doing drills, but not in the frequency required by the AD. Except for Dixon,
critiques of these drills were brief, not very thorough, and seldom were areas of needed
improvement noted. None of the facilities developed plans for performance improvement in
emergency response. Emergency response drills as well as the list of emergency visits are
reported to the institution CQI committee, but there is no discussion of the information or
evaluation of quality or performance measurement. While we were provided with lists of
emergency visits at all facilities except NRC, the tracking tool recommended by the First Court
Expert has not been implemented. There is no review of clinical care the patient received prior
to unscheduled urgent or emergent health care encounters to determine if it could have been
avoided; nor is care provided afterwards reviewed to ensure that a provider reviewed and
acted upon recommendations timely.

Specialty Consultations
Methodology: Interview personnel responsible for tracking/approval of specialty services.
Review tracking logs. Perform record reviews of persons having specialty care needs.
First Court Expert Findings
The First Court Expert found that every area of the specialty care process showed problems.
This included delays in perceiving a need for specialty care; delays in obtaining an appointment;
delays in processing approvals; delays in following up on abnormal consultation findings; and
118

See Mortality Review Patients #20-21, 27, 32.

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problems with follow up of the consultation by facility staff. The First Court Expert found that
the rate of approval by Wexford corporate utilization physicians is variable and dependent on
the physician reviewer. He also noted that at Dixon and SCC there were substantial delays in
obtaining authorization for offsite specialty care, especially for care obtained at UIC.
Consultation reports are often not obtained.
Current Findings
There was no improvement since the First Court Expert’s report. Our opinion is that the
specialty care process of collegial review is a patient safety hazard and should be abandoned
until such time that patient safety is ensured.
Specialty care is needed when a patient requires a special service or consultation that is
unavailable at the facility. This is managed by Wexford Health Sources Inc. in a process called
collegial review. In this process, whenever a physician or mid-level provider believes that a
special service is necessary, the provider refers the patient to the Medical Director of the
facility. If the Medical Director believes that the service is necessary, then the patient is
referred for collegial review. A significant problem with this aspect of the process is that only
20% of Medical Directors are board certified in primary care and only about half have finished
residency training in primary care. Therefore, there are many Medical Directors who have not
been trained on when to appropriately refer for consultation. We found this problem
repeatedly in record reviews. In our opinion, these deficiencies are due to lack of training or to
overly restrictive barriers to specialty care. These episodes of care would not be found on the
specialty care tracking log as they were never referred.
The collegial review is a phone conference call attended by a utilization physician in Pittsburgh,
the facility Medical Director, and the scheduling clerk from the facility. At these calls, the
corporate utilization physician reviews the list of referrals from the facility over the prior week.
The utilization physician either approves or denies the referral. If a service is approved, the
facility scheduling clerk then schedules the patient for the service. If a service is denied, the
utilization physician is to provide an alternate treatment plan for the facility. After the specialty
consultation service occurs, a follow up by a facility provider is to occur within five days. This
visit is to include evaluation of the consult report and any follow up concerns. Each of these
steps (referral, collegial review approval or alternative treatment plan, appointment, and follow
up) are to be documented in the medical record. Though it is not a requirement of the
administrative directives, each of these steps is tracked in logs maintained by the scheduling
clerks.
We listened in on one of these collegial review conference calls and spoke to staff about the
calls at other sites. The calls are brief. One scheduling clerk said sometimes the calls are
canceled because the utilization physician believes all referrals are appropriate. The same clerk
said that typically the calls take 10 minutes. The call we witnessed had no clinical collegial
discussion about individual cases but was more of an approval process in which the utilization
physician states approval or recommends getting another test before the approval is made.

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There is a lack of guidance in policy with respect to specialty care. The IDOC-Wexford contract
has no specifications with respect to timeliness of specialty care. There is no administrative
directive (AD) on specialty care, including timeliness of care. AD 04.03.103 Offender Health Care
Services describes the requirements of obtaining specialty care. With the exception of a
requirement that the vendor Utilization Management Unit will review all referrals within five
working days, there are no timelines associated with obtaining specialty care. None of the
facilities tracked timeliness of specialty consultations. Dixon did perform a one-time study of
timeliness of UIC consultations, which showed significant delays.
Medical records we reviewed did not consistently contain documentation of all benchmark
events including referral, collegial review, alternate treatment plans, appointment, or follow
up, even though documentation in the medical record is either required or implied because
these benchmarks are medical events that need to be documented in the medical record. This
made verification of specialty care impossible.
Each site had a tracking log detailing the benchmark dates of specialty care. None of the
tracking logs was complete and some were inaccurate. Tracking logs were similar but not
standardized. These tracking logs were under Wexford management. The purpose of tracking
logs is both to manage current referrals to ensure scheduling occurs and to review logs for the
purpose of ensuring that all steps of the process are occurring as expected. We noted that
tracking logs showed significant errors. At Dixon, 22% of consultations on the tracking log did
not have a referral date. At MCC, 44% of referrals in 2017 did not have a referral date
documented on the tracking log and only 53% had the date the appointment was completed
documented. Because of lack of information on these tracking logs, we found them unreliable.
Some were inaccurate. At SCC for a three month period on the log, 7% of collegial reviews were
documented as occurring before the date of referral, which is not possible. Also, at SCC for a
period in January of 2017, 60 consultations were documented as being completed before the
referral was made. These impossible scenarios imply that the tracking log is not accurately
maintained and make the log unreliable for validation of knowing whether referrals are timely.
The Administrative Directives require that the specialty care benchmarks are to be documented
in the medical record. We did not find alternative treatment plans documented in the progress
notes of the medical record. These are typically included in utilization doctor’s approval sheet in
the consultation section of the medical record, but it is never clear how the primary provider
incorporates this into actual practice. At NRC, because we were not provided a tracking log, we
attempted to verify all specialty care benchmarks in the medical record. Only 14 (63%) of 22
consultations had a referral. Only three (14%) had a collegial review documented. Only nine
(41%) had an approval. Only 15 (65%) were seen within five days in follow up of the
consultation. As a result, using the medical record, we were unable to verify that benchmarks
for specialty care occur as expected.
A major but unmonitored problem with specialty care is underutilization. The First Court Expert
found the same problem and described it as delays in perceiving a need for the service. This can
occur when physicians are unaware that a specialty procedure or consultation is necessary or
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when the utilization process is so restrictive that providers fail to refer because they believe
that it will not be approved. We were unable to specifically identify the cause in the IDOC but
have definitively identified that it occurs. On the 33 death records reviewed, we noted 95
instances when a procedure should have been requested but was not, and 81 instances where
specialty consultations should have been requested but were not. This is a large number of
unrecognized specialty care referral in just 33 patients and demonstrates significant
underutilization. This does not include need for radiologic studies such as CT scans. We view
this deficiency as a result of improperly trained physicians and a learned process of not
requesting care. This lack of referral places patients at risk of harm and has caused preventable
morbidity and mortality. This is a systemic problem that appears at all facilities we investigated.
In multiple cases on record reviews, patients who needed referral were not referred. Some
resulted in death. Others resulted in morbidity with delayed diagnosis. These cases are found in
record reviews of individual sites and in mortality reviews.
Underutilization is incorporated into IDOC practice. For example, the IDOC has no formal policy
on colorectal cancer screening. Community standards are to screen non-high risk patients for
colon cancer beginning at age 50 with either highly sensitive fecal occult blood tests,
colonoscopy, CT colonography, or flexible sigmoidoscopy. The IDOC does not provide this
screening and has no written guideline. AD 04.03.101 Offender Physical Examination requires
periodic examinations every five years until age 30, every three years between ages of 30 and
39, and every two years for persons 40 years and older. Policy requires an annual TB skin test
and females are screened with Papanicolaou (PAP) test and a screening mammogram at
appropriate ages. There are no other recommendations for screening tests, which is not
consistent with current standards.119 Current IDOC practice for colorectal cancer screening, not
clarified in policy, is to perform digital rectal examination at the annual or biannual
examinations with fecal occult blood testing. Digital rectal examination with or without single
office-based guaiac fecal occult blood testing is not adequate screening for colorectal cancer
and is not recommended. At Danville, a patient who was only offered digital rectal
examinations for colorectal cancer screening died from complications of advanced colorectal
cancer.120 We viewed this death as preventable. Another 56-year-old man who developed
locally invasive rectal cancer described below is another example.
Current standard of care for all persons with COPD and asthma is to have spirometry or full
pulmonary functions tests. Asthma and COPD are different diseases which have different
monitoring objectives. Yet in IDOC they are treated the same, resulting in inappropriate care.
Almost no patients we reviewed with either COPD or asthma have evidence of referral for
spirometry or pulmonary function testing. This is inadequate management and inconsistent
with contemporary standards of care.

Routine screening recommendations are provided by the US Preventive Services Task Force as found at
https://www.uspreventiveservicestaskforce.org/Page/Name/recommendations.
120
Mortality Review Patient #1.
119

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It is recommended that persons with cirrhosis have screening upper endoscopy to evaluate for
varices; treatment with beta-blocker medication if varices are identified; and referred for
screening ultrasound every six months to screen for hepatocellular carcinoma. These screening
tests are only occasionally completed in IDOC and this practice is not codified in policy or in
clinical guidelines. It appears that many facility physicians do not understand how to care for
persons with cirrhosis and do not order these tests when indicated.
We also noted that a significant number of consultations occur without evidence of a report.121
The IDOC refers patients to consultants and to hospitals, but when those consultations and
hospitalizations are completed, the IDOC does not obtain a report of the consultation or
hospitalization in a significant number of these referrals. This is a patient safety risk. When a
report is not present, the providers will be unaware of other recommended testing or
consultations, and will be unaware of the consultant or hospital findings that have a significant
impact on therapeutic plans.
Even when consultation and hospital reports are obtained, they are not always reviewed. An
example was at NRC. We reviewed 22 consultations; only eight consultation reports were
present. On these eight reports there were 19 recommendations of consultants which were not
carried out. This may have been due to the extremely dysfunctional medical record system at
NRC.
At NRC, only eight (36%) of 22 specialty consultations included a report. At SCC, only 19 (35%)
of 35 consultations included a report in the medical record. At LCC, five (63%) of eight
consultations included a report. At MCC, the scheduling clerk told us that approximately 50% of
consultations will not have a report. When reports are not present, the providers will not know
the status of the patient and may fail to understand recommendations, placing the patient at
risk of harm. A referral sheet is sent with patients on all offsite referrals. Consultants usually,
but not always, will write brief comments on these forms to communicate key items to the
primary doctor. However, this is an unreliable system and is incomplete, as it does not give the
full consultant report.
The contract between Wexford and the IDOC requires that the vendor is to meet with hospital
and other providers to coordinate referral of inmates, including the reporting of test results and
medical records.122 The contract also requires that medical records are to contain hospital
discharge summaries and reports of consultations.123 Yet the IDOC has taken a position124 that
they have no control over consultants or outside hospitals, and therefore obtaining a report is
beyond the IDOC’s control. They were mainly speaking of hospital emergency room reports. We
121

As an example, on 33 mortality review records, there were 137 episodes when records were unavailable from offsite
specialty care or hospital care. This included both specialty consultation reports and hospital discharge summaries.
122 Contract between Wexford Health Sources Inc. and State of Illinois Department of Healthcare & Family Services dated
5/6/11 and found at 2.2.3.11 on page 9.
123 Contract between Wexford Health Sources Inc. and State of Illinois Department of Healthcare & Family Services dated
5/6/11 and found at 2.2.3.13.5 on page 10.
124 Letter to First Court Expert regarding Defendants’ comments regarding the confidential draft report of the First Court Expert
dated 11/3/14 and signed by William Barnes on pages 22-23.

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assumed that they hold the same position for consultation reports. They maintain that Wexford
has implemented a system which provides the Medical Director with reliable and timely
information so that appropriate care is provided. We did not find that this was accurate. There
is no evidence in the five day follow up to consultations or in the follow up after
hospitalizations that doctors consistently understood what occurred during the offsite event. If
they did, they did not document it. At times, doctors would document that there was no report
and made no changes to the therapeutic plan because information was still pending. This is a
serious problem. In our experience managing contract medical services and a county-managed
health program, we have always been able to negotiate with consultants and hospitals timely
access to consultant and hospital reports. We view this as a failure of the vendor to perform
and should be fixed via the oversight process.
A special situation exists with respect to use of UIC for consultant care. Years ago, UIC agreed to
provide IDOC with a certain amount of free care. This amounted to 216 inpatient hospital
admissions and 2160 outpatient visits per year. Only four facilities are permitted to participate:
SCC, Dixon, Pontiac, and Sheridan. NRC and SCC are considered the same institution. Each
facility is permitted to send approximately 520 patients a year for specialty consultations. For a
variety of reasons, these specialty consultations are delayed. At Dixon, consultations to UIC
average six months to complete and range from 100 days for a cardiology consultation to 239
days for a gastroenterology consultation. These delays have resulted in morbidity and
mortality, and place the patients at significant risk of harm. There is no process to assess
whether a patient’s condition needs earlier attention. Because the cost of UIC is free and the
cost of alternate care is borne by Wexford, there is significant incentive to send patients to UIC
even if it results in delayed care.
An example of this was at SCC. The patient125 was a 56-year-old who complained of blood in his
stool on 11/8/16. A fecal occult blood test verified blood in his stool. The patient also had
weight loss. The standard of care for a 56-year-old with weight loss and blood in the stool is
prompt colonoscopy and possibly additional work up to exclude colon cancer. This man was not
referred for colonoscopy; instead, he was referred for a gastroenterology appointment on
1/4/17, about two months later. The gastroenterology appointment did not occur until 7/7/17,
about six months after the referral. The gastroenterologist recommended colonoscopy, which
did not occur until 11/27/17, when a locally invasive rectal cancer was identified. This delay of
over a year resulted in unnecessary spread of the cancer. Physicians were aware of the delay
but there was no effort to schedule the patient to a local gastroenterologist for this procedure.
We reviewed aggregate specialty care visits for 2017. They are listed in the table below. Though
the populations at SCC and MCC are similar in that they are both maximum security prisons
without special medical missions, the referrals numbers and rates are quite different. We
question whether the four times higher rate of referral at SCC is related to the free care
provided at UIC. Dixon and SCC, which have free care at UIC, had the highest numbers and rates

125

SCC Hospitalization Patient #6.

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of referral. This implies that other sites may have suppressed referral rates because the cost of
care is borne by the vendor.
Site

Population

Referrals126
per year

Referrals
per 1000

Denials
per year

1681
1183
2298
1806
3029

242
1731
1666
753
994

144
1463
724
417
328

8
87
109
71
237

NRC
SCC
Dixon
LCC
MCC

Denials per % Denied
1000
5
74
47
39
78

3%
5%
7%
9%
24%

Dr. Meeks testified127 that if the site Medical Director or HCUA feel that any request denied is
necessary, it can be appealed directly to the Agency Medical Director. Dr. Meeks stated that
over an eight-month period he thought he had received about 10-15 appeals on a statewide
basis. It is our opinion based on record reviews that there are a substantial number of patients
who are not referred for services who need them. We were unable to identify any data to show
who appeals utilization decisions to the Agency Medical Director, but based on interviews it
appears that the HCUA at the facility is the person who does this. But the HCUA is a nurse who
is not trained to determine whether a referral is necessary. This manner of oversight is
therefore flawed and will not adequately protect patient safety because this should be done by
a physician, and needs to include review of care so that persons who never get referred but
should be referred are identified.
Based on multiple record reviews, including mortality reviews, we have identified considerable
morbidity and mortality associated with untimely or lack of referral for higher level of care. In
review of 33 deaths, we found 93 episodes of care when a patient should have been referred to
a hospital. Many of these delayed or failed hospital admissions contributed to patient death.
While we believe that this occurs as a result of poorly qualified physicians, the utilization
process appears to be a significant barrier to access to timely specialty and higher level of care.
The defects in this cost containment mechanism effectively result in denial of necessary
medical services that harm inmates. For that reason, we make a strong recommendation to
abandon the collegial review process until patient safety can be ensured.
IDOC providers should be strongly encouraged to request specialty consultation when patients’
clinical conditions are complicated, exceed the skills and training of the providers, or are not
responding the initial treatment regimens. It would be in the best interest of the patient and
the IDOC if there was a system wide specialty consultation plan that included contracts with
specialty providers for face-to-face, telehealth, and e-consult consultation. IDOC should expand
and build on the current telehealth program that provides ready access to HIV, hepatitis C, and
renal consultation. The present relationship with the University of Illinois Chicago could be used
126
127

Referral and denials were taken from the latest year’s annual CQI reports provided to us by the IDOC.
Page 23 30(b)(6) deposition of Dr. Meeks on July 25, 2017.

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as a template to expand the number and type of specialty consultations that are readily
available to IDOC providers.

Infirmary Care
First Court Expert Findings
The First Court Expert noted in the final report that there were deficiencies in infirmary policies,
practices, and physical plants. The expert stated that IDOC policies failed to provide a detailed
description of the scope of services that could be safely provided in the infirmary setting and
did not provide guidelines that would assist the clinical staff in determining which patients
should be referred to the hospital and not be admitted to the infirmary. The report criticized
the 23-hour observation policy that allowed nurses to directly admit patients to the infirmary
for short term observation without contacting the provider or to discharge patients without
arranging for post-observation follow-up. They report that Dixon did not have 24 hour/7 days
per week registered nurse presence in the infirmary, and that there was no or only partial nurse
call systems in five facilities. It was also noted that in some infirmaries, bedding linens were of
poor quality and in short supply.
Current Findings
All five of the correctional centers inspected had infirmaries including NRC, SCC, Dixon, LCC, and
MCC. The NRC infirmary was opened in 2016, two years after the First Court Expert’s site visit.
The physical plants of the infirmaries were described in the section on Clinical Space and
Equipment, which noted serious problems with the level of cleanliness, lack of adjustable
hospital beds, torn mattresses, non-functioning negative pressure units in isolation rooms, the
absence or incomplete distribution of nurse call devices, and unsafe shower rooms in many of
the infirmaries.
There was overall compliance with timeliness of nursing admission notes, which were
consistently written at the time of admission, and the frequency of nursing progress notes.
Nursing progress notes were consistently entered no less than daily even when the policy
required only weekly notes. There was varying compliance with the timeliness of provider
admission notes, which were to be written within 48 hours of admission.128 A number of
provider admission notes were not entered in accord with this standard.129 As also directed by
the Offender Infirmary Services directive (see reference above), provider progress notes were
to be written three times a week for “acute” admissions and weekly for “chronic” admissions.
There was inconsistent compliance with this directive in the IDOC infirmaries.130
The Offender Infirmary Services Administrative Directive dated 9/1/2002 states that “the scope
of infirmary services available on site shall be based upon the nature of offender population
Offender Infirmary Services 04.03.120.
NRC Infirmary Patients #1, 3, 4; Dixon Infirmary Patient #1.
130 NRC Infirmary Patients #3, 4; Dixon Infirmary Patients #3, 5; MCC Infirmary Patient #2.
128
129

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and the prevalence of disease entities or disabilities that might benefit from infirmary services
within the facility’s population.”131 It has not been modified since the First Court Expert’s visit.
There are still no written policies that provide guidance to the IDOC clinical staff on which
conditions or level of instability exceed the capabilities of the infirmaries and should be
promptly referred to a hospital. Moreover, based on record reviews, the current complement
of Wexford physicians does not appear to appreciate when patients are unstable and require
hospitalization. This places patients at significant risk of harm. The lack of a clear scope of
service contributed to admission of patients to the infirmaries whose presenting or ongoing
conditions warranted referral to a higher level of care, whether to a hospital or a skilled nursing
facility. Many of these failures to refer to a higher level of care resulted in death.132 Two
examples of failure to refer to higher level of care based on infirmary record review during
facility visits included the following.
A patient with recent assaultive head trauma and an episode of falling out of his bed presented
with fluctuating altered mental status, disorientation, and confusion, and was admitted to the
NRC infirmary.133 The provider’s admission note did not document a neurological exam, the
bruises on the patient’s head, the recent head trauma, and the past history of a
cerebroventricle-peritoneal shunt. This patient’s condition warranted direct referral to a
hospital emergency room for brain imaging study (CT scan) and neurology evaluation to rule
out an intracranial hemorrhage or increased intracranial pressure. This patient’s clinical
condition exceeded the capabilities of the infirmary and he should have been hospitalized. The
care of this patient was negligent and did not reflect the standard of care in the community.
Another patient with a chronic draining leg ulcer was not able to be properly diagnosed and
treated in the infirmary.134 The indicated preliminary diagnostic testing and specialty
consultation were not initiated. When the patient did not improve with the initial antibiotic
regimen, she should have been hospitalized to have additional definitive diagnostic testing and
the timely initiation of the proper intensive antibiotic treatment. Her complex non-healing leg
ulcer, which most likely was due to chronic osteomyelitis, exceeded the scope of service that
could be adequately diagnosed and managed in the IDOC infirmary setting.
At the time of the Experts’ site visits, a high percentage of the patients in the infirmaries were
physically and/or mentally impaired patients with dementia, traumatic brain injuries, advanced
cardiovascular disease, and cerebrovascular disease. Many were incontinent of bladder and
bowel and needed partial or full assistance with activities of daily living (ADLs), including
toiletry, feeding, bathing, dressing, and transfers in and out of beds and chairs. This was
especially true of the Dixon facility which includes a special mission of housing geriatric
patients. Nine (50%) of the 18 patients in the Dixon infirmary were judged by the infirmary
nursing staff as needing full or partial assistance with ADLs and would be better served in a
Offender Infirmary Services, Administrative Directive 04.03.120.
We noted in 33 mortality reviews that there were 93 episodes in 33 patients when the patient should have been referred to
a higher level of care but was not. Many of these resulted in death.
133 NRC Infirmary Patient #3.
134 LCC Infirmary Patient #5.
131

132

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skilled nursing facility.135 Health care administrators, nursing leadership, and correctional staff
leadership in a number of the facilities communicated their concerns about the increasing
number of elderly mentally and physically disabled individuals in the IDOC and their concerns
about the infirmaries’ capability of caring for this complicated patient population. It was
apparent that the IDOC is aware of the need for additional skilled nursing care facilities and
geriatric care housing but has not taken action to address this problem.136 In our opinion, the
Dixon facility is inadequate as the principal housing placement for the geriatric and disabled
population. There has been no evaluation to assess the number of persons needing geriatric
care or skilled nursing placement within the IDOC and no apparent effort to correct existing
inadequate housing for these individuals.
One example at NRC included a patient with diabetes, lymphoma on chemotherapy, deep vein
thrombosis with an inferior vena cava filter, urinary incontinence, decubitus ulcer, and a
hospitalization in 2017 for altered mental status, repeated falls, and cranial burr hole
procedures who spent most of his day in bed.137 He needed assistance with ADLs including
straight catheterization to empty his bladder. He could not walk without assistance. He had a
decubitus ulcer that appears to have developed while in the infirmary. His constant needs
exceeded the capabilities of the NRC infirmary; he would be more appropriately housed in a
skilled nursing facility.
An elderly, incontinent patient at SCC with dementia was noted having his diaper changed.138
The staff stated that he required total care and constant observation. Later in the day, the
patient was observed to be unattended and precariously laying half off the bed at significant
risk for fall.
One long term patient in the Dixon infirmary with advanced dementia had developed
contractures of his upper and lower extremities and deep, infected decubitus ulcers.139 He
required total care including gastric tube feeding, diapers, bathing, and dressing. The extreme
contractures and recurrent pressure sores developed while he was in the infirmary. The
manifestation of these findings indicated that the Dixon infirmary was incapable of providing
the level of care that would be expected in a skilled nursing facility. Once the patient started to
develop contractures, he should have been transferred to a skilled nursing facility in the
community. These and other mentally and physically impaired patients have clinical and nursing
care needs that cannot be adequately met in IDOC infirmaries. IDOC must either internally
develop a certifiable skilled nursing facility that is properly designed, staffed, and equipped or
transfer high risk chronic care patients to certified skilled nursing facilities in the community.
With the exception of LCC, the provider infirmary admission notes contained very limited
history of the reason for admission, the diagnosis, any differential diagnoses, and only brief
Verbal communication with Dixon infirmary nurse.
Deposition of Kim Hugo, April 11, 2018 pp. 69-70.
137 NRC Infirmary Patient #2.
138 SCC Infirmary Patient was observed during rounds. His chart was not reviewed.
139 Dixon Infirmary Patient #3.
135

136

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diagnostic and treatment plans. With the exception of the infirmary at LCC which has an
electronic medical record, the provider progress notes were commonly illegible. Provider
progress notes commonly offered limited if any clinical information, did not include justification
for modifications in treatment plan or medications, and were exceedingly brief with little
clinical information. The assessment and plan in provider progress notes often repeatedly
contained little more than phrases such as stable, no change in condition, or continue present
management.140 Other than limited notes about the illness that prompted the infirmary
admission, there was virtually no documentation or clinical updates about any of the patients’
other chronic illnesses including diabetes, hypertension, congestive heart failure, chronic
kidney disease, etc. The provider progress notes during one SCC infirmary patient’s seven
month admission never commented, even once, on the status or control of his seizure
disorder.141 It was extremely difficult for Experts and other providers to understand the course
of the patient’s condition and the rationale for any of the modifications in treatment. A
provider recently assigned to the SCC infirmary stated that the notes of the previous infirmary
provider were incomprehensible and made it extremely difficult for him to comprehend the
status of the patient and the treatment plan.142 The lack of informative, comprehensive
provider notes that legibly addressed both the acute and chronic needs and illnesses of each
infirmary patient put the health and safety of infirmary patients at risk. The illegibility of the
provider and some of the nursing notes provides strong justification for implementation of an
electronic medical record in all IDOC facilities.
Some infirmary problem lists were missing, had erroneous entries, or failed to include key
chronic illnesses.143 Absent, inaccurate, or incomplete problems created a potential risk to the
comprehensiveness and continuity of the care delivered to a patient housed in IDOC
infirmaries.
The care provided to a number of infirmary patients, as identified during site visits, was found
to be suboptimal and of poor quality. When the admitting diagnosis was not clear or the patient
was not responding to the initial treatment, the providers failed to consider reasonable
alternative diagnoses and order additional diagnostic tests to investigate the initial or other
diagnoses. Patients were prescribed confusing regimens of antibiotics and other anti-infection
agents. Chronic conditions were not aggressively managed, resulting in delays in attaining
reasonable levels of control. This lack of clinical adequacy put the health of patients at risk.
Examples of patients whose infirmary care was suboptimal are provided below.

140

In Mortality Review Patient #9, over six months a doctor wrote an identical note 19 times despite fluctuating clinical
condition of the patient. The note consisted of the sentence, “no specific complaint, no change, dementia, continue same
care.” After the patient had a cardiopulmonary event undocumented by the provider and colon cancer the provider over the
course of approximately a year wrote the identical note repeatedly, “no specific complaint, no change, post colectomy for
metastatic ca [cancer], continue same care.” This was despite the patient having repeated falls and other clinical events
described by nurses.
141 SCC Infirmary Patient #2.
142 Verbal communication from Dr. Roz Elazegui.
143 SCC Infirmary Patients #1, 2, 3; LCC Infirmary Patient #5; MCC Infirmary Patient #1.

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•

A newly incarcerated diabetic patient entered NRC with a black toe and should have
been immediately referred to a hospital emergency room.144 However, he was placed in
the general population and received no follow-up care until two weeks later, when he
had to be emergently referred to the hospital. His hospital treatment included IV
antibiotics for septicemia and surgical amputation of his infected gangrenous toe. Upon
discharge from the hospital he was admitted to the NRC infirmary. After five weeks in
the infirmary, the recommended follow-up appointments with vascular surgery and
podiatry had not yet been scheduled. The infirmary provider notes were mostly illegible
and contained limited clinical information about the post-hospital wound healing. Upon
initial entry to NRC, this patient’s syphilis test was found to be reactive with a high RPR
titer of 1:124 treatment (active syphilis); he was not treated for syphilis prior to his
hospitalization and was not identified as having active syphilis until 33 days after his
admission to the SCC infirmary. The provider had not reviewed the intake laboratory
testing when the patient was admitted to the infirmary. The delay in initiating the
treatment of active syphilis was negligent and put the patient at risk for syphilitic
complications.

•

Another NRC infirmary patient with recent head trauma and a ventriculoperitoneal (VP)
shunt that had been previously placed to treat hydrocephalus was admitted to the
infirmary with altered mental status, confusion, and disorientation; he also had bruises
and a hematoma on his head.145 This patient should have been directly sent a hospital
emergency room but was not. Ten days after admission to the infirmary, the provider
had not performed a neurological exam and had not ordered a brain imaging study to
rule out cerebral hemorrhage, subdural hematoma, and increased intracranial pressure.
The care provided to this patient did not meet the standard of care in the community
and was grossly and flagrantly unacceptable.

•

Another NRC patient was an insulin using diabetic with a wired jaw on sliding scale
insulin and a total liquid diet who had widely fluctuating blood sugars with episodes of
marked hypoglycemia after injection of short acting regular insulin.146 The provider did
not comment on the possible impact of the patient’s entirely liquid diet, which can
result in extreme variations of blood sugar levels. The provider did not comment on
whether this patient had type I or II diabetes. The continued use of sliding scale short
acting insulin should have been discontinued in this patient. The lack of a clear plan
about treating this diabetic who was temporarily unable to eat solid foods put this
patient at risk. Consultation with a diabetic specialist was needed but had not been
solicited. Treatment was also not ordered to address protein in the urine nor was the
pneumococcal vaccine 23 administered; both these interventions are the standard of
care for all diabetics. The care provided to this patient was substandard.

NRC Infirmary Patient #1.
NRC Infirmary Patient #2.
146 NRC Infirmary Patient #4.
144
145

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•

A patient in the SCC infirmary had recurrent deep vein thromboses (DVT) and was
prescribed chronic anticoagulation with warfarin.147 After nine weeks of anticoagulation,
the level of anticoagulation (INR testing) were still sub-therapeutic. The infirmary
provider failed to more expeditiously increase warfarin dosage to achieve a therapeutic
level. This patient was still at risk for a recurrent DVT after nine weeks at SCC. At one
point, the UIC providers requested that the warfarin order be stopped and the
anticoagulant be switched to injectable low molecular weight heparin in preparation for
an upcoming surgical repair of the patient’s post-operative abdominal wound. The
infirmary provider discontinued the oral anticoagulant but failed to prescribe the
injectable anticoagulant, leaving the patient without any blood thinning medication. The
lack of aggressive management of his oral anticoagulation medication and the failure to
immediately prescribe the temporary injectable anticoagulant put the patient at
heightened risk for additional clot formation.

•

Another SCC infirmary patient whose diagnoses included cardiovascular disease,
diabetes, DVT, and seizure disorder had episodes of black outs and significant drops in
blood pressure documented in the nursing notes.148 The infirmary provider failed to
document or address these occurrences of syncope in his progress notes. This patient
should have been, but was not, assessed or tested for arrhythmia, atypical seizure, and
orthostatic hypotension. The provider progress notes never once commented on the
control of patient’s seizure disorder. The patient also had a history a massive DVT but he
had not been prescribed anticoagulant medication and the provider did not provide any
rationale for not treating this potentially life threatening condition. The care provided to
this infirmary patient was grossly and flagrantly unacceptable.

•

Another SCC infirmary patient had a history of arteriosclerotic heart disease (ASHD),
hypertension, and cerebral vascular accident (stroke).149 For the last seven months he
had multiple elevated blood pressure recordings documented in the infirmary record
without any change being made in his antihypertension medication regimen. It was not
until a new provider was assigned to the infirmary in 2018 and increased the blood
pressure medication that the blood pressure finally become controlled. The
management of this patient’s hypertension was negligent and put the patient at
increased risk for another stroke.

•

A patient at LCC had repeatedly sought medical attention since late 2016 for abdominal
pain, blood in her stool, mucous in her stool, change in her bowel patterns, and
progressive weight loss.150 She was seen repeatedly and had been presumptively started
on antibiotics for diverticulitis; the nurses and providers consistently failed to comment
on her steady loss of weight which was readily viewable in LCC’s electronic medical
record. Failing to note that the patient had already lost 29 pounds, one provider wrote

SCC Infirmary Patient #1.
SCC Infirmary Patient #2.
149 SCC Infirmary Patient #4.
150 LCC Infirmary Patient #1.
147
148

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in July 2017 that this patient had no “red flags” for cancer. He was wrong; weight loss is
a strong warning sign for cancer. Due to increased abdominal pain and blood in her
stool, the patient was admitted to the infirmary in September 2018 and treatment for
diverticulitis was continued. It was not until her twelfth day in the infirmary that a
provider recognized that the patient had lost another 18 pounds during the infirmary
admission and a total of 40 pounds since January 2017. Another 20 days passed before
an abdominal CT scan revealed abnormalities consistent with colon cancer with
metastases to abdominal lymph nodes and the liver. Biopsy at UIC Springfield verified
the diagnosis of colon cancer and on 12/18/17, 73 days after her admission to LCC’s
infirmary, the patient had a hemicolectomy with a colostomy performed and she was
started on chemotherapy. The pre-infirmary and infirmary care of this patient failed to
meet the standards of care in the community. The failure of the providers in the clinics
to recognize the patient’s weight loss and symptoms as being suggestive of a
malignancy was indifferent and grossly and flagrantly unacceptable. The slow scheduling
of diagnostic tests and referrals while the patient was housed in the infirmary was
inexcusable; the two and one-half month delay between infirmary admission and
surgery potentially decreased the quality and duration of this patient’s life.
Patients admitted to the infirmaries with less complicated conditions (post-op, basic wound
care, no assistance with ADL’s, etc.) were more likely to be adequately managed. However,
patients with complicated conditions and multiple diagnoses that required close monitoring
and diligent provider involvement were frequently noted to have received substandard levels of
care. Some of these patients had clinical needs that exceeded the clinical experience and
knowledge of the providers. IDOC providers do not have timely, if any, access to nationally
respected, comprehensive, current electronic medical references when they need expedited
answers to clinical questions. Most importantly, the negative impact of the provider’s
knowledge gap would have been lessened if the infirmary providers readily requested specialty
consultation concerning diagnostic testing and treatment. There were multiple instances when
the infirmary (and sick call and chronic care) providers failed to consult specialists when there
were clear indications that clinical advice and assistance was needed. The infirmary providers
either lacked the knowledge and competence to recognize that they needed clinical assistance
or they were reluctant to seek outside consultation due to institutional culture and practice.
The Wexford “collegial” process that required providers to submit justification for offsite
specialty consultations and offsite (and some onsite) diagnostic tests only serves an
administrative “gate keeper” function and is an unnecessary barrier that delays or prevents the
scheduling of needed consultation.
Examples of infirmary patients whose clinical conditions should have generated a request for
specialty consultation but for whom the provider failed to submit requests for this clinically
warranted specialty assistance follow.
•

A insulin requiring diabetic patient in the NRC infirmary with a wired, fractured jaw on a
total liquid diet had widely fluctuating blood sugar levels that were not able to be

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controlled by the infirmary provider.151 This is an unusual clinical situation and the
advice of an endocrinology specialist was needed but not requested. The infirmary
provider’s insulin orders put the patient at significant risk for hypoglycemia.
•

Another patient in the SCC infirmary with severe cardiovascular disease, peripheral
artery disease, iliac artery stent, diabetes, seizure disorder, and a history of DVT had,
over a seven month duration, episodes of black outs and significant drops in blood
pressure recordings.152 The infirmary provider ordered no interventions and failed to
seek consultation with cardiac and vascular specialists. When a new infirmary provider
was assigned to the infirmary, the patient was immediately referred to both cardiology
and vascular surgery specialty clinics.

•

A patient in LCC’s infirmary had multiple chronic conditions including congestive heart
failure, atrial fibrillation, and mitral valve replacement.153 She developed persistent dark
colored, draining, and itching sores. The infirmary provider’s attempts to treat this skin
problem were unsuccessful. The provider never considered that one of the patient’s
medications, known to cause itching and blistering skin lesions, could be the cause of
her skin condition. Dermatology consultation should have been requested but was not.
Over an eight month period in the infirmary, the patient’s vital signs documented eight
episodes of bradycardia (slow heart rates less than 60 beats per minute) that were
never addressed in the provider’s progress notes. No consideration was given to the
decreasing one of the patient’s medications that commonly causes bradycardia. The
patient’s severe chronic cardiac illnesses and her eight documented episodes of
bradycardia never resulted in a referral to cardiology specialists. The patient was
urgently hospitalized when her pulse rate increased to 130 beats per minute and her
oxygen saturation suddenly dropped. While hospitalized she was found to have sick
sinus syndrome, which can cause intermittent bradycardia and tachycardia; a cardiac
pacemaker was implanted. This patient’s conditions were complicated, yet specialty
consultation with cardiology and dermatology were not solicited prior to her emergency
hospitalization. Her intermittent episodes of bradycardia went unnoticed by the
provider; it appears that the provider was not reviewing the vital signs that were
frequently recorded by the nursing staff. The care provided to this patient was
negligent. The failure to adequately monitor this patient and to seek timely specialty
consultation for complex dermatological and cardiac conditions did not meet the
standard of care in the community.

•

Another patient in the LCC infirmary with blackened toes due to frost bite was treated
with an array of antibiotics but was not immediately referred to a podiatrist as is the
standard of care in the community.154 Only after two months in the infirmary, when her
right large toe became gangrenous was she referred to a podiatrist. The podiatrist

NRC Infirmary Patient #4.
SCC Infirmary Patient #2.
153 LCC Infirmary Patient #2.
154 LCC Infirmary Patient #3.
151
152

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arranged for the toe to be surgically amputated. Immediate referral for podiatric
consultation when the patient was admitted to the infirmary could potentially have
prevented the need for the amputation.
•

Another patient in the LCC infirmary had a history of recurrent DVT with pulmonary
emboli and a chronic draining lower extremity leg ulcer.155 During her infirmary stay, the
patient was treated with five different antibiotics in six different, confusing
combinations. The working diagnosis appears to have been osteomyelitis but this was
never noted in the provider’s treatment plan. The provision of multiple antibiotics in
varying combinations without a definite diagnosis was not in accord with national
standards of care and put the patient at risk for drug resistance and severe
gastrointestinal complications. A definite workup for osteomyelitis, including bone
probing, bone biopsy, and specialized bone scans, was never ordered. Infectious
disease, orthopedic, and possibly dermatology consultation to clarify the diagnosis was
needed but was not requested. The provider’s extremely belated requests for infectious
disease consultation for assistance with the choice of antibiotics, not to establish a
diagnosis, was inappropriately denied by Wexford’s collegial referral process. If even the
appropriate preliminary diagnostic tests and consultations had been performed at the
infirmary, this patient should have been hospitalized for definite diagnostic tests and
intensive treatment. The failure to solicit specialty consultation during this patient’s six
month stay in the LCC infirmary without resolution of her draining leg ulcer and the
inexplicable combinations of antibiotics and antifungal agents reflected poor
understanding of this patient’s possible diagnoses, and was incompetent.

Pharmacy and Medication Administration
Prescription medication is a common form of medical treatment today. In the general
community, 37% of adults aged 18-44 took a prescription drug in the last 30 days, 70% of adults
aged 45-64 took a prescription drug in the last 30 days, and 91% of those aged 65 and older
took a prescription drug in the last 30 days.156 Persons incarcerated in correctional facilities are
well known to have a greater disease burden than the general community.157 A survey done by
the Bureau of Justice Statistics of inmates in jails and prisons in 2011-2012 found that 66% of
those in prison reported taking prescription medication for a chronic medical condition.158

LCC Infirmary Patient #5.
National Center for Health Statistics. (2017) Health, United States, 2016 with Chartbook on Long-term Trends in Health.
Hyattsville, MD. https://www.cdc.gov/nchs/fastats/drug-use-therapeutic.htm.
157 Nowotny. K., Rogers, R. & Boardman, J. (2017) Racial disparities in health conditions among prisoners compared with the
general population. SSM-Population Health. 3; 487-496. Elsevier. Macmadu, A. & Rich, J. (2015) Correctional Health is
Community Health. Issues in Science and Technology. 31 (1). Binswanger, I., Krueger, P., Steiner, J. (2009) Prevalence of chronic
conditions among jail and prison inmates in the USA compared with the general population. Journal of Epidemiology and
Community Health. 63(11):912-919.
158 Maruschak, L. (2015) Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-2012. Bureau of Justice
Statistics available at https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5219.
155
156

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The use of prescription medication in health care is governed by both state and federal
regulations designed to provide protection for the patient, treating clinicians, and the general
community. The safety of medications in the delivery of patient care has been a major area of
emphasis since the 1990’s, when the Institute of Medicine reported that medication errors
were a significant contributor to morbidity and mortality.159 Since then, numerous
organizations, including the federal government and accreditation organizations, have studied
the problem of medication safety and put forth guidelines that improve patient safety. These
include computerized provider order entry, medication reconciliation, use of clinical
pharmacists, patient-specific unit dose packaging, adherence to the “five-rights” of medication
safety, bar code medication administration, and minimization of interruptions during all aspects
of medication preparation and delivery.160 The methods to deliver medication in correctional
facilities are expected to be like those evident in the general community, including
implementing changes to improve safety.
Availability and access to medications involves the cooperation of custody and other programs.
Correctional officer support is essential to complete medication administration efficiently and
safely. This includes providing escort, controlling movement, reducing distractions (e.g.,
television, noise levels, fights, etc.), accounting for missing inmates, and ensuring that inmates
ingest medication that has been administered. Custody officer support needs to be guided by
custody post orders or Administrative Directives that give standardized guidance to custody
staff on how they are to cooperate with nurses when they administer medication. When this
does not occur, nurses must individually negotiate with officers, resulting is varying levels of
cooperation when nurses attempt to administer medication. This reduces standardization of
practice, causes inefficiency and delay, and as a result increases risk of medication errors.
Medications may be only needed once a day, but a few medications may require as many as
four to six doses in a 24-hour period. Correctional facilities may reduce some of the burden of
medication administration by allowing inmates to keep and take their own medications as
needed, but this is usually limited to groups of medications not likely to be misused and to
inmates who are capable of self-administration. When inmates are unable or not allowed to
take medication on their own, a nurse must administer each dose. There are also some patients
who need closer monitoring of their clinical condition, such as when medications are first
initiated, the patient is experiencing side effects, or the when the patient’s condition is not
improving. These patients should be scheduled for nurse administered medication.
Patient adherence with medication treatment is essential in achieving desired clinical
outcomes. When patients do not receive medication as ordered, treatment is compromised.
There are many reasons a patient in a correctional facility does not receive medications as
prescribed. These can include the medication has not yet been received from the pharmacy,
the nurse did not see that the medication was ready and available to administer, the officer
Institute of Medicine. (1999) To err is human: building a safer health system. Washington DC: National Academy Press.
Safety Primer (2017) Medication Errors available at https://psnet.ahrq.gov/primers/primer/23. Agency for Healthcare
Research and Quality, U.S. Department of Health and Human Services.
159

160Patient

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may not have released the inmate from his cell to obtain the medication, the inmate may be
elsewhere (at court, in the visiting room, with an attorney, attending a program, working etc.),
the inmate may have been transferred to another housing location or institution, or the inmate
may not want to take the medication. Each of these reasons requires a different action by the
nurse to ensure that the patient receives ordered treatment. For example, inmates may refuse
medication, but if so, the nurse needs to refer the patient to a provider to discuss a change in
the plan of care. If the inmate has been transferred, the nurse needs to locate the inmate and
transfer his medication, or notify the new location that the inmate needs to receive medication,
and so forth. Whenever an inmate is not present or refuses a prescribed dose of medication,
the nurse must investigate further to determine what steps must be taken to continue the
inmate’s care. Each of these missed medications and the reason must also be documented on
the MAR.
Nurses and correctional officers must work collaboratively to ensure that patients ingest
medications, as medications that are diverted in the correctional setting become contraband
and are a challenge to safety and security of operations. Correctional officers are responsible
for preventing and eliminating contraband. A single pill or capsule is considered contraband
when it is not being administered by a nurse or taken by an inmate as a keep on person (KOP)
medication. It is important that policies and procedures clearly identify when it is not
acceptable for medication to be in the possession of an inmate and that correctional staff are
vigilant in monitoring for the presence of contraband and the potential for misuse or drug
overdose.
First Court Expert Findings
The First Court Expert found no problems with the system to provide pharmacy/medication
administration services. The Expert found discontinuity in medication treatment for individuals
with chronic disease, which was unrecognized and not addressed by treating clinicians. This was
because the MAR was not filed timely in the medical file and nurses did not notify providers
when an inmate missed taking medication. The Expert also found at NRC that medication
administration was significantly delayed because an officer was not assigned to escort the
nurse, per policy.
Current Findings
We agree with the First Court Expert’s findings. We have additional findings that evidenced a
far worse situation from the First Court Expert’s report. We found systemic medication
administration practices that are unsafe and not consistent with community standards at every
facility visited. We also found that some problems with medication are not recognized and
those that are recognized are not addressed. The failure to rigorously monitor and address
problems with medication treatment is a systemic issue that results in medication errors,
resulting in adverse patient events and creating on ongoing risk of harm to patients.
Pharmacy Services
Most pharmaceuticals are provided by BosWell Pharmacy Services, an institutional pharmacy
located in Pennsylvania. Orders are either faxed, or in the case of LCC, entered by computer.
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Each order is verified by a pharmacist, the prescription filled, and the medication shipped to the
institution, arriving the next day. Staff assigned to work in the medication storeroom at the
institution track each medication that has been ordered, reconcile its receipt, and put it into the
area used by nurses to prepare medication for administration. UIC provides medications to
treat inmates with HIV and HCV via an interagency agreement. Each institution also has a
“back-up” pharmacy in the local community which can fill prescriptions needed more urgently
than can be delivered by BosWell. We did not find any significant issues with the availability or
timeliness of prescribed medication supplied by either BosWell or UIC.
A consulting pharmacist visits each site regularly at least once a quarter to inspect the
medication area and audit charts. The results of these reviews are included in the institution
CQI meetings. We identified concerns when we inspected medication rooms. There was no
schedule of sanitation and disinfection activities for the medication areas. At NRC and LCC,
medication storage rooms were dirty and disorganized. At Dixon and LCC, we found multiple
use containers (e.g., Lidocaine) that were open and not dated. We also found expired
medication and testing material at these two facilities.
Policy and Procedure
IDOC provides minimal direction and guidance about how medications are ordered and
administered. For example, it states that prescriptions must be signed by a physician or dentist;
it does not state the elements of a complete order. Facilities have operational procedures for
pharmacy services and medication administration. Procedures we reviewed were several years
old and often not signed. While they do provide more specific directions about when and how
medication will be accounted for and administered at the facility, they still are too general. For
example, the operational procedure at LCC does not state the elements of a complete order. It
also does not specify how the nurse administering medication is to identify that it is the correct
inmate. Health care staff are therefore left to their own devices and there is no mechanism to
insist upon legible, complete orders or instructions about how inmates are to be identified
before receiving medication. This leads to variation and unsafe practices as described in the
following paragraphs.
An example of how the absence of policy and procedure leads to poor practices is one we
observed at MCC. Nurses used a list of inmates who are prescribed controlled substances to
select and sign out medication from the cabinet where controlled substances are kept. All the
medications were put into a collective cup. Once all the controlled substances were collected,
the nurse took the cup to the medication room and, by visual identification only, selected which
controlled substances each patient was to receive and put them into the respective patient
envelope. Not only was the nurse dispensing; there was no accountability for the proper
disposition of each medication and the potential for error magnified by not using the MAR to
select medications. In another example, at LCC, unlicensed staff delivered KOP medications to
inmates without the MAR present to verify the medication against the physician order and to
document that the medication was administered. We found many MARs in which there was no
documentation that the patient received ordered medication.

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The IDOC has no Administrative Directives or post orders that provide guidance on how officers
are to cooperate with nursing staff when nurses administer medication. At NRC, as an example,
nurses individually negotiate for this cooperation when they administer medications. This
practice at NRC resulted in the poor practices we observed at that facility. There needs to be a
standardized procedure for officer cooperation with nurses during medication administration
that ensures nurses are able to satisfactorily administer medication in accordance with
accepted nursing practice.
Medication Orders
Dispensing and administration of medication must only be done under physician order. Illinois
statute161 requires that a physician prescription contain the name of the patient; the date when
the prescription was issued; the name and strength of the drug or device prescribed; the
quantity; the directions for use; the prescriber’s name, address, and signature; and the DEA
number for controlled substances. We did not find evidence that the prescription process in
IDOC conforms to state regulation. Providers do not always write orders on the order form; we
found multiple examples among charts reviewed of orders written on the physical exam form
or on the lab results or in the progress notes, but a corresponding order was not written on the
physician order form. It is the order form that is used to inform the pharmacy that there is a
prescription to be filled, otherwise care is not implemented. Providers write orders that at
times were not legible to the experts or the nurses working with the provider who wrote the
order. Some orders were incomplete and documentation in the chart did not indicate the
reason or intended goal of treatment.
Nurses are responsible for transcribing orders onto the MAR. At all facilities, we found orders
which had not been transcribed onto the MAR or that were transcribed late. At NRC, nursing
staff give KOP medication to inmates at intake without consistently transcribing the order and
documenting administration of medication onto the MAR. Therefore, there was no
documentation that the patient received ordered medical care. We also found instances of
nurses overwriting new orders over old orders on the MARS at every facility. This is alteration
of a legal record and should be ceased immediately. Finally, we observed nursing staff
transcribing orders onto the MAR using the label on the blister pack instead of the original
order; this is a poor practice because it does not identify dispensing errors.
Medication Administration
At all the facilities we visited, the process for medication administration was fraught with
problems. None of the methods used to administer medication at the five facilities we visited
ensure that the five rights of medication administration are observed. These are the right
patient, the right medication, the right dose, the right route, and the right time. Problems which
were universal included:

Illinois Compiles Statutes; 225 ILCS 85/3 as found at
http://www.ilga.gov/legislation/ilcs/fulltext.asp?DocName=022500850K3.
161

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1. Failure to identify that it was the right inmate, using two-part identification (e.g. use of
identification badge and verification of date of birth or institution number).
2. Failure to verify that the inmate received the right medication in the right dose at the
time of administration.
3. Lack of hand hygiene, cross contamination of the envelopes, and occasionally the pills
themselves.
4. Untimely or failure to document medication administration to include the reason why
an inmate did not receive a medication that was due.
5. Not observing the inmate to ensure that medication has been ingested.
6. Not accounting for missing inmates or arranging to administer the dose later.
7. Not signing the MARs so that it was possible to identify from the initials who had
documented on the MAR.
Most medications are taken orally, in tablet or capsule form. These are packaged in 30-day
blister packs that are labeled specifically for each patient. This is patient-specific unit dose
packaging. This type of packaging reduces medication errors made by nurses in preparing and
administering medication. At every facility we visited, this safety feature is totally abandoned
because nurses take the pills out of the pharmacy dispensed package and put them in
improperly labeled envelopes, which are repeatedly used, or medicine cups. This practice is
known as pre-pouring and is widely recognized as unsafe. Nurses essentially duplicate what has
already been done by the pharmacy, introducing the possibility of putting the wrong
medication into the wrong patient envelope or another type of error. It also wastes the cost of
packaging, which is expensive compared to other forms of stock medication.
We were told that pre-pour is necessary because doing it correctly takes too much time and, in
some facilities, the physical plant makes it impossible to use a medication cart. We note that
two of three of the IDOC maximum security facilities (MCC and Pontiac Correctional Center)
were built in the 19th century, and the remaining maximum security facility (SCC) was built in
the early 20th century. These facilities are so old that they are an impediment to appropriate
administration of medication. Some areas do not have elevators and nurses are not able to use
medication carts when they administer medications in many areas of these facilities. At NRC,
inmates are essentially locked down 24 hours a day (except four hours per week), resulting in
nurses delivering all medications cell to cell. Physical plant and operational practices are
common reasons given for reluctance to adopt safer practices that meet nursing practice
standards. However, IDOC is not so unique that these problems have never been experienced
elsewhere and not been resolved. Other correctional systems have implemented patient
specific unit dose systems and were able to address these types of problems in the process.
Because of these conditions, nurses make an accommodation to custody in using medication
administration procedures (e.g., pre-pouring, not opening doors to properly identify inmates,
and not having the MAR with them when they administer medication) that are not in keeping
with current standards of nursing practice. Instead, custody should develop with the medical
program an acceptable and safe alternative, given the existing physical plant barriers. In every
facility, the Warden is the Chief Administrative Officer and the HCUA of the facility reports to
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the Warden. This appears to have resulted in procedures that accommodate custody needs
even when it results in medication administration practices that violate nursing practice
standards.
Further, we observed nurses floating medication well in advance of administration, which alters
the medication’s properties, and crushing medication that was put in the reused envelopes,
which contaminates other medications put into the envelope. These practices put inmates at
risk of receiving ineffective treatment and adverse drug reaction.
Medication Continuity
Chronic disease patients are not monitored to ensure continuity in treatment nor is their
compliance with prescribed treatment assessed. Chronic disease medications are provided to
patients either as “Keep on Person” (KOP) or each dose is administered by a nurse. We found
many examples of patients whose ordered medications were never provided, were delayed
starting, and were stopped because the patient had not been seen by a provider to renew
medication. Record reviews indicated that appointments for chronic care are not scheduled to
take place prior to expiration of chronic disease medication orders. As a result, providers often
reorder medications without seeing the patient to conduct a clinical evaluation to determine
whether the treatment plan should be continued or changed, based upon the how well the
patient’s chronic disease is controlled.
Facility policy and procedures162 direct that the MAR be available with the medical record at the
time of a chronic care provider visit. However, we saw no evidence that current MARs were
available at the time a patient saw a provider. We also saw no evidence that providers review
the MAR and discuss the patient’s adherence as part of chronic care appointments. Facility
policy and procedures163 also instruct nurses to refer patients to a provider for evaluation and
possible change in treatment if they refuse to take prescribed medication. In the records we
reviewed, there were multiple examples of patients not taking medication as prescribed who
were not referred for provider evaluation.
Monitoring Performance
Pharmacy audits and inspections, which are done routinely, document the problems described
above. These reports are reviewed and included in the institution CQI meetings. They
document ongoing problems system wide with medication, including: use of the envelope
rather than MAR to prepare medication; failure to document medication given on the MAR;
failure to transcribe orders onto the MAR; administering medication for which there was no
order, or when the inmate was not present at the facility; administering medications that differ
from the order; documenting in advance that medication was administered; and the presence
of open, undated, multi-use containers of medication. There has been some coaching and
LCC, SCC, and DCC Operations Policy and Procedure P. 107 Management of Chronic Disease and MCC Policy and Procedure
V3-12 Medical management of offenders with a chronic condition. No policies and procedures were provided for NRC.
163 LCC, SCC, and DCC Operations Policy and Procedure P. 128 Medication Services and MCC Policy and Procedure V 4-1
Pharmacy Services. No policies and procedures were provided for NRC.
162

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counseling of individuals, but there has been no review or analysis done to identify root causes
for these persistent failures, and no effort made to eliminate systemic causes of failure or
improve performance through corrective action planning. In the meantime, inmates are
subjected to delays and interruptions of treatment, unsanitary conditions, and medication
errors.
We note that some of the root cause problems appear to be related to custody control of
medical processes within the institution and the apparent reluctance of health staff to openly
discuss with custody the need for their cooperation in the process of medication
administration. The governing bodies of CQI committees at several facilities were mostly
custody-trained staff. This is an impediment to effective monitoring of clinical processes, such
as medication treatment. Participation and support of custody staff in CQI is very important;
however, medical staff must direct and control the monitoring of health care and be able to
drive necessary performance improvements.

Infection Control
Infection control is an essential element of an adequate health care system. The inmate
population has a high prevalence of communicable and infectious diseases. Because of the high
prevalence of communicable diseases, a highly functioning infection control program must be
in place to identify, track, and assist in management of these illnesses.
Approximately 4-6% of TB cases reported in the United States occur among people incarcerated
at the time of diagnosis. The incarcerated population contains a high proportion of people at
greater risk of TB than the overall population.164 In 2013, there were 36,064 persons with HIV
infection in the civilian population of Illinois, with a population over 18 years old of 9.7 million
or 0.4% of the population. In 2010-2015, IDOC had 686 inmates with HIV infection or 1.5% of its
population.165 The IDOC HIV prevalence was almost four times as high as the civilian HIV
prevalence. It is estimated that approximately 160,000 persons in Illinois have hepatitis C or
about 1.6% of the Illinois population, as opposed to 5.6% known cases in IDOC and an
estimated 10% overall estimated prevalence. The IDOC had at least 3.5-6.25 times the rate of
hepatitis C infection of the civilian population. The burden of sexually transmitted disease,
MRSA, and scabies are also typically higher in prison systems.
Conditions of confinement promote the spread of disease because of environmental conditions
within the prisons. Inmates are housed in close quarters. In our IDOC Prison Overview section
we spoke about how crowded the IDOC prisons are. The overcrowded conditions, particularly in
antiquated facilities, promote transmission of multiple types of infections and contagious
diseases. Individuals have no control over the quality of air they breathe via the facility
ventilation system; they live in cells or dormitories that have been occupied by others and are
TB in Correctional Facilities in the United States, Centers for Disease Control and Prevention as found at
https://www.cdc.gov/tb/topic/populations/correctional/default.htm.
165 HIV in Prisons, 2015 – Statistical Tables , Laura Maruschak and Jennifer Bronson, Ph.D., BJS Statisticians; August 2017, NCJ
250641, US, Department of Justice Bureau of Justice Statistics.
164

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expected to clean their living area with supplies that are available; they are provided food
prepared by inmate workers to eat with silverware and plates cleaned by inmate workers; they
are provided linens and clothing that are washed by inmate workers or wash linens themselves
with laundry soap that is available; they use toilets, sinks, and showers that are used by many
others. Every one of these activities of daily living carries multiple opportunities for
communicable or infectious disease transmission and illness for both staff and inmates.
Infection control programs in the correctional setting establish and monitor procedures to
prevent exposure to diseases that can be transmitted in the correctional setting. Infection
control programs also identify sources of infection through screening and take steps to prevent
or mitigate infection of others, to treat persons with infectious diseases, and improve the
health and safety of staff and inmates by providing information on prevention, education on
self-care, and immunizations.166 These efforts require surveillance of disease by accurate
statistical means, both for required reporting purposes and so that the IDOC medical program
can understand how to study, plan, and prepare for the care they will need to provide. The
infection control program is usually coordinated by a registered nurse with consultation from a
designated provider with expertise in infectious diseases,167 and supported by data collection
methods that can reasonably track diseases within the prison system.
First Court Expert Findings
The First Court Expert found IDOC’s infection control program was a moving target across the
system, with some facilities having well developed infection control programs and other
facilities having programs described as being in their infancy. Facility health care staff had been
provided with an exposure control manual, but IDOC provided no oversight of infection control.
At some facilities, no one was clearly designated with responsibilities for infection control, and
the duties were simply added to those of the HCUA or DON. Other facilities had identified a
specific nurse responsible for infection control, but the duties of the position had not been
defined. In addition, no training in how to operate an effective infection control program had
been provided to those individuals who had been assigned responsibility for infection control.
Examples of systemic issues described by the First Court Expert which occurred as a result of
the disarray in infection control monitoring and lack of oversight from IDOC included the failure
to launder bed linens of infirmary patients in water temperatures hot enough to destroy
pathogens transmitted by blood and body fluids; negative pressure rooms that were not
functional and not monitored to ensure that negative pressure was maintained to prevent
transmission of airborne illnesses; lack of proper sanitation of medical equipment; and lack of
disinfection procedures to provide clean surfaces when examining patients.
Current Findings
The systemic issues described in the First Court Expert Report still occur today. While there has
been some improvement in the use of paper barriers on examination tables, little else has
166Bick,

J. (2006) Infection Control in the Correctional Setting. In M. Puisis, (Ed.) Clinical practice of Correctional Medicine. (2nd
ed.) Philadelphia: Mosby Elsevier. 230-231.
167 Lane, M. (2006) The infection control program. In M. Puisis, (Ed.) Clinical practice of Correctional Medicine. (2nd ed.)
Philadelphia: Mosby Elsevier. 460-461.

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changed with regard to the infection control program. The following summary of our findings
reinforces the findings of the First Court Expert. We had multiple additional findings that give us
concern.
The IDOC has had numerous recent outbreaks of contagious and infectious diseases. Since
2008, there have been several outbreaks of scabies in Illinois prisons. The latest was in
Taylorville in 2016, in which the prison was locked down and 214 inmates were treated.168 In
2012, a norovirus outbreak sickened 140 inmates at SCC.169 The numbers of inmates affected in
these outbreaks reflects poorly on the surveillance and typical preventative measures enacted
by infection control procedures to abort the contagion earlier and prevent the widespread
infections that occurred at these facilities. An inmate at SCC also contracted Legionnaire’s
disease in 2015.170 At the Danville Correctional Center, 78 persons were affected by
histoplasmosis in 2013, likely from soil disruption. This outbreak was initially thought to be
adenovirus, but required investigation by the federal Centers for Disease Control and
Prevention and was found to be histoplasmosis.171, 172
Typically, outbreaks such as these are monitored and sometimes managed by the infection
control program. Yet in the IDOC, there was no designated individual responsible for infection
control at four of five facilities we visited, including at SCC, where one of the outbreaks
described above occurred, as well as the isolated case of Legionnaire’s disease. At SCC,
infection control duties were dispersed amongst several staff nurses, the DON, and the HCUA,
and the program was not effective. The norovirus outbreak at SCC was large, and typically early
infection control measures would be expected to reduce the size of such an outbreak. At the
same four facilities there were no schedules for routine sanitation and disinfection of health
care areas. Basic maintenance of rooms was lacking. MCC has an extensive collection of policies
and procedures that detail cleaning and sanitation of every room in the health care building.
At MCC, responsibility for infection control resides with one of the nursing supervisors. Her
responsibilities are managing TB surveillance, performing sanitation inspections, ensuring food
handlers are cleared for work, monitoring skin infections, interface with the Illinois Department
of Public Health, monitoring negative pressure rooms, and monitoring hygiene in clinical
spaces. In addition, she manages HIV and hepatitis C clinics, coordinates follow-up of patients
treated for TB infection, and provides supervision of inmate peer educators. It is our opinion
that the infection control nurse is an essential component of the health care program at IDOC
facilities and is a full-time position.

Scabies Outbreak Causes Temporary Lockdown of Taylorville Prison, Doug Finke, The State Journal Register, September 19,
2016.
169 Norovirus Outbreak Hits Illinois Prison; Food Safety News December 29, 2012.
170 Stateville Inmate Diagnosed with Legionnaire’s Disease, Dawn Rhodes, Chicago Tribune August 12, 2015.
171
New
details
regarding
illness
among
inmates
at
Danville
Correctional
Center.
Found
at
https://www2.illinois.gov/idoc/news/2013/pages/danvilleccillness.aspx.
172 Centers for Disease Control and Prevention website Outbreaks and Investigations lists Histoplasmosis in an Illinois Prison.
Details given were that this occurred in August-September 2013 with 78 cases and likely related to disruption of soil containing
bird droppings. Found at https://www.cdc.gov/fungal/outbreaks/index.html.
168

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We observed significant challenges to safety and sanitation at every facility visited. For
example, at SCC we observed cockroaches, gnats, and flies in the infirmary; the room used for
hemodialysis (considered a sterile procedure) had peeling paint on the walls, there was
standing water on the floor, and the garbage can was not covered. The kitchen/dining area was
occupied by birds, and their droppings were evident on the walls and floors. At Dixon, all three
floors of the medical building had missing floor tiles, which is a sanitation issue in an area
dedicated to the delivery of health care.
NRC is the only facility among the five we visited that does not conduct monthly safety and
sanitation inspections. At the other facilities, safety and sanitation inspections do not
adequately identify problems requiring remediation. For example, we found faulty negative
pressure isolation rooms and nonfunctional dental equipment that were not identified because
they are not included in the safety and sanitation inspections. We also found furniture,
equipment, and hard surfaces (floors, ceilings, sinks, cabinetry) were rusted, broken, or
deteriorated in health care areas at all facilities, which had not been documented as issues
needing repair on safety and sanitation rounds.
Moreover, review of safety and sanitation findings in the minutes of CQI meetings document
the persistent failure or lengthy delay in remedying identified problems. Safety and sanitation
inspections should inspect or monitor the condition, function, and annual certification of
clinical equipment, functionality of the negative pressure rooms, integrity of bed and chair
upholstery, completeness of medical cart and emergency response bag logs, the training of
health care unit porters, and other health care issues.
The TB prevention and control program in IDOC is not effective. The hallmarks of an effective
TB program in correctional facilities are: initial and periodic TB screening, successful treatment
of TB disease and infection, appropriate use of airborne precautions, comprehensive discharge
planning, and thorough and efficient contact investigation when a case of TB disease is
identified.173
At IDOC, TB screening is improperly performed, treatment of infection is delayed, and negative
pressure rooms (an airborne precaution) often are not functional or monitored. We did not
evaluate TB discharge planning or contact investigation, although in the absence of an
individual assigned responsibility for infection control, these interventions are most likely
sporadic and haphazard as well. At NRC, nurses do not read tuberculin skin tests properly and
only document results in the health record when they have time. Instead of inmates being
escorted to the medical clinic for nurses to read their tuberculin skin tests, nurses must go cell
to cell. In addition, NRC officers do not open the food port for inmates to extend their arm for
nurses to palpate and measure the results of the test. Instead, nurses read the test by looking
through the glass window of the cell door, which is inappropriate technique.174 There was
TB in Correctional Facilities at https://www.cdc.gov/tb/topic/populations/correctional/, Epidemiology of Tuberculosis in
Correctional Facilities 1993-2014 at https://www.cdc.gov/tb/publications/slidesets/correctionalfacilities/default.htm.
174 A tuberculin skin test is read by manually palpating the size of induration of the test site with good overhead lighting. To
read a tuberculin skin test through a glass window is inappropriate.
173

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evidence in the review of records that other sites distrust TB screening performed at reception
centers and rescreen inmates upon arrival at their parent facility. We also observed that nurses
at Dixon merely look at the skin test site through the cell door rather than palpating and
measuring induration in a well-lit area. We did not observe nurses reading tuberculin skin tests
at all facilities, but based upon the two sites where we observed poor practices, we conclude
that TB screening at IDOC is not adequate.
We reviewed the records of four patients who had completed treatment for latent TB infection.
In three cases, the patient was subjected to multiple skin tests (which were positive) and
multiple chest radiographs, which were unnecessary, before treatment was finally initiated. In
the other case, treatment was initiated even though skin testing was ordered but never
completed, based upon a history of a positive skin test reported by the inmate when he
requested treatment initiation. Initiation of treatment for latent infection was haphazard and
delayed.
Negative pressure isolation rooms were either not functional or the monitor was not working at
three of the five sites we visited. At NRC, the monitor in one room was not working and in the
other room the vent was taped shut, disabling the negative pressure. At SCC, neither room was
functional and the equipment had not been serviced for years. At LCC, two of three rooms were
not functional. Negative pressure rooms need to be maintained and ready for use; this is not
the case in the IDOC, and places patients and staff at risk of airborne infection.
The UIC provides treatment of inmates with HIV and hepatitis C via telemedicine. For hepatitis
C, UIC has no role in managing hepatitis C patients before referral and after antiviral treatment
and has no role in screening for these diseases. UIC provides no assistance in managing other
complications of hepatitis C including cirrhosis, varices, or ascites as examples. IDOC facility
providers are responsible for that care but do not appear to know how to provide it. One or
more nurses are designated at each site to coordinate these clinics and the care of these
patients. The quality is highly dependent upon the interest and capability of each nurse
assigned these responsibilities. There is no one identified to monitor or oversee the work of the
clinic coordinators, who must negotiate with all the other users of the telemedicine space to
schedule clinics timely. Coordination between the UIC infectious disease specialists and primary
care providers is problematic, as evidenced in the example of one patient with HIV; the
specialist recommended lowering the patient’s dose of metformin (a medication used to treat
diabetes) because of an interaction with one of the HIV medications prescribed.175 The primary
care provider at the facility responsible for the patient’s diabetic care never acted on the
recommendation. The HIV specialist reduced the dose of metformin at the next visit. The
patient was at risk of clinical deterioration because of the primary care provider’s omission for
five months.
IDOC has adopted what it describes as opt-out HIV testing at intake, but policy and practice are
not consistent with the use of this term. Opt-out testing is recommended by the Centers for
175

Dixon Infection Control Patient #3.

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Disease Control because it supports early identification and treatment.176 The IDOC
Administrative Directive still requires that consent be obtained before drawing blood for HIV,
and in practice this consent is still obtained.177 The practical effect is that fewer newly arriving
inmates are screened for HIV as compared to hepatitis C. The IDOC should revise the
Administrative Directive to eliminate the requirement for written consent and initiate opt-out
HIV testing.
We also question the effectiveness of periodic screening programs for HIV and hepatitis C
infections. We noted on one death review178 a man who was not known to be HIV infected and
was not offered HIV screening at two annual health evaluations we reviewed, despite having a
history of multiple sexual partners, prior blood transfusions, and a history of sexually
transmitted disease all of which were risk factors for HIV infection. He ultimately developed
severe HIV disease, which was unrecognized for several years until he was finally admitted to a
hospital, where he died of severe complications of his undiagnosed and untreated HIV disease.
Sentinel cases such as these should prompt an investigation into why the system failed to
timely screen, diagnose, and treat this patient, whose death was preventable. The infection
control nurse should monitor results of HIV and HCV screening to verify that policies to screen
for communicable diseases are effective.
All five of the facilities visited report cases of culture positive Methicillin-resistant
Staphylococcus Aureus (MRSA) as is required by IDOC. However, only MCC tracks all skin and
soft tissue infections (independent of whether a culture is performed) as recommended by the
First Court Expert. In addition, tracking should include culture and sensitivity results to ensure
correct antibiotic selection and housing location of the patient. Infection control nurses should
review tracking results to identify clusters of infections by housing unit, perform additional
case-finding, and identify environmental factors that may be promoting infection. Factors in
correctional settings found to contribute to skin and soft tissue infections include sharing
towels and soap, ineffective laundry practices, poor sanitation of exercise equipment and
showering facilities, poor hygiene practices, unnoticed infections that leak pus, and poor access
to medical care.179 Tracking enables sources of infection to be identified and steps taken to
eliminate factors associated with disease transmission. For example, at MCC one of two cases
of skin infection reviewed was a patient who developed infection six days after hernia surgery
and having been returned immediately to general population at the facility.180 This case of soft
tissue skin infection raises questions about the ability of the patient to adhere to wound care
instructions and suggests consideration of a policy of admitting inmates to the infirmary only
after it is determined that the patient is stable and able to adhere to wound care instructions.

Opt-out testing means that testing will be performed unless the patient refuses the test. Opt-in testing means that the
patient is offered testing and it is performed only upon patient consent. The IDOC has large rates of refusal of HIV testing,
unlike other similar correctional centers that offer opt-out testing. Opt-out testing generally raises the rates of screening.
177 Administrative Directive 04.03.11 Section5 II. F. 5. d.
178 Mortality Review Patient #22.
179 Smith, S. (2013) Infectious Diseases. In L. Schoenly and C. Knox (Eds.) Essentials of Correctional Nursing. New York: Springer.
P. 189.
180 MCC Infection Control Patient #7.
176

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The IDOC requires a monthly report of communicable diseases and infection control data. This
report includes items such as the number of MRSA cases, HIV and HCV tests performed, the
number of tuberculin skin tests administered, the use of negative pressure rooms, etc. We
found that these reports are submitted to the Quality Improvement Committee (QIC) and
included in the monthly minutes. However, there is no trending or analysis of infection control
data. There is no discussion in the infection control report or CQI minutes of, for example, why
only half of incoming inmates are tested for HIV, given the statewide opt-out policy. A more
notable example of the lack of introspection about communicable and infectious disease are
three needle stick injuries which occurred in 2017 at Dixon, and the fact that there has been no
focused review of these injuries to determine what measures would increase worker safety.
We found numerous examples of poor infection control practices on the part of health care
professionals. At all facilities, inmates are not routinely provided eye protection during dental
procedures. At NRC, the dentist examined patients without changing gloves between patients
and reached into a bag of sterile mirrors to select one for use, contaminating all the other
mirrors which were then used on subsequent patients. At SCC, the hemodialysis unit does not
have a dedicated chair and technician for dialysis of patients who have hepatitis B, thereby
exposing other dialysis patients to this blood borne infection. At NRC and SCC, paper barriers
are not available to use on any of the examination tables and they are not cleaned between
patients. Finally, the order in which instruments were sterilized was incorrect in four of five
facilities we visited. The placement of sterilization equipment and procedures should proceed
from dirty to sterilized. At four of five facilities we visited, the placement of the ultrasonic
cleaner required clean instruments to pass over the dirty area, thus contaminating their
sterilization. At SCC, sterilized instruments were removed from their packages and put in an
open bin in the trauma room, making them clean, rather than sterile, instruments. The nursing
supervisor could not explain why these instruments were clean rather than sterile.
Inmate porters are assigned to work in the health care areas of each of the five facilities we
visited. At only two of the facilities had the inmate porters received training in how to clean and
sanitize patient care areas, and how to take personal protective measures before working in
the health care area. Only two facilities had vaccinated the inmate porters for viral hepatitis.
The assignment of untrained and unvaccinated inmates to clean and sanitize health care areas
exposes these inmates as well as patients receiving care to several infectious diseases with
potentially serious health consequences, and is deliberately reckless.
Infirmary linens are still laundered in residential style washers and dryers at all the facilities we
visited, except NRC. At NRC, a log provided by the institution showed water temperatures were
less than the 165°F required by AD 05.02.180 about 30% of the days reviewed. Water
temperatures were not hot enough to effectively sanitize laundry from the infirmary at any
facility we visited. We also observed furniture and equipment throughout each of the health
care areas at every facility we visited that was torn, frayed, rusted, and corroded. These
objects, including stretchers, exam tables, stools, cabinets, and work surfaces cannot be
properly sanitized and are sources of communicable disease in a setting that treats and cares
for patients who are ill, medically fragile, and immunocompromised. While some have been
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identified as needing repair or replacement, the safety and sanitation rounds do not often
include these health care areas and there is no effective tracking of the repair or replacement
of these items. It is understood that it takes time to repair or replace worn equipment, but in
IDOC the volume of items needing repair and the length of time that unacceptable conditions
linger indicate pervasive and systemic problems with environmental controls to prevent
communicable disease.
The First Court Expert noted that the Communicable and Infectious Diseases Coordinator in the
Office of Health Services retired some time ago and that the position was never filled. That is
true today as well. There is no one in the Office of Health Services who has responsibility
statewide to direct and oversee infection control in the IDOC. The IDOC also does not have an
infectious disease physician responsible for directing infection control activity within the
department. The Infection Control Manual was last updated in 2012, and many of the resources
in the manual are out of date or more current material is available. The facility health care
programs have some policies and procedures for infection control, but we found these also not
up to date. Nursing Treatment Protocols are also provided by the IDOC for possible infections
such as scabies, rash, urinary infection, pediculosis, chicken pox, and skin infections. These were
last updated in March 2017 and are adequate, but stand-alone rather than as part of a
comprehensive infectious disease program. The need for statewide oversight is evident to
resolve issues, such as the conflict between the IDOC practice of HIV opt-out testing and the
AD, to eliminate the continued insufficient laundering of infirmary linens, to address the
problem of needle stick injuries, to provide meaningful analysis of communicable disease
surveillance, and to provide guidance to facility health care programs on infection control
performance expectations.

Mortality Reviews
Methodology: We interviewed the Agency Medical Director and senior leadership of Wexford,
reviewed death summaries, and reviewed death records.
First Court Expert Findings
The First Court Expert and his team evaluated a total of 63 deaths records. There were one or
more significant lapses of care in 38 (60%) of cases. Of cases with significant lapses, 34 (89%)
had more than one lapse. The internal IDOC mortality review process was seriously flawed.
Reviews are performed by the doctor most closely involved in care of the patient. Twenty (52%)
of death summaries were reviewed. In none were any lapses of care identified. Only a few
deaths were reviewed by the Office of Health Services, but these were selected based on lapses
identified by local review. The First Court Expert found that for many patients who were
chronically ill with terminal conditions there were no resources in place to assist health care
staff with management of end of life symptoms. As well, the First Court Expert found that once
a patient signed a do-not-resuscitate order, they were no longer treated even for simple
reversible illness.
Current Findings
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We confirmed all the First Court Expert’s findings and found additional evidence of clinical
lapses of care with respect to deaths. We added a perspective of preventable deaths because
preventable deaths reflect the degree of harm to patients.
The U.S. Department of Justice (USDOJ) tracks inmate deaths.181 For 2014, the latest year of
available statistics, The IDOC had the sixth lowest mortality rate (182/100,000 inmates) of the
50 state systems. The average mortality rate of state correctional systems was 275 per 100,000
inmates. The IDOC, in their comments on our report, assert that “the low IDOC mortality rate
would be representative of a health system functioning at or above the norm of its
comparators.”182 However, these data are not adjusted183 for any risk or variable. According to
the Department of Justice authors, “overall mortality rates and mortality rates by state and by
cause of death may not be directly compared between states due to differences in age, sex,
race or Hispanic origin, and other decedent characteristics.”184 It is misleading to use crude
mortality rates alone to compare quality of health care of different prison systems without any
adjustment for these multiple variables.185 As the IDOC states later in their comments on our
report, specifically about use of hepatitis C and age as they relate to mortality, “One would
have to conduct an adjusted multivariable statistical analysis with complete and comparable
data from all other state DOCs to examine the independent contributions of age and hepatitis C
to the variation in mortality rates across systems.” We agree with that statement and note that
to the best of our knowledge, reliable risk, age, and sex adjusted mortality rates are not
available, allowing for use of crude mortality data to compare medical care between state
prison systems.
The Court has asked the Expert to “assist the Court in determining whether the Illinois
Department of Corrections (IDOC) is providing health care services to the offenders in its
custody that meet the minimum constitutional standard of adequacy.” We have used mortality
review to identify quality of care and systemic issues that can provide definitive information in
Mortality in State Prisons, 2001-2014 – Statistical Tables; Margaret Noonan, US Department of Justice, Bureau of Justice
Statistics, December 2016, NCJ250150.
182 Letter via email from John Hayes and Michael Arnold, Office of the Attorney General to Dr. Puisis: Re: Lippert v. Baldwin, No.
10-cv-4603 – Defendants’ comments to the Draft Report of the 2nd Court Appointed Expert dated September 10, 2018.
183 Adjusting allows for comparison of different populations by reducing variations and to standardize populations. Adjustment
is a statistical technique to reduce variability between populations when multiple variables affect the outcome. This allows for
different populations to be compared.
184 Page 2, bullet on Deaths reported by state in Mortality in State Prisons, 2001-2014 – Statistical Tables; Margaret Noonan, US
Department of Justice, Bureau of Justice Statistics, December 2016, NCJ250150.
185 To support the assertion that the IDOC mortality rate indicates above average medical care, the State references a study
from Centers for Medicare & Medicaid Services (CMS). This study was a study of hospitalized patients. CMS used a “riskstandardized rate of mortality within 30 days of hospital admission” for their study and studied only patients over 65 years of
age. According to the CMS report (Hospital-Side All-Condition, All-Procedure Risk-Standardized Mortality Measure: Draft
Measure Methodology for Interim Public Comment prepared by Centers for Medicare & Medicaid Services (CMS) October 2016
as found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/HospitalWide_All-Condition_All-Procedure_Risk-Standardized-Mortality-Measure_Public-Comment.pdf) they adjusted for case mix,
types of conditions, and procedures of patients; did not include patients if 30-day mortality could not be reasonably considered
a signal of quality; and did not include patients under 65 years of age. This methodology does not make the case that use of
crude prison mortality can be used as a measure of quality of medical care, as the crude mortality rates did not adjust for any
variables affecting prison populations.
181

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answering the Court’s question. We performed in-depth evaluations of 33 deaths. These
mortality reviews identified numerous quality of care issues that are systemic and are
important in answering the question required by the Court. These reviews demonstrate
significant systemic and quality of care issues that were confirmed in site-visit record reviews,
on-site observations, and interviews.
Of the deaths that occur, it is critical to understand whether mortality is preventable or
demonstrates correctable errors. For this purpose, correctional programs typically perform
organized mortality review. Organized mortality review should be performed for every death.
Participants in this review should be senior physicians, administrative and nursing staff, and
other senior leaders of relevant disciplines whose services may have had an impact on the
death (e.g., pharmacy, mental health, etc.). Generally, most correctional centers include a
custody representative in mortality review meetings. Persons directly responsible for care of
the patient are interviewed for their perspective on the care they rendered. However, persons
who cared for the patient should never be placed in positions of reviewing the death, as they
could not be expected to give an unbiased review.
Mortality reviews typically review care as far back as necessary to understand the evolution of
the patient’s illness and can be six months to a year or more. Mortality reviews should be
constituted as to identify errors and problems with care. These errors and problems need to be
addressed in a follow-up manner (typically through quality improvement corrective actions or
investigations) so as to prevent the error or problem from occurring again.
There were 174 deaths in the IDOC in 2016 and 2017.186 We intended to review 89 death
records but because of time limitations we were only able to review 33 (19%) deaths from 12
facilities, which is a sample of 46% of the IDOC facilities. Eleven of 33 deaths were preventable.
Eight of 33 were possibly preventable. Nineteen (58%) of the 33 deaths reviewed were either
preventable or possibly preventable. This is an extraordinary number of preventable or possibly
preventable deaths and speaks to the ongoing serious harm to patients from care in the IDOC.
We do not assert that this sample can be extrapolated to the entire population. However, even
if there were only 19 preventable or possibly preventable deaths out of the 174 deaths, that
would be 11% of the deaths, which is still a very high number. Our findings confirmed the First
Court Expert’s report that none of the Wexford death summaries identified any problems. All of
the Wexford death summaries that we were provided were performed by physicians who were
responsible for care of the patient and failed to identify any problems, even when grossly and
flagrantly unacceptable care was provided.
We reviewed two years of care as documented in the health record for most of the 33 deaths.
The reviews were detailed reviews of individual episodes of care. We have provided the
spreadsheets which give detail on every episode of care reviewed as well as detailed narrative
Defendants stated in their comments that we requested 174 death records, but this was inaccurate. There were a total of
174 deaths in 2016 and 2017. Of these deaths we chose 89 records to review. We asked to receive death records in December
2017, but did not receive records until March 2018 and received almost all records by April of 2018, well into our investigation.
186

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summaries for each death.187 We identified 1757 errors in care. Many of these were common
errors, but many were serious. These errors reflect poor primary care knowledge and training.
Most were related to primary care functions, such as taking adequate history, examining the
patient, and developing a treatment plan, which accounted for almost half of errors. In our
opinion, this demonstrates the lack of primary care training of the medical staff. About 8% of
errors were nursing errors related to nurses not referring or consulting a physician for serious
problems such as abnormal vital signs, red-flag symptoms or signs, or other serious
abnormalities. Approximately 10% of errors were related to not referring a patient to a
specialist or for special testing. This verifies our finding that significant underutilization occurs
in the IDOC. About 5% of errors were related to not timely sending patients to a hospital for
evaluation. Many of these errors contributed significantly to the deaths.
The 33 death record reviews contained 73 episodes of grossly and flagrantly unacceptable care.
For a few record reviews, there was a repetitive pattern of inappropriate care that in aggregate
constituted grossly and flagrantly unacceptable care. This type of care is so egregious that it
would typically result in a peer review for possible reduction of privileges or referral to licensing
boards for evaluation of sanction of their license. These are serious errors. A sampling of these
included the following:
•

A 30-year-old man was in the process of valve replacement surgery for a congenital
heart condition when he was incarcerated.188 IDOC physicians failed to contact his
cardiologist and his planned surgery was never recognized, even though a letter from his
civilian cardiologist recommending surgery was in the IDOC medical record. He was
routinely referred to UIC cardiology, who requested an echocardiogram and old records
because the history was uncertain. The echocardiogram report documented that valve
surgery was indicated. This report was never obtained or reviewed. When the patient
developed arrhythmia, hypotension, and near syncope, a doctor failed to take action.
The patient’s diagnosis was unknown for six months of incarceration and he died of
complications of his congenital heart problem without IDOC physicians ever knowing
what his diagnosis was.

•

A patient had diabetes, decompensated cirrhosis, and an unknown skin condition.189
She developed fever (101.8°F), hypotension (88/50), and periorbital swelling. Her
condition indicated sepsis and warranted hospitalization, yet the patient was treated
without a diagnosis with oral Bactrim, pushing fluids, and Tylenol with infirmary
admission by phone consultation. The doctor stated he would consider laboratory tests
and a chest x-ray in the morning. The next day, the doctor noted right upper quadrant
pain with a distended abdomen. The doctor ordered routine labs and diagnosed fever.
Two days after infirmary admission, the doctor referred the patient to a hospital when
the blood pressure was 60/palpable. When the patient returned from the hospital there

187 The spreadsheet detailing episodes of care is included as an appendix to this report. Also, a table of the breakdown of the
1757 errors is also listed as an appendix to the mortality narrative summary.
188 Mortality Review Patient #2.
189 Mortality Review Patient #6.

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was no report and it was not clear that staff knew what occurred. The day the patient
returned from the hospital, she vomited dark red emesis and was hypotensive (75/48).
The only order was to “continue present management.” The patient had repeated
episodes (four) of bloody emesis during the night. The doctor was called at home but
took no action. In the morning and when the patient was in shock, the doctor obtained
a “do not resuscitate” (DNR) order from the patient. Her barely legible signature did not
match her typical signature and the signature appeared to have been obtained under
duress. After obtaining a DNR, the doctor sent the patient to the hospital, where no
intervention was taken because of the DNR order. The patient expired of bleeding
varices.

190
191

•

A 51-year-old had headache, complaint of fever, and vomiting.190 Treatment for this
condition was infirmary admission, IV fluid, and intravenous antibiotics for presumed
pharyngitis. These signs were inconsistent with pharyngitis. The patient continued to
vomit, yet continued to be managed for pharyngitis. The provider ordered labs on the
second infirmary day that were not done. Later, on the second day on the infirmary, the
patient developed altered mental status and hypothermia, and was not responding.
These are red-flag signs. The patient was not sent to a hospital despite signs of acute
sepsis. No laboratory tests had yet been done after two days of infirmary housing. On
the third infirmary day, the patient was found on the floor and would open his eyes only
to severe stimulus. He was not sent to a hospital until he was found unresponsive and in
shock (BP 68/palpable). The patient died in the hospital; there was no autopsy.

•

A 45-year-old mentally ill man developed a firm neck mass.191 He was initially diagnosed
with parotitis, even though the parotid gland is on the face, not the neck, and the
parotid gland demonstrated no evidence of infection. There was therefore a two month
delay in diagnosing his neck cancer. After four months, the patient was still awaiting
treatment when he passed out and had hypotension (60/40). This warranted
hospitalization. The doctor diagnosed loss of consciousness; the plan was to place the
patient on the infirmary for observation without ordering any diagnostic testing.
Radiation therapy was started. About a month after radiation started, the patient was
hospitalized for chemotherapy. A day after return from the hospital, the patient was
found on the floor and was lethargic and unresponsive. A nurse called a doctor who
ordered “neuro checks,” but did not send the patient to a hospital. The following day,
the patient had a single dilated pupil consistent with brain damage, a red-flag sign that
should have resulted in immediate hospitalization. The doctor ordered morphine for
unclear reasons. Later that day a doctor evaluated the patient and noted that the
patient had a fall the day before. The doctor did not examine the patient and apparently
failed to note the dilated pupil. The doctor took no action except to increase morphine.
The following day the patient was found unresponsive and was sent to a hospital, where

Mortality Review Patient #7.
Mortality Review Patient #8.

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he died. A hospital EKG showed that the patient was in atrial fibrillation. One of the side
effects of atrial fibrillation is stroke, which may have accounted for the dilated pupil.
•

A 24-year-old with mental illness swallowed two plastic sporks (combination spoon and
fork) that was witnessed by a correctional officer.192 A doctor did not evaluate the
patient but ordered an x-ray, which would not likely show the ingested plastic item. The
x-rays were normal. About two and a half months later, a nurse practitioner evaluated
the patient. The NP failed to recognize a 33-pound weight loss, but the patient did tell
the NP that he had swallowed a spork a long time ago and needed it removed. The NP
made an assessment that the patient had an ingested spork but took no action. The
patient remained untreated and eventually lost 54 pounds and had repeated episodes
of abdominal pain with an inability to eat without pain, nausea, and diarrhea. Eventually
the patient was found unresponsive, was sent to a hospital, and died. On autopsy, the
two swallowed sporks were found having caused esophageal perforation, which was the
cause of death.

•

A 70-year-old man with atrial fibrillation and severe bradycardia needed and received a
pacemaker.193 Two years after the pacemaker was inserted, the patient experienced leg
edema, weight gain, and had signs of heart failure (BNP 712; shortness of breath,
orthopnea, and edema). Although the doctor noted a heart rate of 44 and questioned
whether the pacemaker was functioning, the doctor took no action with respect to the
pacemaker. An EKG showed aberrant ventricular conduction with ventricular escape,
indicating pacemaker malfunction. The patient needed immediate hospital admission,
but the doctor only admitted the patient to the infirmary and treated for heart failure
on the infirmary. The patient continued to have low heart rate and began complaining
of chest pain. If the pacemaker was functioning, the heart rate would not be expected
to fall below the set point of the pacemaker, so it was clear the pacemaker was not
functioning. Yet the doctor took no action. Two days later, the patient was found dead.

•

A 75-year-old man experienced weight loss and anemia, yet was never offered
colonoscopy.194 He had pancytopenia, which corrected to anemia; and
thrombocytopenia, low albumin, and weight loss, but was not evaluated for these
problems. He had a prosthetic leg from prior amputation from osteomyelitis and the
prosthesis was causing an ulcer. Wexford initially denied repair of the prosthesis but
then authorized a limited repair, which failed to correct the problem. The patient began
using a wheelchair because of the problem with the prosthesis. After using the
wheelchair, the patient developed a pressure ulcer on his buttock which was
inadequately monitored. The patient was kept in general population. The ulcer began
draining pus and a sedimentation rate of 60 indicated possible osteomyelitis (infection
of bone), yet no evaluation occurred. The pressure ulcer worsened, yet providers failed

Mortality Review Patient #15.
Mortality Review Patient #18.
194 Mortality Review Patient #19.
192
193

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to manage the pressure ulcer in accordance with contemporary standards, and
appeared not to know how to manage the patient. Instead of referring to a skilled
nursing unit, the patient was still housed for a long period of time in general population.
Nurses described a tunneling wound draining pus and at one point even showing bone,
yet providers failed to document a thorough examination of the wound and even
described the wound as “healthy,” without ordering any diagnostic studies to eliminate
osteomyelitis. The patient lost 42 pounds. Despite these abnormal findings, the patient
was kept in general population, where eventually a cell mate reported that the patient
had not eaten in two days. A nurse placed the patient on the infirmary and called a
doctor, who ordered IV antibiotics by phone without diagnosis. Later that day, the
patient was found unresponsive and was sent to a hospital, where he died. He had
overwhelming sepsis, with both bacteria and fungus growing in blood cultures, likely
from his infected pressure ulcers.
•

Another 72-year-old patient was inadequately evaluated over an eight-month period for
abdominal pain, but eventually was sent to an emergency room, where a CT scan
showed a large retroperitoneal mass consistent with cancer.195 The patient was sent
back to the prison with a recommendation for outpatient work up. One would expect
this to be worked up within weeks. This did not occur. The patient had lost 50 pounds.
Over three subsequent months a work up did not take place, although referrals were
made. The patient was not monitored well. Eventually, while in general population, the
patient developed pressure ulcers and had significant weight loss, yet he was not
housed on the infirmary. Three months after the diagnosis of the mass, the patient was
admitted to the infirmary only because security complained that he could not be
managed in general population. He was admitted as a chronic care patient. The day
following admission to the infirmary, a doctor noted that the patient was confused,
which was a red-flag sign, but undertook no evaluation. This was a new diagnosis and
the patient should have been hospitalized. Two days later, the patient remained
confused and was incontinent but was still not evaluated or sent to a hospital. That day
the patient became delirious and was talking to people in his cell who weren’t there. A
nurse referred the patient to mental health. Two days later, the patient still had no
evaluation and was noted to be lethargic, confused, mumbling unintelligibly. A doctor
took no action. Later that day the patient was sent to a hospital for lethargy and uneven
respirations. The patient died in the hospital never having a diagnosis of his
retroperitoneal mass found over three months ago.

•

Another 46-year-old man had neutropenia196 for over three years without appropriate
evaluation.197 The patient had intermittent fevers and altered mental status for over a
year without appropriate evaluation. The patient had confusion and was incontinent
without recognizing that it was inappropriate, yet evaluation for serious central nervous

Mortality Review Patient #21.
Neutropenia is a low white count. In this case the patient had low lymphocytes, one of the white blood cell types. This
element, when low, is consistent with HIV infection and should have prompted that test.
197 Mortality Review Patient #22.
195
196

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system disorder was not done. The doctor, who was a surgeon, inappropriately believed
that the patient had lupus, a collagen vascular disorder, which was an incompetent
diagnosis and unquestionably related to his lack of primary care training. A
rheumatologist initially refused to see the patient because the patient did not have
serologic evidence of lupus. A rheumatologist eventually saw the patient almost a year
later and again confirmed that the patient was unlikely to have lupus. Despite the
confusion, the patient was kept in general population. Eventually, the doctor provided
the patient with an assistive device without attempting diagnosis of his difficulty
ambulating. The doctor took virtually no history and performed virtually no
examinations for extended periods of time. The patient was mistakenly given
methotrexate, a medication that can lower white counts. Eventually the patient was
unable to walk and was given a wheelchair. When he developed severe hypoxemia
(70%), hypotension (90/66) and tachycardia (128), he was sent to a hospital, where
septic shock and HIV infection were diagnosed. He died in the hospital with an AIDSrelated central nervous system disorder and disseminated systemic infection, never
having been appropriately evaluated at the prison for his problem. The patient was
described as having multiple pustular lesions on his left leg, right foot, right hip, penis,
and abrasions on the hip and shoulder, none of which were recognized at the prison.
The patient also had severe unrecognized malnutrition. We incidentally note that this
patient was evaluated at least twice on annual examinations and had risk factors for HIV
infection (blood transfusions, multiple sexual partners, and a sexually transmitted
disease), and yet was never offered HIV testing.
•

198

Another patient had hepatitis C and cirrhosis evident as early as June of 2012, yet facility
providers failed to list cirrhosis as a problem and did not monitor the patient for this
condition.198 Doctors did not initially order tests typically ordered for cirrhosis (EGD to
screen for varices and ultrasound to screen for hepatocellular carcinoma) and the
patient was not monitored for ascites. In May of 2015, the patient eventually received
an ultrasound, which showed a liver mass. A CT scan later that month confirmed a liver
mass. The patient was referred for interventional radiology for a biopsy in August 2015,
but this was denied by Wexford UM and instead an MRI was recommended. The reason
was unclear, as a biopsy was indicated. An MRI was done in October but a biopsy was
never done. The patient developed hypoxemia (oxygen saturation of 79%) with
hypotension (96/64) and the patient was admitted to the infirmary, but should have
been admitted to a hospital. The day following admission to the infirmary the patient
developed fever, but no action was taken. The patient had massive ascites, fever,
hypotension, and hypoxemia, yet was kept on the infirmary. The following day the
patient again developed hypotension (88/60) and hypoxemia (84%) on four liters of
oxygen and was sent to a hospital, where he died. The delay in transfer to a hospital
contributed to his death. He also never had a biopsy of his liver mass and therefore
never had a diagnosis.

Mortality Review Patient #23.

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199
200

•

Another patient was being treated for a lymphoma but treatment was delayed four
months.199 The chemotherapy treatment resulted in low white counts, for which
medication was prescribed (Granix) to be administered after chemotherapy to raise the
white count. After one of the chemotherapy sessions, the patient failed to receive the
Granix. After this error, the patient developed fever and inability to stand
independently. This was a red-flag sign indicating infection and warranting
hospitalization, but instead the patient was placed on a medical housing unit without
any diagnostic intervention. Two days later the patient had nausea and diarrhea and
fever of 101°F. This was a life-threatening status and red-flag warning, and the patient
should have been admitted to a hospital; instead, a doctor started oral antibiotics
without ordering laboratory tests (WBC, platelets, blood cultures, or other diagnostic
tests for infection). The following day the patient was hypotensive (90/60) and felt sick,
but no action was taken. On the third day on the medical housing unit the patient
developed pus draining from his ear, a red-flag sign in a potentially neutropenic patient,
yet the doctor only ordered a blood count and metabolic panel, tests which were never
done. The following day the doctor again noted pus coming from the ear and ordered
intravenous Levaquin for otitis externa, which is not a typical plan for otitis externa. This
patient needed admission to the hospital, as he had life threatening status. He was not
seen for three days when he was found unresponsive, bleeding from his mouth and
penis, with a 101°F fever and in shock. He was finally hospitalized. The bleeding and
fever were most likely due to complications of his chemotherapy, after which the
patient failed to receive necessary medication. The patient apparently expired in the
hospital.

•

Another patient, a 66-year-old African American man with history of hypertension, high
blood lipids, diabetes, asthma, and chronic kidney disease was only being monitored for
hypertension, diabetes, asthma, and high blood lipids.200 He had poorly controlled
diabetes, was a smoker, and had hypertension yielding a 46% 10-year risk of heart
disease or stroke, yet was only on a low-intensity statin. His diabetes was poorly
controlled for two years. The patient had repeated episodes of shortness of breath with
exertion yet was not evaluated with appropriate testing (EKG, echocardiogram, stress
test, or pulmonary function test), even though the diagnosis was uncertain. Shortness of
breath can be a sign of angina. On 1/28/16, a doctor saw the patient for chest pain with
elevated blood pressure (169/94). The EKG was equivocal, showing non-specific STT
wave changes, which can be consistent with angina. The doctor, however, noted no
acute changes on the EKG and told the patient he would need a cardiac treadmill after
he paroled. The doctor increased Norvasc for the blood pressure. This was indifferent,
as work-up of the angina should not be delayed until the patient paroled. Ten weeks
later, the patient experienced shortness of breath and oxygen saturation of 85%. A
doctor started Lasix by phone, but the oxygen saturation decreased to the 60s. The

Mortality Review Patient #25.
Mortality Review Patient #28.

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patient was sent to the hospital, but expired. Autopsy showed an active plaque rupture
consistent with myocardial infarction.
•

Another patient had prior traumatic injury resulting in a VP201 shunt in his brain.202 He
also had seizure disorder and history of deep vein thrombosis. The patient also had an
IVC filter,203 but this was unrecognized at IDOC facilities. He was also treated with
Coumadin, an anticoagulant, and aspirin. The reason for being on aspirin was not
documented, but this placed the patient at risk for life-threatening bleeding. There was
no indication for aspirin. IVC filters are typically used when there is a contraindication to
anticoagulation, such as the repeated seizures the patient had. When an IVC filter is
used in conjunction with anticoagulation medication, a specialist should be consulted.
Typically, when an IVC filter is used, the patient is not treated with anticoagulation. The
patient had repeated seizures but was nevertheless not sent to a neurologist, although
doctors could not manage the seizures. The patient was transferred to the Hill facility;
after transferring he experienced repeated seizures and was hospitalized. The patient
was found to have pseudoseizures.204 After hospitalization, the patient was admitted to
the infirmary. On admission, a NP noted that the patient had ataxia and unequal pupils,
which are red-flag signs of central nervous system disease. The patient had a recent
normal CT scan in the hospital. Nevertheless, unequal pupils and ataxia, particularly in a
patient with a VP shunt, are serious signs which warranted immediate re-hospitalization
or confirmation with the hospital regarding the prior diagnoses. The patient was
unsteady, and instead of hospitalizing the patient, the NP placed his mattress on the
floor. The patient remained on the infirmary for three weeks. The patient experienced
progressively deteriorating altered mental status. He was noted by nurses to be unable
to stand, incontinent, and not responsive for several weeks. Yet during this time there
was no adequate neurologic examination of the patient, despite his ataxia and unequal
pupils. The patient also developed bruising over elbows, then buttock, back, arms, and
legs. Yet despite being on Coumadin and aspirin, the doctor did not order an INR a test
to measure whether the patient was over anticoagulated. The grossly and flagrantly
unacceptable care continued for weeks until the patient began urinating blood. Still, the
doctor only incompetently treated for a presumed UTI. The doctor still did not check an
INR. The patient had gross bleeding for several days with bleeding from urine, from
bruises on his back, from a nasal laceration, and in his stool. He developed bleeding
around his eyes spontaneously. Still no action was taken. Finally, a nurse found the

Normally, cerebrospinal fluid circulates in the ventricles of the brain. Due to injury or congenital abnormalities, there may be
defects which cause the cerebrospinal fluid to accumulate, causing excess pressure on the brain. In order to resolve this, a
drainage system is created to drain cerebrospinal fluid from the brain to the peritoneal cavity. This ventriculo-peritoneal (VP)
shunt is subject to blockage and when a person has a VP shunt, any alteration of mental status should prompt evaluation of the
shunt by brain imaging to ensure that excess fluid is not accumulating in the brain.
202 Mortality Review Patient #30.
203 An IVC filter is a filter placed in the inferior vena cava to block thromboses from the legs. Typically, when IVC filters are used,
anticoagulation is not necessary. This patient probably had the IVC filter because of history of repeated seizures which placed
the patient at risk for intracranial bleeding. Yet this IVC filter was unrecognized throughout his incarceration.
204 This is seizure-like activity without corresponding EEG abnormalities of brainwaves, indicating that the episode is
psychogenic.
201

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patient unresponsive, with new bruises on his hip and head, and fixed pupils bilaterally.
The patient was finally sent to a hospital. At the hospital, the INR was 10 and the patient
had a massive subdural bleed causing a brain shift and herniation. The diagnosis was
hypercoagulable state from Coumadin causing brain hematoma and herniation.
•

205

Another patient was a 58-year-old man who was transferred to Robinson from
Graham.205 He had high blood pressure for at least seven months, but it was not
treated. He also had elevated risk for heart disease for at least seven months, but was
not treated with a statin. The patient was bleeding from his rectum, but never received
a colonoscopy and was continued on non-steroidal medication. After being at Robinson
for about six months, the patient experienced chest pain with nausea and dyspnea, with
blood pressure 200/118 and pulse of 129. An EKG showed new onset atrial fibrillation
with marked ST depression in lateral leads. This is consistent with acute coronary
syndrome and warrants immediate hospitalization and cardiac catheterization. Even the
automated reading said, “immediate clinical assessment of this individual is strongly
recommended.” Instead, a nurse called a doctor, who gave an order by phone for single
doses of Inderal and clonidine. The patient was having acute coronary syndrome and
should have been hospitalized for immediate catheterization. The following day, the
doctor took a history of typical chest angina with exertional squeezing, chest pain
associated with nausea, and shortness of breath. Another EKG was done, and the atrial
fibrillation was no longer present. Instead of immediately obtaining cardiac
catheterization or cardiology evaluation, the doctor started a statin and aspirin but no
anti-angina medication. Weeks later, a family member called with concern that the
patient was having chest pain when walking to the dining hall. An administrator
scheduled a routine referral to a physician, who instead of admitting the patient for
catheterization ordered the patient a wheelchair. The doctor added Norvasc for
elevated blood pressure. This potentially could have increased the risk for myocardial
infarction. The patient had another episode of exertional chest pain with shortness of
breath diagnosed as chest wall pain. After another episode of chest pain, a nurse
obtained an EKG that again showed ST segment depression consistent with acute
ischemia, warranting immediate hospitalization and catheterization. Instead, a doctor
ordered 23-hour observation without any intervention. The nurse told the patient to
change his job assignment so he wouldn’t have to work in a job that precipitated chest
pain. Four days after this episode, the doctor referred the patient for a routine stress
test. Instead of a stress test, the Wexford UM program had the patient referred for a
routine cardiology appointment, which would ultimately delay the cardiac intervention.
This appointment occurred a month later. The cardiologist recommended cardiac
catheterization “in the near future.” About two weeks later, the patient again developed
chest pain. A nurse obtained an EKG that showed atrial fibrillation, which the nurse
described as “A fib same as previous.” This should have resulted in immediate
hospitalization. Instead, a doctor ordered 23-hour observation without intervention.
About six hours later, the patient was found on the floor with a forehead laceration and

Mortality Review Patient #33.

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surrounded by vomit. He had no pulse or respirations and was transferred to a hospital,
where he was pronounced dead.
At least nine of 19 of preventable or possibly preventable deaths were cared for by poorly
trained physicians. One preventable death involved care by a nuclear radiologist. Two involved
care by a surgeon. Three preventable and two possibly preventable deaths involved care by
another surgeon. Another death involved care by a doctor who had a year of training in
pathology. The remaining doctors either had illegible signatures or we were unable to
determine their training because we did not have credentials for them. It is our firm opinion
that the lack of primary care physicians in the IDOC health care system is resulting in
preventable deaths, which shows a gross departure from normal standards of care.
The IDOC leadership is unaware that they have preventable deaths. Both Dr. Meeks and a
Regional Coordinator testified that the Regional Coordinators perform mortality review.206 We
have asked for but have not received these Regional Coordinator mortality reviews. The Agency
Medical Director does not independently conduct mortality review. Dr. Meeks stated that
Wexford performs a mortality summary, but there is no formal Wexford mortality review that
we were provided. The Regional Coordinators are nurses and would not be able to effectively
review physician care or identify if it was adequate or inadequate. These reviews, if done, are
insufficient as mortality review. One of the Regional Coordinators, who is responsible for a
region where we found preventable death, testified that none of the death reviews he
performed indicated inadequate care.207 Wexford does not perform mortality review; instead,
it completes a death summary, which is a non-critical summary of the death. This is done by the
Medical Director of the site who is often the same doctor who cared for the patient and who
often was responsible for the incompetent care. The 2011 contract with Wexford has no
requirement for mortality review; its only requirement is that there shall be documentation of
deaths.208 Wexford has no process to critically review deaths and therefore any critical clinical
deficiencies are unnoticed and unmonitored, resulting in ongoing harm to patients in the IDOC.
Identification of errors can be perceived by the vendor as well as the IDOC as a liability concern.
This possibility may result in failure to identify errors or to hide errors to reduce their liability
and protect their reputation. If this occurs, significant errors remain unaddressed. The needs of
the jurisdiction and vendor, however, should not be contraposed to the needs to protect
patient safety. The system of mortality review should be constructed to protect patient safety.
For these reasons, when vendors provide medical care, the hiring authority should lead or
participate in mortality review to ensure that patients are protected and/or an independent
evaluator should perform this review. In this respect, we agree with the First Court Expert on
his recommendation to have an independent reviewer of all deaths.

Page 34 deposition of Joseph Ssenfuma, Regional Coordinator, on September 28, 2017 and page 34, 30(b)(6) deposition of
Dr. Meeks on July 25, 2017.
207 Page 35 deposition of Joseph Ssenfuma, Regional Coordinator, on September 28, 2017.
208 Item 7.1.2.1.2 Contract between Wexford Health Sources Inc. and Illinois Department of Healthcare and Family Services
signed on 5/6/11.
206

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Dental Program
Dental: Executive Summary

While aspects of the dental programs at some prisons we visited have improved and others
have declined, the net result is a worsening of the dental programs since the First Court
Expert’s Report. Our visits confirmed most of the First Court Expert’s findings and identified
issues the First Court Expert did not mention. Based on the prisons we visited, IDOC dental care
remains not minimally adequate; and it is substantially below accepted professional standards
despite the four years the IDOC and Wexford had to remedy the previously identified program
deficiencies.

Dental: Staffing and Credentialing

Methodology: Reviewed staffing documents, interviewed dental staff, reviewed the Dental Sick
Call Logs, and other documents.
First Court Expert Findings
Most staffing was adequate and in compliance with Administrative Directive 04.03.102, Section
9, a, b, and c. Glaring omissions were the lack of dental hygienists at Dixon and Henry Hill
Correctional Centers. Dental hygienists are an essential part of the dental team.
Current Findings
Staffing has deteriorated since the First Court Expert’s Report. We concur with the First Court
Expert’s finding that dental hygienists are essential members of the dental team and should be
on staff at all IDOC facilities.209 Notwithstanding the finding that staffing followed
Administrative Directive 04.03.102, we found staffing (primarily dentist) shortages at several
facilities due to IDOC’s and Wexford’s inability or unwillingness to fill vacancies timely.210
Adequate staffing requires the appropriate number and mix of dental personnel positions and
that these positions be filled. While NRC and SCC appear to have adequate dental staffing to
address patient treatment timely, this is not true for Dixon and MCC. In fact, in 2017 MCC
prisoners had to wait more than 15 months for fillings and for dentures. Dixon staffing is
particularly problematic, since there is no dental hygienist and staffing shortages have resulted
in the clinic being closed Mondays for more than a year. It is noteworthy that the Dixon dental
hygienist position has not been established despite the First Expert’s finding that it is essential.
Among the dental program’s systemic inadequacies we identified are under diagnosis and
under treatment of dental disease. Consequently, when diagnosis and treatment become
minimally adequate, the prevalence of diagnosed dental disease will be higher and necessitate
Makrides, N. S., Costa, J. N., Hickey, D. J., Woods, P. D., & Bajuscak, R. (2006). Correctional Dental Services. In M. Puisis (Ed.),
Clinical Practice in Correctional Medicine (2nd ed., pp. 556-564). Philadelphia, PA: Mosby Elsevier, p. 557 (“In prisons where
routine dental care will be provided, the basic dental team should consist of a dentist, dental assistant, and dental hygienist”)
210 For example, MCC has two dentist vacancies. One vacancy is an IDOC position that has been unfilled for approximately two
years. We were told that IDOC has asked Wexford to fill it.
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increased dental staffing. We do not consider this in our assessment of dental staffing but
recognize that this will have to be addressed as part of remediation.

Dental: Facility and Equipment

Methodology: Toured dental clinics, radiology areas, and dental intake areas to assess
cleanliness, infection control procedures, and equipment functionality. Reviewed the quality of
x-rays and compliance with radiologic health regulations.
First Court Expert Findings
Much of the equipment was old, corroded, and badly worn. Cabinetry and countertops were
generally badly worn, corroded, or rusted, broken, and not up to contemporary standards for
disinfection.
Current Findings
Overall, facilities and equipment have deteriorated since the First Court Expert’s Report. We
concur that most of the equipment in the clinics is old and worn, with many chair and counter
surfaces cracked and difficult to decontaminate. Four years have passed since that assessment,
and while some equipment has been replaced, for the most part, equipment has deteriorated.
In addition, we found that the most problematic deficiency to be the inadequate panoramic xray units and processor at NRC, which will be discussed in a later section. Not only are many
panoramic x-rays clinically inadequate but the NRC clinic intraoral film processor been
inoperative for three years and dentists at Dixon have not been able to take intraoral x-rays for
several months. Similarly, the x-ray film processor in the MCC North clinic has been inoperative
and exposed film must be carried to the radiology clinic for processing.

Dental: Sanitation, Safety, and Sterilization/Autoclave Log

Methodology: Reviewed Administrative Directive 04.03.102. Toured dental clinics and dental
intake examination areas. Observed dental treatment room disinfection. Interviewed dental
staff. Observed intake dental examinations and patient treatment. Reviewed last two years of
entries in autoclave log.
First Court Expert Findings
In several institutions, proper sterilization flow was not in place. At one institution, spore
testing of the autoclaves was being performed monthly rather than weekly. At another
institution, bulk storage of biohazardous waste was maintained in open, large cardboard boxes
on pallets in the dental clinic. In none of the clinics were the sterilization area211 and the
radiology area posted with proper hazard warning signs. 212 Safety glasses were seldom worn by
patients.
CFR 1901.145(e)(4). (“The biological hazard warning shall be used to signify the actual or potential presence of a biohazard
and to identify equipment, containers, rooms, materials, experimental animals, or combinations thereof, which contain, or are
contaminated with, viable hazardous agents.”)
212 Occupational Safety and Health Standards – Toxic and Hazardous substances. 29 CFR 1910.1096(e)(3)(i). “Each radiation area
shall be conspicuously posted with a sign or signs bearing the radiation caution symbol and the words, ‘CAUTION RADIATION
AREA’”. Emphasis in original.
211

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Current Findings
Overall, sanitation, sterilization, and, safety have deteriorated since the First Expert’s Report,
primarily due to inadequate hand sanitation at NRC and MCC. However, autoclave log
maintenance has improved at SCC and MCC. We concur with the First Court Expert’s finding of
lack of appropriate warning signs, patient protective eyewear and lead aprons with thyroid
collars not used routinely,213,214,215 and inadequate sterilization flow at several facilities.
However, while the instrument flow was less than ideal, instruments could still be sterilized and
stored adequately.
In addition, we found that surface decontamination was adequate but made challenging by the
cracked and inadequate dental chair surfaces and countertops in many clinics. The most
problematic issue (not found by the First Court Expert) was the inadequate infection control
practices between intake exam patients at NRC, in which the patients were examined by a
dentist who typically did not change gloves (or wipe them with alcohol between exams) and
MCC (where the dentist did not wash his hands or disinfect them with alcohol wipes between
changing gloves).216 That this egregious breach of infection control could occur suggests
inadequate monitoring by Wexford and the IDOC.

Dental: Comprehensive Care/Removable Dental Prosthetics

Comprehensive or routine care (to include removable dental prosthetics) is non-urgent
treatment that should be based on a health history, a thorough intraoral and extraoral
examination, a periodontal assessment, and a visual and radiographic examination. A
sequenced plan (treatment plan) should be generated that maps out the patient’s treatment.
Methodology: Interviewed dental staff, reviewed dental charts of inmates who received nonurgent care to include removable prosthetics, observed dental treatment. Selected charts for
Guidelines for Infection Control in Dental Health-Care Settings ---2003. MMWR, December 19, 2003/ 52(RR17):1:16; pp. 1718. (“PPE [personal protective equipment] is designed to protect the skin and the mucous membranes of the eyes, nose, and
mouth of DHCP [dental health care provider] from exposure to blood or OPIM [other potentially infectious materials]. Use of
rotary dental and surgical instruments (e.g., handpieces or ultrasonic scalers) and air-water syringes creates a visible spray that
contains primarily large-particle droplets of water, saliva, blood, microorganisms, and other debris. This spatter travels only a
short distance and settles out quickly, landing on the floor, nearby operatory surfaces, DHCP, or the patient. The spray also
might contain certain aerosols (i.e., particles of respirable size, <10 µm). Aerosols can remain airborne for extended periods and
can be inhaled” and “Primary PPE used in oral health-care settings includes gloves, surgical masks, protective eyewear, face
shields, and protective clothing (e.g., gowns and jackets). All PPE should be removed before DHCP leave patient-care areas (13).
Reusable PPE (e.g., clinician or patient protective eyewear and face shields) […]”). Emphasis added. Moreover, eyewear
protects eyes from objects or liquids accidentally dropped during the course of treatment.
214 Why we Take Infection Control Seriously. UIC College of Dentistry. Viewed at https://dentistry.uic.edu/patients/dentalinfection-control, viewed February 2, 2018 (“We use personal protective equipment […] as well as provide eye protection to
patients for all dental procedures.”) Emphasis added.
215 While radiation exposure from dental radiographs is low, dentists should follow the ALARA Principle (As Low as Reasonably
Achievable) to minimize the patient’s exposure. Dentists should follow good radiologic practice and (inter alia), use protective
aprons and thyroid collars. Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation
Exposure. ADA and FDA (2012), 14. Emphasis added.
216 Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations
for Safe Care. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; October 2016,
p.7.
213

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review randomly from Prosthetics List (patients with two partial dentures) and Daily Dental
Reports (patients who received fillings and biennial examinations).
First Court Expert Findings
Routine care was almost always provided without a comprehensive examination, a treatment
plan, a documented periodontal assessment, a documented soft tissue examination, and
without bitewings or other radiographs diagnostic for caries.
There was seldom a dental prophylaxis or oral health instructions provided prior to routine
restorative care to include removable prosthetics. Without these basic elements in place,
quality routine care is almost impossible. As such, there is no real system in place to provide
routine comprehensive Category 3 dental care.
The radiographs and examinations/treatment plans were so incomplete or vague that it could
not be determined if all necessary care was completed prior to prosthetic impressions.
Blood pressures were not being taken on inmates with a history of hypertension.
Current Findings
Overall, comprehensive care is unchanged since the First Court Expert’s Report. We concur that
routine care (to include removable prosthetics) is inadequate and is provided without adequate
x-rays, periodontal assessment, and documented oral hygiene instruction and a sequenced
treatment plan.217,218 Moreover, we agree that the biennial examination, as currently
performed, is of little clinical value.
Rather than relying on intraoral x-rays, the accepted professional standard for routine
examinations,219 dentists base their charting for caries on the panoramic x-ray in conjunction
with a visual exam. Not only is this insufficient to diagnose interproximal (between the teeth)
decay but it ignores the existence of periodontal disease. Moreover, even when periodontal
disease is occasionally categorized per Administrative Directive 04.03.102 (Dental Care for
Offenders), there is no documented periodontal probing220 and the location of the disease is
Stefanac SJ. Information Gathering and Diagnosis Development. In Treatment Planning in Dentistry [electronic resource].
Stefanac SJ and Nesbit SP, eds. Edinburgh; Elsevier Mosby, 2nd Ed. 2007; pp. 11-21, passim.
218
IDOC agreed that “[r]outine comprehensive care should be provided for through a comprehensive exam and treatment
plans. The exam [should include] radiographs diagnostic for caries, a periodontal assessment, a soft tissue exam, and accurate
charting of the teeth,” and “hygiene care and oral health instructions be provided as part of the treatment process.” IDOC
Response, ¶XIII (5).
219 Dentate or partially dentate adults who are new patients should receive an “[i]ndividualized radiographic exam consisting of
posterior bitewings with panoramic exam or posterior bitewings and selected periapical images.” Furthermore, recall patients
[i.e., biennial exam patients] should receive posterior bite wing x-rays every 12 to 36 months based on individualized risk for
dental caries. With respect to periodontal disease, “[i]maging may consist of, but is not limited to, selected bitewing and/or
periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically.” Dental
Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure. American Dental
Association and U.S. Food and Drug Administration, 2012. Table 1, pp. 5-6.
220 Stefanac SJ. (A panoramic radiograph has insufficient resolution for diagnosing caries and periodontal disease. Intraoral
radiographs (e.g., bite wings) and periodontal probing are necessary), p. 17. Also, (Periodontal Screening and Recording (PSR),
an early detection system for periodontal disease, advocated by the ADA and the American Academy of Periodontology since
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not noted.221 As with most of the other patients who received comprehensive care including
removable prosthetics, sequenced treatment plans and periodontal assessments that included
documented probing were absent.
Biennial exams were scanty and of minimal clinical value since they were informed by neither
bite wing x-rays nor documented periodontal probing. Documented oral cancer screening and
sequenced treatment plans were rare.
Absent a sequenced treatment plan informed by intraoral x-rays222 and periodontal probing,
the dentist does not have sufficient information to make an informed decision. In the
community, what is called a biennial exam is analogous to a periodic exam.223 The biennial
exam is cursory, and not substantially different from the inadequate exam performed at intake.
Not only is periodontal disease underdiagnosed but it is undertreated. In none of the dental
charts reviewed was there a treatment plan that identified specific non-surgical periodontal
procedures such as scaling and root planing. Moreover, the Daily Treatment Report that lists
the treatment provided to each patient has no section for periodontal treatment.224 The IDOC
and Wexford dentists and dental hygienists we interviewed who were in private practice were
familiar with the industry-standard dental procedure codes. However, there is no column for
scaling and root planing (SRP)225 and no way of knowing if it is performed. Similarly, dentists
and dental hygienists knew what periodontal screening and recording (PSR) was but did not use
it in IDOC, although many acknowledged using it in private practice.
The Wexford contract specifies that “[v]endor shall provide dental checkups to offenders every
two years, or more often if clinically indicated, and evaluations must be provided within 14 days
after the offender's request for routine care treatment.” However, it is mute on the more
critical issue, the maximum waiting time for treatment. So, under current dentist staffing, a
prisoner who needs (for example) three fillings that require three appointments could
conceivably wait more than three years for the last tooth to be filled. It is more likely than not
that the teeth awaiting filling will become more difficult to fill or become non-restorable and
require extraction and cause preventable pain.
1992, is an accepted professional standard.), pp. 12-14. See American Dental Hygiene Association. Standards for Clinical Dental
Hygiene Practice Revised 2016, pp. 6-9. (Periodontal probing is also a standard of practice for dental hygiene).
221 The only categories related to specifically periodontal disease are Ib (“acute periodontal abscess”), Ic (“acute periodontitis”),
Ie (“acute gingivitis”), IIIb (“localized gingival involvement”), and Vb (“lack of visible gingival irritation”). Id. Attachment A.
222 See NCCHC P-E-06 (Oral Care), ¶8 ([r]adiographs are used in the development of the treatment plan”.)
223 The ‘uniform record system’ sponsored by the American Dental Association is the Code on Dental Procedures and
Nomenclature. “In August 2000 the CDT Code was designated by the federal government as the national terminology for
reporting dental services on claims submitted to third-party payers. The industry standard code for a periodic exam is D0120. It
is defined as “[a]n evaluation performed on a patient of record to determine any changes dental and medical health status
since a previous comprehensive or periodic examination. This includes an oral cancer evaluation, and periodontal screening
where indicated, […])”.” American Dental Association Dental Procedure Codes, 2015, pp. 1, 5.
224 The categories are “scale and prophylaxis,” “gingivitis,” and “periodontal.” While “scale and prophylaxis” is mappable to ADA
treatment code D1110 that has a standard profession-wide definition, “gingivitis” and “periodontal” are not directly mappable
to an ADA code. The IDOC and Wexford dentists and dental hygienists we interviewed who were in private practice

were familiar with the industry-standard dental procedure codes.

225

ADA codes D4341 and D4342.

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Wait times are most problematic at MCC, with April 2018 backlogs for fillings and dentures
more than 15 months. While Wexford does not report periodontal treatment wait times, dental
hygienist caseload (in number of patients) is reported in the monthly April 2018 CQI minutes.
We imputed dental hygienist wait time to be approximately 16 months.226 While a cleaning or
prophy is not a periodontal procedure, it is often a precursor to periodontal treatment (if
periodontal treatment has been prescribed by a dentist on the treatment plan). A wait of more
than a year before periodontal treatment can begin, even if it is diagnosed, is unreasonable and
such a treatment delay can result in preventable disease progression with concomitant bone
loss.
While patients planned for removable prosthetics are not treated by outside specialists but
rather onsite dentists, approval for dental prosthetics must be obtained from Wexford through
a process referred to as “collegial review.” The reviewer is Dr. Karanbir Sandhu, who serves on
a part-time basis as a Wexford Prosthetic Advisory Dentist. Dr. Sandhu is not specialist in
prosthodontics, or for that matter any other aspect of dentistry.

Dental: Intake (Initial) Examination227

Methodology: Reviewed dental records and panoramic x-rays of inmates who have received
recent intake (initial) examinations. Reviewed Administrative Directive 04.03.102.
First Court Expert Findings
Although a review of records revealed that the IDOC followed its screening examination policy,
oral health instructions are omitted as part of the process. Egregious deficiencies were
observed at the NRC during the screening exam. The exam was extremely cursory and did not
include an adequate head and neck, and soft tissue examination. The health history was
sketchy and poorly documented. Radiology safety protocols were non-existent. Area
disinfection and clinician hygiene between patients was very poor. Inappropriately, most
dentists use the screening exam, the panoramic radiograph, and the charting as a treatment
plan from which to deliver routine care.
Conditions that require medical attention were not red-flagged. Medical consultations were not
documented in the dental record. The quality and consistency of the medical history in the
dental record was inadequate.
Current Findings
Overall, the initial examination is unchanged since the First Court Expert’s Report. We concur
that the initial examination is inadequate and fails to include appropriate head, neck, and soft

The April 2018 CQI minutes (based on March data) reported a dental hygienist caseload of 1018 patients and the March
2018 Dental Report noted that the hygienist performed 61 cleanings/prophylaxes. This equates to a more than 16-month
backlog.
227 The First Court Expert Report describes the examination performed at intake screening as a “Screening Examination;”
however, Administrative Directive 04.03.102 describes it as a “complete dental examination.” We use the terminology of the
Administrative Directive and refer to the intake or initial dental examination as a complete dental examination.
226

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tissue assessments. While the First Court Expert found that area disinfection was poor228, there
was no mention of the breaches of infection control by the NRC and MCC dentists described in
previous reports. In addition, we found as follows.
The initial examination is governed by Administrative Directive 04.03.102 which states (inter
alia) that
Within ten working days after admission to a reception and classification center
or to a facility designated by the Director to accept offenders with disabilities for
a reception and classification center, each offender shall receive a complete
dental examination by a dentist.229
While “complete dental examination” is not defined in Administrative Directive 04.03.102, the
examination performed at the three R&C centers we visited is by no means “complete” because
it is too brief and not informed by intraoral x-rays, a documented periodontal probing, and a
consistently performed oral cancer screening.230, 231 The deficiencies of this examination are
particularly problematic, since it is used to classify treatment needs and determine treatment
priority.
Notwithstanding the plain text of Administrative Directive 04.03.102, it is apparently IDOC’s
position that the dental examination performed at intake is a screening examination (citing
NCCHC Oral Care Standard P-E-06) is cursory and need not be performed by a dentist. 232
However, compliance with Oral Care Standard P-E-06 (assuming IDOC adopts it as its standard)
requires that in addition to an oral screening, an oral examination should be performed by a
dentist within 30 days of admission.233, 234, 235
Which we found at NRC.
Administrative Directive 04.03.102 (¶II F 2) (emphasis added). Furthermore, the exam should include, “[c]harting of the oral
cavity and categorization of status or treatment needs in accordance with the American Public Health Association's priorities
delineated in Attachment A.” Id. at (¶II F 2a).
230 This is generally done by holding the anterior portion of the tongue with 2x2 gauze and reflecting the tongue with a mouth
mirror. This is a professional standard for an oral examination. See, for example, National Institutes of Health. National Institute
of Dental and Craniofacial Research. Detecting Oral cancer. A Guide for Professionals. Viewed 6/4/2018 at
https://www.nidcr.nih.gov/sites/default/files/2017-09/detecting-oral-cancer-poster.pdf.
231 Stefanac SJ. (“Evaluation of head and neck structures for evidence of tissue abnormalities or lesions constitutes an important
part of a comprehensive examination.”), p. 12. See also Shulman JD, Gonzales CK. Epidemiology/Biology of Oral Cancer. In
Cappelli DP, Mosley C, eds. Prevention in Clinical Oral Health Care. Elsevier (2008) (“Regular, thorough intraoral and extraoral
examination by a dental professional is the most effective technique for early detection and prevention of most oral cancers.
[…]”) p. 41.
232 IDOC Response to First Expert Report, pp. 32-33.
233 2014 NCCHC Oral Care Standard P-E-06, p. 81 and 2018 NCCHC Oral Care Standard P-E-06, pp. 96-97.
234 IDOC’s selective invocation of the NCCHC Standard is inappropriate. If (as the IDOC Response maintains), initial dental
examination is a screening and not a “complete dental examination” as set forth in the Dental AD, when does an IDOC prisoner
receive an oral examination (that per NCCHC P-E-06 should be performed within 30 days of admission)?
235 IDOC Response to First Expert Report, p. 33. (“Initial dental contacts between clinicians and offenders at IDOC reception
centers constitute dental screenings, as defined by the NCCHC. Accordingly, the reception center dentist performs a “visual
observation” and notes “obvious or gross abnormalities requiring immediate referral to a dentist.” Subsequent referrals result
in a dental examination, which comports with the NCCHC definition of “examination.” Because its procedures meet NCCHC
standards, IDOC believes they meet the minimum constitutional standard of adequacy.) They do not.
228
229

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However, IDOC’s assertion that since subsequent referrals result in a dental examination IDOC
complies with the NCCHC Oral Care Standard ignores the plain text of P-E-06, since under
IDOC’s idiosyncratic interpretation, the only prisoners who would receive a dental examination
would be those who were referred based on a screening that could be performed by a nondentist or even the current inadequate intake examination performed by a dentist.
While IDOC does not define “complete dental examination,” the definition of a comprehensive
or complete dental examination is set forth by the American Dental Association (ADA) and the
NCCHC.236 The ADA defines a Comprehensive Oral Examination (Procedure Code D0150).237
Similarly, a comprehensive clinical examination includes an intraoral and extraoral soft tissue
examination (primarily screening for oral cancer); a periodontal examination using, at a
minimum, Periodontal Screening and Recording (PSR); an examination of the teeth; and a
radiographic examination using panoramic and intraoral x-rays.238 Furthermore, as mentioned
earlier, the ADA and Food and Drug Administration (FDA) recommend that intraoral x-rays
should be part of a dental examination.
At two prisons (NRC and LCC), the dentists did not document a thorough soft tissue
examination. For example, they did not visualize the lateral and posterior regions of the tongue,
potential sites of squamous cell carcinoma. Performing a thorough soft tissue examination is
critical for a new inmate, since unless the prisoner requests care within two years, the next
exam will be biennial under current policy.239
We visited three prisons that performed intake screening; NRC, LCC, and MCC. The NRC has the
largest volume, processing 15,942 prisoners in 2017. All inmates have a panoramic x-ray taken
and receive a cursory direct-view oral examination that includes a scanty health history. Not
only is the exam uniformly deficient, but the quality of the panoramic x-rays used is poor and
documentation was deficient.240 Furthermore, infection control was inadequate at two
“Oral examination by a dentist includes taking or reviewing the patient's oral history, an extraoral head and neck
examination, charting of teeth, and examination of the hard and soft tissue of the oral cavity with a mouth mirror, explorer,
and adequate illumination.” NCCHC Oral Care Standard P-E-06, 2018, p. 96. Emphasis added.
237 “[This code is] [u]sed by a general dentist and/or a specialist when evaluating a patient comprehensively. This applies to new
patients; established patients who have had a significant change in health conditions or other unusual circumstances, by report,
or established patients who have been absent from active treatment for three or more years. It is a thorough evaluation and
recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through
additional diagnostic procedures. […] This includes an evaluation for oral cancer where indicated, the evaluation and recording
of the patient's dental and medical history and a general health assessment. It may include the evaluation and recording of
dental caries, missing or unerupted teeth, restorations, existing prostheses, occlusal relationships, periodontal conditions
(including periodontal screening and/or charting), hard and soft tissue anomalies, etc.” American Dental Association Code on
Dental Procedures and Nomenclature, 2015; p. 6.
238 Stefanac SJ, pp. 12-15, passim. Emphasis added.
239 This deficiency is compounded by the fact that dentists do not document soft tissue examinations at biennial exams (see
infra).
240 Of 20 panoramic x-rays from screening exams performed January 23, 2018, nine (45%) were clinically inadequate;
characterized by poor contrast (washed out) or the presence of artifacts that interfered with interpretation. Our findings were
confirmed by an SCC Quality Improvement Study in which intake screening charting was compared with the results of clinical
examinations performed on the same patients. Of the 21 NRC charts, 62% had no charting of pathology (e.g., “abscessed teeth,
teeth that needed extraction, [and] periodontal disease, (+3) mobility in teeth, grossly decayed teeth, impacted wisdom teeth
in the maxillary sinus, and numerous visible dental caries”), with the remainder having only a partial charting.
236

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facilities.241,242
The oral hygiene instructions (OHI) were inadequate at all prisons we visited. For example, at
MCC, they consisted of consisted of saying, “make sure you brush and floss,” and took no more
than a minute.243 This is not adequate oral hygiene instruction. Furthermore, while spooled
dental floss is deemed contraband at MCC, the dentist did not mention the existence of (not to
mention how to use) floss alternatives.

Dental: Extractions

Methodology: Reviewed records of inmates who had extractions, randomly selected from Daily
Dental Reports October 2017 through January 2018 and Dental Sick Call Logs. Interviewed
dental staff.
First Court Expert Findings
Antibiotics were provided routinely after dental extractions at some institutions.
A proper diagnostic reason for extraction was seldom part of the dental record. Documentation
was, overall, very poor.
Current Findings
Our finding that extraction care is adequate diverges from that of the First Court Expert which
suggests that many of the previously identified deficiencies have been remedied. Moreover, we
identified current and additional findings as follows.
With few exceptions, extractions were informed by adequate preoperative x-rays and were
accompanied by signed consent forms. However, while the tooth to be extracted was
identified, the reason for the extraction was rarely noted. On the other hand, most of the
health history forms were not updated. Generally, patients with dental infections who were
prescribed antibiotics had the tooth extracted timely,244 that is within the therapeutic window
of the antibiotic245 (i.e., within 10 days – the duration of most of the antibiotic prescriptions).246
The most egregious example was at NRC which we discuss in the NRC Report. “The dentist donned gloves, selected mouth
mirrors from a bag of sterile mirrors that he opened and placed on a bracket table before the first exam. A standard dental light
illuminated the patient’s mouth. He reviewed the panoramic x-ray and took a cursory health history. He used one or two
mirrors to reflect the cheeks and adjusted the light for optimal illumination. While his gloved hands did not always touch the
patient, in approximately half the exams we observed, they touched the patient’s face, lips, or mouth. He did not change gloves
between patients consistently. In fact, there were several instances where he examined a patient wearing the gloves he used to
touch a previous patient’s mouth or face. He did not wash hands between patients because the exam room had no sink.”
Centers for Disease Control and Prevention.
242 Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: Centers for
Disease Control and Prevention, US Dept. of Health and Human Services; October 2016, p.7.
243 Oral Hygiene Instructions (ADA Code D1330) “may include instructions for home care. Examples include tooth brushing
technique, flossing, and the use of special oral hygiene aids.” ADA Procedure Codes.
244 MCC was particularly problematic. “Of the 11 who were prescribed antibiotics, all but one (91%) waited more than 10 days.”
MCC Report. See sick Call discussion supra.
245 Shulman JD, Sauter DT. Treatment of odontogenic pain in a correctional setting. Journal of Correctional Health Care (2012)
18:1, 58 – 69; p. 68.
241

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Dental: Sick Call/Urgent Care / Treatment Provision

Methodology: Interviewed dental staff. Reviewed Dental Sick Call Logs and Daily Dental
Reports. Reviewed randomly selected records of inmates who were seen on sick call. Reviewed
recent intake examination records.
First Court Expert Findings
The SOAP format was not being used to document urgent care encounters.
The lag time between an Inmate Request Form for pain and alleviation of the pain was
unacceptable. It often took four or more days for urgent care patients to be seen. Patients who
are in pain should be able to access care within 24-48 hours.
Current Findings
Overall, urgent care has not changed materially since the First Court Expert’s Report and
remains inadequate. We concur with the First Court Expert that urgent care was generally
untimely. In addition, we identified current and additional findings as follows.
Prisoners access dental care via submitting a written request, going on nurse sick call, or
communicating their problem with staff. There is substantial variation in the wait time for
prisoners with a painful dental condition who submit a sick call request or sign up for nurse sick
call, with several prisons (e.g., MCC, SCC, and Dixon) having median times to be seen by a
provider for dental pain of more than two days. Some prisons have a nurse sick call process
where prisoners who state dental pain are assessed timely by a nurse using a “dental pain”
protocol and are palliated and referred to the dental service.247 At some prisons, requests for
dental urgent care that are sent directly to the dental service are delayed due to an intervening
weekend or when the dentist is not available (e.g., NRC, Dixon), or a staff shortage (e.g., MCC).
When a patient with an urgent care complaint is seen by the dentist, the SOAP format is not
consistently used for dental sick call progress notes (e.g., NRC, SCC) nor is the health history
updated – a system wide problem.

Dental: Orientation Handbook

Method: Reviewed the Orientation Handbook and other orientation documents.
First Court Expert Findings

246 Makrides, N. S. et al.(“[d]elayed dental treatment of the original focus of the [tooth-related] infection may turn a minor
problem into a serious condition. Although infection is usually self-limiting and spatially-confined, it may spread because of a
highly virulent organism. Complications could include Ludwig’s angina, mediastinitis, cerebral abscess, maxillary sinusitis,
chronic fistulous tracts, and infective endocarditis.” (p. 559).
247 At NRC, there is no process for nurses, when the dentist is not available, to perform a face-to-face examination on dental
patients who state they have pain to identify pain and infection and provide analgesics and referral to a mid-level or advanced
level provider if immediate treatment is necessary.

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Access to care was inadequately detailed or not mentioned at all in most of the orientation
manuals reviewed. Inmates do not receive adequate instructions on how to access urgent or
routine care.
Current Findings
Overall, inmate orientation to dental care has improved since the First Court Expert’s Report.
While we concur with the First Court Expert that the orientation handbook could benefit from
additional information about access to dental care, there was sufficient information provided
about sick call in general for inmates to access dental care. Furthermore, dentists provided
relevant information during the NRC, LCC, and MCC intake exams.

Dental: Policies, Procedures, and Program Management

Methodology: Reviewed Administrative Directives that deal with the dental program.
Interviewed dental staff. Reviewed dental charts. Toured dental clinical areas. Reviewed
organizational charts.
First Court Expert Findings
Institutional Policy and Protocol Manuals were usually very incomplete, outdated, or not
present at all. Dental programs were implemented and managed with few guidelines and little
oversight. The IDOC Administrative Directives are incomplete and provide little guidance for
developing and managing a successful dental program.
The Administrative Directives do not address quality of care issues, clinic management, record
management, or staff oversight and responsibilities. Dentists are provided no orientation to the
IDOC dental program or training on how to manage their institution’s programs. This, in
conjunction with inadequate quality assurance and peer review, suggests a lack of oversight on
the part of the IDOC and Wexford. Moreover, there is no administrative dentist to oversee and
manage the IDOC dental program.
The policy mandating biennial routine examinations does not seem beneficial. It takes up a
great deal of administrative time. Inmates have full access to dental care. Dentists should use
their time providing this care, especially considering the dental staffing guidelines.
Current Findings
Overall, policies, procedures, and program management have not improved materially, and we
concur that they are inadequate. In addition, we identified current and additional findings as
follows.
Administrative Directive 04.03.102 is flawed and should be rewritten. The components of the
initial examination should be specified. Is it a “complete examination” per ¶ II F (2) or a
“screening examination?” To remove ambiguity, all procedures should be defined to be
consistent with the federally recognized ADA Procedure Codes.248 So, for example, a complete
The uniform record system sponsored by the American Dental Association is the Code on Dental Procedures and
Nomenclature. “In August 2000 the CDT Code was designated by the federal government as the national terminology for
248

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oral examination for a new patient (D0150) has a profession-wide definition, as does periodic
oral examination for an established patient (D0120) that is analogous to a biennial examination.
As noted by the First Experts, Administrative Directives, and dental program guidance from
IDOC are lacking.
The IDOC Medical Director stated that while he is responsible for the dental program, he relies
on a Wexford dentist for oversight. He acknowledged that this was not a good arrangement and
prefers a Chief of Dentistry who is a state employee as part of his regional team.249
In a response to a recommendation made in the First Expert Report, IDOC stated that it has
committed to creating and filling a 0.25 FTE Statewide Dental Director position.250, 251 After
almost four years, no such position has been established.

Dental: Failed Appointments

Methodology: Reviewed Dental Sick Call Logs. Interviewed dental staff. Reviewed Daily Dental
Reports.
First Court Expert Findings
The broken appointment rate was above 10% at several institutions and as high as 40% at three
institutions. The latter are alarming rates.
Current Findings
Overall, failed dental appointments have not improved materially since the First Court Expert’s
Report.252 While the failed appointment rate appears to have improved compared to the First
Expert Report, it could not be determined for NRC and Dixon. However, a scan of Dixon daily
and monthly dental logs suggests that failed appointments may be a problem.

Dental: Medically Compromised Patients

Methodology: Reviewed health history form and records from recent intake exams. Compared
the health history in the dental chart to the medical problem list. Reviewed randomly selected
charts of patients on Chronic Care Lists for diabetes and anticoagulant therapy.
First Court Expert Findings
The medical health history section of the dental record was sketchy and incomplete. Conditions
that require medical attention were not red-flagged. Medical consultations were not
documented in the dental record. The quality and consistency of the medical history in the
reporting dental services on claims submitted to third-party payers.” American Dental Association Dental Procedure Codes,
2015, p. 1.
249 Meeks Interview, ¶35.
250 IDOC Response pp. 9, 31.
251 IDOC should have at a minimum a 0.5 FTE position for a Statewide Dental Director to oversee the Wexford contract as it
relates to dental care. Leaving dental oversight to the vendor is inviting the fox to guard the hen house.
252 A facility that does not track and routinely report the failed appointment rate is deemed inadequate.

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dental record was inadequate. Blood pressures were not being taken on inmates with a history
of hypertension.
Current Findings
Documenting the health history of medically compromised patients has not changed materially
and remains inadequate since the First Court Expert’s Report. We concur with the First Court
Expert’s findings. In addition, we identified current and additional findings as follows.
The health history form is too limited and omits conditions relevant to dental care, for example,
anticoagulant therapy. Moreover, there is insufficient room on the form for adding information.
Health histories were not filled out or updated at the last visit in most charts. In addition, there
was no documented periodontal assessment and request for follow-up for diabetics, which is
particularly problematic given the relationship between periodontal disease and diabetes.253

Dental: Specialists

Methodology: Interviewed dental staff, reviewed CQI documents, and reviewed dental charts
of all inmates who were seen by an oral surgeon.
First Court Expert Findings: None.
Current Findings
Dental specialty referral has not changed materially since the First Court Expert’s Report and
remains adequate. We concur with the First Court Expert’s findings. In addition, we identified
current and additional findings as follows.
Approval for onsite or offsite oral surgery consultations requires the consent of the Wexford
Regional Medical Director through a process referred to as “collegial review.” The reviewer for
oral surgery consultations is Dr. Karanbir Sandhu, who serves on a part-time basis as a
Prosthetic Advisory Dentist. Dr. Sandhu is neither an oral surgeon nor a specialist in any other
aspect of dentistry.
Several prisons have arrangements for local oral surgeons to provide care on site for less
complex procedures and transport prisoners to the oral surgeon’s practice for complex
procedures. Other prisons send all prisoners who require oral surgery care off site. Oral surgery
consultations we reviewed were appropriate, and appointments were made timely.

Dental: CQI

Methodology: Reviewed CQI minutes and reports. Interviewed dental staff.
See, for example, Herring ME and Shah SK. Periodontal Disease and Control of Diabetes Mellitus. J Am Osteopath Assoc.
2006; 106:416–421; Patel MH, Kumar JV, Moss ME. Diabetes and Tooth Loss. JADA 2013;144(5);478-485 (adults with diabetes
are at higher risk of experiencing tooth loss and edentulism than are adults without diabetes); and Teeuw WJ, Gerdes VE, and
Loos BG. Effect of Periodontal Treatment on Glycemic Control of Diabetic Patients. Diabetes Care 3 (3) :421-427, 2010
(periodontal treatment leads to an improvement of glycemic control in type 2 diabetic patients).
253

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First Court Expert Findings
The dental contribution usually was limited to monthly statistics. Most dental programs had no
studies, assessments, or subsequent improvements in place. There is no peer review process in
place within the IDOC dental program. There is little direction or meaningful oversight of the
IDOC dental program to ensure that proper policies and protocols are in place and followed,
and that dental standards of care are practiced.
Current Findings
The dental CQI program has improved marginally since the First Court Expert’s Report but
remains inadequate. We concur with the First Court Expert. In addition, we identified current
and additional findings as follows.
CQI studies were limited in scope and follow up with corrective action plans was lacking.254 For
example, the 2016-2017 SCC CQI Report described study of compliance with the charting at the
initial examinations at NRC. Among the findings from the NRC charts were that 62% had no
charting of pathology, with the remainder having only a partial charting; for example, visible
heavy tartar [calculus], and periodontal needs were never charted or indicated. Moreover, the
panoramic radiographs from NRC varied in diagnostic quality. However, we were not provided
with any corrective action plans.
The LCC 2017 Annual Governing Body Report described a quality improvement study on “[t]he
time frames for dentures start to finish including healing. Is it within 3 months?” There were
neither recommendations nor a planned follow up. The study was, at best, trivial. Given the
inadequacy of the clinical aspects of the dental program described in this report, a ‘study’ of
how long it takes to fabricate a denture ignores far more relevant issues, such as inadequate
health histories, inadequate diagnosis of periodontal disease, and failure to use intraoral x-rays.
We were provided with a summary of two MCC studies. A study of 50 patients who were on the
restoration (filling) list May 2015 to December 2015, with treatment dates ranging from August
2016 until September 2016, found that 94% had successful restorations without need of
extraction. However, the actual study was not provided, just a five-line summary, so its validity
cannot be assessed. Another MCC study summary, “Effects of lockdowns and dental coverage
on filling numbers and backlog numbers,” had no analysis, just a recitation of findings.
Peer Review
We asked to see all peer reviews of dentists working at the eight facilities on our site visit
schedule and were informed that dentists (unlike other practitioners) are not routinely peer
reviewed. According to Attorney Ramage, speaking for Wexford,255 neither the IDOC contract256

While a study of the quality of SCC onsite oral surgery consultations and one follow-up was performed, the Root Cause
Analysis recommended by Dr. Meeks was not performed. Furthermore, Dr. Meeks recommended that Dr. Funk and Mr. Mote
monitor the oral surgeon’s performance at other institutions. We requested the Root Cause Analysis and other follow-up
material; however, they were not provided,
255 Email from Andrew Ramage to Michael Puisis 3/29/2018.
254

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nor Wexford policy requires that dentists be peer reviewed.257 He further stated that “[r]outine
peer reviews of dentists are not a mandatory standard of NCCHC;”258 however, he is confuted
by the NCCHC, which specifically includes dentist peer reviews in its Clinical Performance
Enhancement Standard P-C-02.259
Moreover, “Wexford Health has never found a true dentist ‘peer review’ to be a productive
means to determine clinical quality.”260 Finally, it is Wexford’s position that the dentist peer
reviews are not a part of the community standard.261 While clinical peer review is not the
community standard for dental care in a private practice environment, it is the community
standard for organized dental practices such as the military, Department of Veterans Affairs,
and Departments of Corrections that have recently emerged from federal monitoring (e.g.,
California and Ohio.)262
We were provided with peer reviews of Drs. Crisham (performed 12/30/15) and O’Brien
(performed 1/16/17) who practiced at Dixon, and we were able to locate five of the 20 charts
on which the peer review was based. Our findings were consistent with those of the reviewer;
however, several critical elements were absent from the checklist, and were not evaluated.
Consequently, many of the fundamental flaws we found in the dental care provided at Dixon,
such as inadequate treatment plans, failure to use bite wing x-rays to inform caries diagnosis,
and failure to diagnose and treat periodontal disease, were undiscovered. Dental peer review
as implemented by Wexford is poorly designed and does not therefore determine clinical
quality.
The contract addresses “physician peer review,” which applies to the onsite Medical Director, staff physicians, nurse
practitioners, physician assistants, and psychiatrists; however, dentists and psychologists are excluded. Wexford Contract,
¶2.2.2.19 and ¶7.1.5.
257 However, Wexford Clinical Performance Enhancement Policy P-403 states, “[a] minimum of one annual “peer review” [will
be performed] whereby a practitioner’s clinical performance is evaluated by a senior or supervising practitioner, and, when
necessary, senior practitioners are evaluated by regional/corporate staff. […]” ¶III A3; and “[t]he senior dentist will complete a
peer review for each dentist and ensure the completion of the biennial external review for those qualified. The Regional
Medical Director will assign a peer reviewer for small contract locations having single or part-time dentists.” Wexford Resp.
RTP#5, Question 2, p. 0405.
258 Ramage email, id.
259 “In contrast [to an annual performance review], a clinical performance enhancement review focuses only on the quality of
the clinical care that is provided. This type of review should be conducted only by another professional of at least equal training
in the same general discipline. For example, an RN should evaluate other RNs and LPNs, a physician should review the work of a
physician, and a dentist should review the work of a dentist;” and “[Clinical Performance the standard requires that the
facility’s direct patient care clinicians and RNs and LPNs are reviewed annually. Direct patient care clinicians are all licensed
practitioners who provide medical, dental, and mental health care in the facility. This includes physicians, dentists, midlevel
practitioners, and qualified mental health professionals (psychiatrists, psychologists, psychiatric social workers, psychiatric
nurses, and others who by virtue of their education, credentials, and experience are permitted by law to evaluate and care for
mental health needs of patients). NCCHC recognizes that there are many other professions that have licensed practitioners
(e.g., dental hygienists) who may be considered direct patient care clinicians. While it is good practice to include these
professionals in the clinical performance enhancement process, technically it is not required by the standard.” National
Commission on Correctional Health Care, Clinical Performance Enhancement (https://www.ncchc.org/clinical-performanceenhancement-1) viewed 3/30/18 (emphasis added).
260 Ramage e-mail, id.
261 Id.
262 California Department of Corrections Inmate Dental Services Program. September 2014, ¶ 4.3; Ohio Department of
Corrections Policy 68-MED-12, ¶ VI B 3.
256

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Internal Monitoring and Quality Improvement
Methodology: Interview facility health care leadership and staff involved in quality
improvement activities. Review the quality improvement meeting minutes and annual CQI
reports.
First Court Expert Findings
The First Court Expert found that the IDOC does not have the ability to monitor itself in part
because it lacks data on key processes of care. For that reason, he recommended use of
tracking logs to facilitate efficient review and data collection of quality performance measures.
He found that data sources, including tracking logs, are not consistently used. He found that
some facilities performed no quality improvement activity and other facilities collected data but
did not measure the quality of performance against a standard. He was unable to find any
facility they investigated that measured quality of performance against a standard. He also
failed to find any facility that initiated any effort to improve the quality of the program. None of
the quality improvement coordinators had any formal training in quality improvement
methodology. He also noted that although his team found a high rate of lapses of care in
mortality review, internal mortality review identified no lapses in care.
Current Findings
We found there were some improvements since the First Court Expert’s report. We did not
confirm the finding that some of the facilities performed no quality improvement activity. Every
facility we investigated had quality improvement meetings, produced quarterly and annual
reports, and performed studies. We found, however, that annual reports and quality
improvement studies were ineffective. We also did not find that facilities were not measuring
quality against a standard. Some studies were undertaken that measured against
Administrative Directive requirements as a standard. The First Court Expert failed to find any
facility that initiated any effort to improve quality. We found that all facilities we investigated
initiated effort, but these efforts were ineffective. The lack of experienced or knowledgeable
CQI staff and the failure to integrate quality into the fabric of operations was significant and
made the CQI programs ineffective. There was also an absence of evaluation of clinical quality,
which contributes to preventable morbidity and mortality. The ineffectiveness of the CQI
program, in our opinion, was a result of the following.
None of the facilities investigated had anyone who had expertise or knowledge of CQI
methodology or implementation. CQI coordinators at NRC, SCC, and MCC are medical records
personnel. None had any experience or training in CQI and had no knowledge of how to
implement a CQI program. They were named CQI coordinators apparently because they could
manage the paperwork requirements with respect to producing monthly minutes and annual
reports. At two facilities, Dixon and MCC, the HCUAs were acting CQI coordinators by default
because there was no one else available for this task. These individuals had no experience or
training in CQI methodology. It did not appear that facilities understood how to design or
implement an outcome study, and process studies failed to include any discussion or analysis of

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variables involved in the process of care being studied. Outcome and process studies are
required elements of the IDOC Administrative Directive on quality improvement.
None of the facilities had a reasonable CQI plan. An annual CQI plan needs to identify the major
areas of investigation that the CQI committee is working on in the upcoming year. These plans
should be based on the most important identified problems at the facility. Instead, the annual
CQI plans at all facilities were generic and gave no formulation of the plan for the upcoming
year’s CQI work. The SCC and NRC plans were identical and copied one from the other, even
though each site had separate types of problems. Problems were not identified and CQI studies
did not match problems that existed at the facilities we visited.
None of the facilities had a Medical Director who participated meaningfully in CQI work. The
absence of clinical medical leadership in quality improvement work is significant, as studies lack
a clinical perspective necessary for medical CQI work.
Quality of physician care was not included in any CQI studies. The lack of physician quality
reviews was significant. Mortality review is not performed. Peer review, as has been discussed,
was ineffective and, in our opinion, did not accurately reflect the quality of provider care at the
facilities we investigated. CQI studies evaluate mostly whether an intervention such as sick call
or chronic illness clinic happened. But there is no evaluation as to whether it was adequately
performed from a clinical basis.
All facilities had difficulty in identification of their key problems, indicating that a critical
analysis of their processes of care was lacking. We view this as a lack of knowledge of how to
implement CQI. When facilities were able to identify problems, they failed to thoroughly
evaluate the problems. One facility, NRC, did identify medication errors as a problem, which we
agreed with. However, there was no analysis of why the problem was occurring and no attempt
to establish corrective action plans to correct the problem, so the problem persisted and was
repeatedly reported in CQI meeting minutes. SCC identified that referral from nurse sick call to
providers was not timely. This study was repeatedly performed without any evaluation as to
why this was occurring with an attempt to fix the problem. The problem persisted.
We noted pervasive and systemic problems with preparing and administering medications. This
process is not standardized across the system. Problems with administration of medication
place inmates at risk of harm. We noted problems with failure to complete parts of the intake
process. There is a problem with timely scheduling of specialty care and chronic care. There
were problems with surveillance and tracking of infectious and contagious disease. There were
problems with standardization of maintaining equipment and supplies. There was no
standardized sanitation program. There is no system to monitor sentinel events or adverse
clinical events. The IDOC lacks both a process to identify problems and lacks the ability to
correct these systemic problems. In systems under Court supervision that we have monitored, a
fundamental element of the exit strategy is the ability of the system to self-monitor by
identifying problems and taking corrective action to fix the problem. The ability to self-monitor

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is essential for a correctional health program but the IDOC currently does not demonstrate
capacity to self-monitor.
Access to data useful for quality improvement purposes was poor at all facilities. The First Court
Expert recommended that facilities utilize logs for various services as data sources to evaluate
processes of care. This is still not in evidence at any facility. Data that is available is not useful
for the purposes of quality improvement. The annual CQI reports give statistical data without
any analysis that identifies problems or gives evidence that the system is performing as
expected. The IDOC does not use data to measure adequacy of the program. Data is presented
without analysis. The type of data provided give no indication of whether the program is in
control.
Many “studies” were in areas that would be expected to yield good results. These were
meaningless studies, as there was no effort to improve the program; instead, a study was
designed so that it yielded a good result.
Review of primary source credentials of physicians at the annual meeting is not done. Instead,
the site only verifies that the physician has a license. This affects the quality of physicians.
The Governing Body at SCC and NRC have three members, two of whom are custody trained
staff; the Warden and the Regional Manager of Wexford. Half of the Governing Body at MCC
are also custody staff. The Governing Body of the CQI program should be predominantly
medical staff, as it is a medical program.

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Recommendations
We have listed below key recommendations from the Second Court Expert. These are followed
by the verbatim First Court Expert recommendations with our comments on each placed in
italics after the First Court Expert recommendation. We include our additional
recommendations following the First Court Expert recommendations.

Key Recommendations of Second Court Expert
Current Recommendations
1. Governance of the medical program must change. The medical program needs to be
under medical control, not custody control. This would entail a restructuring of the
medical program and Office of Health Services such that custody leadership are not
responsible for medical operational control of the medical program. This will require an
augmentation of the Office of Health Services so that it is capable of managing and
monitoring clinical care. The health authority and responsible physician, if they are not
the same person, need to be members of the Office of Health Services. The Office of
Health Services needs regional physicians to monitor physician quality; an Infection
Control physician and coordinator; a quality improvement coordinator; and sufficient
data analysts to maintain data and statistical information necessary for operational
management.
2. The medical program should have a budget that is managed by the health authority. Any
vendor contracts should be under control and direction of the health authority.
3. IDOC should conduct a staffing analysis under the direction of medical, not custody,
leadership that determines systemic staffing needs necessary to adhere to
Administrative Directives and acceptable standards of medical and nursing care. This
analysis needs to consider all levels of staffing and must include relief factors.
4. Physician staff must be properly trained, credentialed, and privileged. In order for this to
happen, we strongly recommend that the IDOC negotiate with the state universities that
have medical school programs to provide physician and possibly comprehensive care in
the IDOC.263 Physicians should be required to be credentialed similar to state university
medical school requirements. Such a program should have an enhanced telemedicine
component, including for specialty care.
5. The collegial review process should be immediately abandoned as a patient safety
hazard. If a utilization program is re-instituted, the Office of Health Services should hire
an additional board certified physician to perform prospective review.
6. The medical policies of the IDOC need to be augmented and refreshed and be made
consistent with standards of the National Commission on Correctional Health Care.
These policies should cover all aspects of a medical program and must be maintained by
the IDOC, not the vendor.

These universities might include University of Illinois Chicago; Southern Illinois University; and the Rockford School of
Medicine.
263

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7. The IDOC should negotiate with the Illinois Department of Public Health for IDOC to
fund and maintain an infectious disease-trained physician and infection control
coordinator who would jointly work with IDPH and IDOC and would coordinate, advise,
and lead the infection control program in the IDOC. This can be pursued as an
interagency agreement. The infection control coordinator should be a person with a
master’s training in public health nursing.
8. An analysis of geriatric and disabled patient needs in the IDOC needs to be done. The
purpose would be to determine the numbers of individuals who require skilled nursing,
supportive nursing, and infirmary levels of care. The IDOC needs to build or rehabilitate
facilities to accommodate the current needs of these types of patients, with facilities
that are appropriate for the level of need. Alternatively, if this cannot be done, the IDOC
needs to find placement for the geriatric population in community facilities appropriate
for their needs and properly licensed and managed in accordance with community
standards.
9. The IDOC needs to have a statewide electronic medical record that includes physician
order entry and electronic MARs. The implementation would include a device survey to
determine the number of devices that need to be in place; a wiring survey to assess the
capacity of existing communication wiring; access to an electronic medical reference
system paired with the electronic record such as UpToDate®; and consideration to
augment the current communication wiring to accommodate a more robust
telemedicine program.
10. The IDOC needs to hire a statewide dental director, establish standardized statewide
dental policies, and establish a monitoring system to ensure adequate dental services
are provided.
11. The IDOC medical program needs to be able to effectively self-monitor all aspects of the
medical care program. This will require knowledge of quality improvement
methodology, data systems to obtain the necessary information to analyze and monitor
care, and capable staff who can provide leadership.
12. The IDOC should develop combined medical and custody Administrative Directives that
specify the participation of custody in ensuring that patients attend all scheduled
medical appointments in the desired location and ensuring that custody collaborates
with nurses so that nurses are able to properly administer medications.

Organizational Structure, Facility Leadership, and Custody Functions
First Court Expert Recommendations
1. All Medical Directors must be board certified in a primary care field. The State has misread
this, indicating that all physicians must be board certified. The investigative team has
indicated that other primary care staff physicians should have completed an accredited
residency training program in internal medicine or family practice, and be either board
certified or becoming board certified within three years of employment. Only the State
Medical Director could grant exceptions to this requirement based on his or her own
assessment of the candidates. The basis for this recommendation is that in our experience
and discussion with other State Medical Directors, there have been a disproportionate
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2.
3.
4.
5.
6.

7.
8.

9.

number of preventable negative outcomes related to primary care services provided by
non-primary care trained physicians. The investigative team does not believe that
experience practicing in a field without the required training is adequate in mitigating the
preventable negative outcome. We generally agree with this recommendation. All
physicians practicing primary care need to be trained in primary care. We believe that this
recommendation will not be accomplished using the current contract process. See Key
Recommendation #4 above.
All clinicians should have access to electronic medical references at the point of care. We
agree with this recommendation.
Every special medical mission facility must have its own Health Care Administrator. We
agree with this recommendation.
The Director of Nursing position in all facilities is a full-time position whose time should
not be taken away by corporate responsibilities. We agree with this recommendation.
Establish approved budgeted positions for SCC and the NRC which allow for each facility
to function independently. We agree with this recommendation.
Provide a full-time Health Care Unit Administrator as well as a full-time Quality
Improvement Coordinator/Infection Control Nurse for both SCC and NRC. We agree that a
full time HCUA should be budgeted at SCC and NRC. However, we recommend that every
site have a full time CQI coordinator. The infection control nurse FTE equivalent should be
determined based on the expected activities at that facility. For intake facilities the
infection control nurse should be full time. For large facilities with any medical mission,
infection control positions should also be full time.
Each facility is to develop and implement a plan to insure registered nurse staff is
conducting sick call. We agree with this recommendation.
Medical vendor health care staff assigned leadership positions, such as the director of
nursing, supervisory nurse, or medical records director, will not be assigned corporate
duties such as time keeping, payroll, or human resource activities. This is similar to
recommendation #4 above and we agree with this recommendation.
IDOC [is] to develop and implement a plan which addresses facility specific critical staffing
needs by number and key positions, and a process to expedite hiring of staff when the
critical level has been breached. We agree with this recommendation but note that this
should be part of the staffing analysis recommended above in Key Recommendation #3.

First Court Expert’s IDOC Office of Health Services Staffing Recommendations
1. Immediately seek approval, interview, and fill the Infection Control Coordinator
position. We agree with this recommendation but add that the infection Control
Coordinator can be a nurse consistent with Key Recommendation #7. This nurse needs to
work collaboratively with an infectious disease trained physician. The Infection Control
Coordinator should have a master’s degree in public health nursing.
2. Establish and fill the position for a trained Quality Improvement Coordinator who will be
responsible for directing the system wide CQI program. We agree with this
recommendation. The required training for this position can be a systems engineer,
nurse, or other person trained in CQI methodology (e.g. six sigma). Persons considered

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for this position need to have CQI training prior to hiring. They should not learn on the
job.
3. Establish, identify, and fill the positions for three regional physicians trained and board
certified in primary care who will report to the Agency Medical Director and perform at
a minimum peer review clinical evaluations, death reviews, review and evaluate
difficult/complicated medical cases, review and assist with medically complicated
transfers, attend CQI meetings, and one day a week, within their region, evaluate
patients. Resources for these positions could be taken from monies allocated to the
medical vendor for regional physicians. We agree with this recommendation.
Additional Recommendations
1. IDOC custody should perform a staffing analysis to ensure that they have sufficient
officer staff to ensure that medical programs can appropriately and effectively function.
This is particularly true with respect to medication administration and ensuring that
patients show up in required clinic spaces for appointments that are ordered. This study
should include a survey of available transport van to ensure that IDOC has sufficient
transportation vehicles to transport inmates for their scheduled appointments.
2. Contract monitoring needs to be improved to include meaningful operational metrics
and must include quality of care for physicians, mid-level providers, and nurses.
3. Privileges for physicians should only be granted to doctors who have residency training
in the service for which they are seeking privileges.
4. The physician performance evaluation component of peer review needs to be
performed by persons trained in primary care and needs to be augmented to
adequately reflect quality of care.
5. The sanctioning component of peer review needs to be started. Any physician
committing grossly and flagrantly unacceptable care needs to undergo peer review for
possible reduction of privileges.

Use of University of Illinois

The First Court Expert had no recommendations related to UIC.
Current Recommendations
1. In addition to Key Recommendation #4 above, we strongly suggest that IDOC explore
the possibility of utilizing the university programs to assist with respect to
comprehensive medical care, dialysis, dental, nursing, and pharmacy programs.

Clinic Space and Equipment
First Court Expert Recommendations
1. All sick call must take place in a designated area that allows sick call to be conducted in
an appropriate space that is properly equipped and provides for patient privacy and
confidentiality. We agree with this recommendation. The existing spaces and conditions
at NRC, Dixon, and some of the rooms at MCC are unacceptable for the performance of
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sick call services, and to protect patient privacy and confidentiality. Non-functional or
missing equipment and supplies were noted in clinical areas at almost all of the five
facilities inspected. These deficiencies present barriers to the delivery of care and create
an unprofessional work environment for both clinical and correctional staff.
2. Equipment, mattresses, etc., which have an impervious outer coating must be regularly
inspected for integrity and repaired or replaced if it cannot be appropriately cleaned
and sufficiently sanitized. We agree with this recommendation. Torn mattress coverings
and/or uncovered foam cushions were noted at NRC, SCC, and MCC. Varying degrees of
torn examination table upholstery were noted at SCC, LCC, and MCC. Frayed and ripped
upholsteries on staff chairs in the clinical areas were noted at SCC and MCC. These
deficiencies make it impossible to properly clean and sanitize the beds and examination
tables, creating infection control risks and an unprofessional work environment for
clinical staff.
3. A paper barrier which can be replaced between patients should be used on all
examination tables. We agree with this recommendation. Varying degrees of absent
changeable paper barriers on examination tables and no evidence of a suitable alternate
method to sanitize examination tables between patients were identified at all of the
facilities, with the exception of MCC. This deficiency creates an infection control risk for
patients and staff.
4. Handwashing and sanitizing must be provided in all treatment areas. We agree with this
recommendation. Sinks were lacking in all nurse sick call areas and one provider backup
exam room at NRC, one nurse sick call room at SCC, three nurse sick call rooms at
Dixon, one provider room at LCC, and one clinical exam room at MCC. Hand sanitizing
gel was not consistently identified as available in treatment rooms lacking sinks.
Additional Recommendations
5. All of the infirmaries must have sufficient numbers of hospital beds with adjustable
heights, heads, and legs, and safety railings to meet the clinical and safety needs of the
high-risk infirmary patient population. The infirmaries at NRC, SCC, and MCC lacked an
adequate quantity of hospital beds.
6. Nurse call devices must be installed in all infirmaries. The infirmary at MCC was the only
infirmary found to be lacking nurse call devices.
7. All facilities must have a sufficient number of examination rooms to accommodate all
the nurses and providers who are simultaneously assigned to see patients. NRC, Dixon,
and LCC do not have an adequate number of properly equipped examination rooms to
accommodate all of their treating nurses and providers. This is a barrier to access to
care at these facilities.
8. The showers in the infirmaries and other special housing units (geriatric, ADA, etc.) must
have intact, non-slip floors, safety grab bars, shower chairs, and proper ventilation to
assure the safety and health of the high-risk population assigned to these special
housing units. Showers in special housing units in all of the facilities inspected had
notable structural and safety deficiencies that put the health and safety of this
compromised population at risk.

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9. The physical condition of the hemodialysis unit at SCC must be immediately addressed
by the contracted vendor, IDOC, and Wexford.
10. The flooring on all three floors of the health care building at Dixon must be immediately
replaced. The vast number of cracked, missing, and loose floor tiles throughout the
three-story health care building puts patients, medical staff, and correctional staff at risk
for injury.

Medical Records
First Court Expert’s Recommendations
1. Problem lists should be kept up to date. We agree with this recommendation but believe
it is a physician practice issue not a medical record issue.
2. Only providers should have privileges to make entries on the problem list. We agree
with this recommendation.
3. The system of “drop filing” should be abandoned. We agree with this recommendation.
4. Medical records staff should track receipt of all outside reports and ensure that they are
filed timely in the health record. We agree with this recommendation. See also First
Court Expert’s recommendation #8 in specialty care below.
5. Charts should be thinned regularly and MARs filed timely. We agree with this
recommendation.
6. Consideration should be given to scanning specific important records into the new
electronic system if possible. It is our opinion that all medical record documents that are
not electronic need to be scanned to the electronic record. This should not occur just “if
possible;” it is required.
Additional Recommendations
7. See Key Recommendation #9 above.
8. If paper records are continued, all records need to be located near by the medical
records office so that any volume of the record can be easily obtained for clinical care.
9. The medical record must include dialysis records or summaries of dialysis records so
that clinical staff understand the status of the patient’s dialysis.
10. Medical records rooms need to be secured. Only medical record staff should pull or refile medical records. Only authorized personnel should be permitted in a medical record
room.
11. Records should be maintained in accordance with guidance from the Illinois Department
of Human Services.
12. When records are pulled for use, an outguide should be used to identify that the record
has been pulled and where the record is.
13. Policy for medical records needs to be revised to include the electronic medical record
currently in use and should also address security and confidentiality of the medical
record paper or electronic.

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Medical Reception
First Court Expert Recommendations
We agree with the First Court Experts recommendations which include:
1. Sufficient nursing and clinician staff to complete the reception evaluation in one week.
2. A process that ensures that a clinician reviews all intake data, including laboratory tests,
TB screening, history and physical, etc., and develops a problem list and plan for each
problem.
3. Forms to identify acute symptoms (i.e., a review of systems).
4. A requirement that clinicians, during the history, elaborate on all positives from the
nurse screen.
5. A system of placing patients on hold in the midst of appointments or incomplete
treatment.
6. A policy that requires the medical record to be well organized and the staff to ensure
this is accomplished.
7. A quality improvement process that monitors completeness, timeliness, and
professional performance, and is able to intervene in order to implement
improvements.
8. A Medical Director trained in primary care.
9. A HCUA dedicated to NRC and appropriate supervisory resources.
10. A well-trained Quality Improvement Coordinator at each reception center and each
facility dedicated to ensuring the timeliness, completeness, and appropriateness of
clinical decisions.
We disagree with the First Court Expert’s recommendation to have a system that ensures
relevant electronic data arrives with patients from Cook County Jail. While access to the
electronic medical record is desirable, we find that provision of a paper medical transfer
summary is adequate.
Additional Recommendations
11. IDOC health care leadership should develop and implement an electronic medical
reception tracking log that documents the timeliness of completion of all required
medical reception transfer activities.
12. IDOC should amend medical reception forms to include a comprehensive review of
systems (ROS) to identify serious medical conditions.
13. Providers need to take and document a medical history and not rely only on the nurse
history.
14. At medical reception, medical records staff should initiate a green jacketed medical
record for each patient, with documents filed under the correct tab, eliminating drop
filing.
15. Examination rooms should be adequately equipped and supplied, including paper for
examination tables to provide infection control barriers between patients. Furniture
that is torn or in disrepair should be replaced.

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16. At LCC, a microscope should be purchased for medical reception evaluations to diagnose
vaginal infections.
17. Staff should change gloves and wash their hands between patients.
18. The IDOC Administrative Directive 04.03.101 should be revised to eliminate obtaining
written consent for HIV testing given the opt-out policy that has been established.
19. Weight scales should be periodically calibrated (e.g., weekly).
20. At LCC, nurses should perform and document urine pregnancy testing on all women of
child-bearing age.
21. Nurses should measure uncorrected and corrected visual acuity in each eye and
document results in the medical record. If large Snellen charts are used, the nurse
should ensure the patient stands the correct distance away from the chart. Consider
smaller hand-held Snellen charts.
22. Use QuantiFERON testing to detect TB infection rather than tuberculin skin testing.
23. As long as TST is being performed, nurses should correctly read tuberculin skin tests via
palpation and measurement of induration. This should be done in a medical setting, not
through the food port.
24. Nurses should timely document tuberculin skin test results in the medical record (e.g.,
within 24 hours).
25. Providers should document review of medical transfer information sent by county jails.
26. Providers should perform a history to include pertinent review of systems for each
chronic disease and/or significant illness.
27. Providers should order CIWA and/or COWS monitoring in accordance with current
guidelines for patients withdrawing from alcohol, opiates, or other drugs.
28. Providers should provide continuity of medications unless there is a clinical indication
for changing medication regimens (e.g., glargine to NPH insulin, etc.).
29. Providers should document all significant medical conditions onto the patient’s problem
list.
30. Nurses should transcribe all medication orders (i.e., KOP and nurse administered) onto a
MAR at medical reception and document administration of KOP medications at the time
they are administered to the patient.
31. Health care leadership should develop systems to ensure that all physician orders are
timely implemented (e.g., EKG, blood pressure monitoring, etc.).
32. Providers should timely follow-up on all abnormal labs.
33. Providers should use a chronic disease form or document that they are evaluating the
patient for chronic care when seeing patients for the first chronic disease appointment
within 30 days.
34. Health care leadership should revise medical reception policies and procedures to
provide sufficient operational detail to staff to adequately complete each step of the
process.
35. Health care leadership should develop and monitor quality indicators related to each
step of the medical reception process.

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Intrasystem Transfer
First Court Expert Recommendations
1. Custody must propose a list of transferring inmates to medical at least 24 hours prior to
transfer.
2. Inmates with scheduled offsite services should be placed on medical hold until the
service has been provided.
3. A nursing supervisor should regularly review a sample of transfer summaries of patients
about to be transferred to ensure completeness of the data.
4. Office of Health Services should provide a guide as to how to efficiently review a record
to identify important elements to be included in the summary.
5. When patients arrive, they must be brought to the medical unit and a nurse must be
responsible for facilitating continuity of required services.
6. At least quarterly, this service must be reviewed by the QI program.
We agree with these recommendations.
Additional Recommendations
7. IDOC should develop an intrasystem transfer policy and procedure consistent with
NCCHC standards, and that provides sufficient operational guidance to staff regarding
each step of the process.
8. IDOC/Wexford should train staff regarding the revised policy.
9. Nurses should complete each element on the intrasystem transfer form and address all
aspects of health care requiring continuity.
10. A system should be developed and implemented that provides sending facilities
feedback when there are errors on the intrasystem transfer form.

Nursing Sick Call
First Court Expert Recommendations
1. Each facility is to develop and implement a plan to ensure:
a. Sick call is conducted in a defined space that is appropriately equipped and
provides patient privacy and confidentiality.
b. Sick call requests are confidential and viewed only by health care staff.
c. The review/triage of sick call requests and conducting of sick call is performed by
a licensed RN.
d. Legitimate sick call encounters to include collecting a history, measurement of
vital signs, visual observations, and a “hands on” physical assessment.
e. There must not be arbitrary restrictions on the number of symptoms to be
addressed at an encounter.
f. Following Office of Health Services policy and procedure.
g. Complete documentation.
h. Implementation of a sick call log.
i. Administration must ensure health care activities such as sick call are not
routinely cancelled, as this results in unacceptable delay in health assessment.
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We agree with these recommendations.
Additional Recommendations
2. IDOC should revise its Administrative Directives on nursing sick call to provide adequate
policy, operational, and procedural guidance regarding how to implement the policy.264
The policy should include:
a. Designating what IDOC forms are used for inmates to submit written health
requests and which staff are responsible for ensuring that they are available to
inmates on a daily basis.
b. Developing a standardized paper or electronic Nursing Sick Call Tracking Log.
c. Installation of lockable Health Request form boxes that are accessed only by
health care staff in each inmate housing unit.
d. Inmates must be permitted out of their cells on a daily basis to confidentially
submit their health requests into health request boxes, except in restricted
housing units where nurses collect health request forms.
e. Health care staff should collect health care request forms seven days per week.
f. Health care staff should legibly date and time receipt of health requests.
g. An RN should triage health requests and document a disposition on the form
(e.g. urgent, routine). Nurses should legibly date, time, and sign the form,
including credentials.
h. Each health request should be entered onto the Sick Call Log, including the
urgency of the disposition.
i. A nurse should schedule patients to be seen in accordance with the urgency of
their complaint.
j. Nursing sick call should be conducted in adequately lighted, equipped, and
supplied rooms with access to a sink for handwashing. This includes a desk and
chairs so the nurse and patient can be seated, and an examination table,
otoscope, scale, etc. Consider installing lockable cabinets to store supplies (e.g.,
nurse protocol forms, gauze, tape, tongue blades, etc.).
k. Nurses should have the medical record available at the time of the sick call
encounter.
l. An RN nurse should perform and document an assessment of each patient in
accordance with treatment protocol forms and/or sound nursing judgement.
m. Nurses should refer patients to providers in accordance with the treatment
protocol and in accordance with sound nursing judgment.
n. Health requests should be filed chronologically in the medical record.
o. At the regional and institutional level, health care leadership should develop and
monitor quality indicators associated with each step of the sick call process.
3. IDOC should standardize the nursing sick call process to all institutions.265

Variances to the policy should only be granted to institutions that have demonstrated that access to care is timely and
appropriate.
265

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Chronic Care
First Court Expert Recommendations
1. Patients should be seen in accordance with the degree of control of their diseases, with
more poorly controlled patients seen more frequently and well controlled patients seen
less frequently. We agree with this recommendation.
2. Chronic care forms and flow sheets should be updated and designed so that all chronic
diseases are addressed at each visit. We agree with this recommendation. We add that
use of an electronic medical record can eliminate the problem of inadequate forms and
the time wasted completing multiple forms for persons with multiple chronic illnesses.
3. HIV patients should be followed regularly by IDOC providers in the chronic care program
to monitor for medication compliance, side effects of therapy, and overall health status.
We agree that IDOC physicians should monitor patients between UIC telemedicine visits
to address problems that occur.
4. The Asthma Treatment Guideline should be replaced with a guideline on the treatment
of pulmonary diseases to include COPD and chronic bronchitis as well as asthma. This
guideline should be modeled after the NHLBI.266 We agree in part. It is our opinion that
it is not efficient or productive for the IDOC to write chronic clinic guidelines, as they will
not have the expertise or time to do this. Their guidelines should be confined to the
timeliness and frequency of clinics, the required laboratory and other testing for inmates
with chronic illness, and the conditions under which patients are referred for specialty
management of a chronic illness. It is our opinion that the IDOC should refer providers to
national standards of medical care in lieu of chronic disease guidelines. These should
include at a minimum:
o Standards of Medical Care in Diabetes, American Diabetes Association as found
at http://care.diabetesjournals.org/content/38/Supplement_1/S1.full.
o 2014 Evidence-Based Guideline for the Management of High Blood Pressure in
Adults, Report from the Panel Members Appointed to the Eighth Joint National
Committee (JNC 8). As found at
http://jama.jamanetwork.com/article.aspx?articleid=1791497.
o Guidelines for the Diagnosis and Management of Asthma (EPR-3), National
Heart, Lung, and Blood Institute as found at http://www.nhlbi.nih.gov/healthpro/guidelines/current/asthma-guidelines.
o 2013 American College of Cardiology/American Heart Association Guideline on
the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk
in Adults as found at
https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.6385
3.7a.full.pdf.
o Prevention and Control of Tuberculosis in Correctional and Detention Facilities:
Recommendations from CDC found at
http://www.cdc.gov/mmwr/PDF/rr/rr5509.pdf
National Heart Lung and Blood Institute; Guidelines for the Diagnosis and Management of Asthma (EPR-3) published August
2007 as found at https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma.

266

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o Global Initiative for Chronic Obstructive Lung Disease updated 2016 as found at
http://www.goldcopd.org/uploads/users/files/WatermarkedGlobal%20Strategy
%202016(1).pdf.
o HIV/AIDS guidelines sponsored by National Institutes of Health found at
https://aidsinfo.nih.gov/guidelines.
o The Management of Sickle Cell Disease, National Institute of Health/National
Heart, Lung, and Blood Institute as found at
http://www.nhlbi.nih.gov/files/docs/guidelines/sc_mngt.pdf.
When a patient has a disease other than one supported by a referenced guideline, the IDOC
should require that provider refer to UpToDate® as a reference.
5. There should be a chronic clinic devoted to women’s health to include specific
guidelines on cervical and breast cancer screening as well as other issues unique to this
population. We agree with this, but note that IDOC has Administrative Directive
guidance on initial and subsequent cervical and breast cancer screening. Even though
there is an obstetrician available for pregnancy care, access of females to care for
female care issues could be improved.
6. The TB guideline should be updated to provide basic information regarding interferon
gamma testing, including appropriate uses of this test. It is our opinion as stated in
Infection Control Recommendation 1.d. that interferon gamma testing should replace
Mantoux skin testing for tuberculosis screening of all individuals.
7. Policy should require that patients who miss medications repeatedly or for a significant
period of time are referred to a provider to address the issue. We agree with this
recommendation.
8. Copies of the current MAR should be available for the provider’s review during chronic
care clinic. We agree with this recommendation.
Additional Recommendations
9. All chronic illnesses should be monitored at every chronic disease clinic.
10. Consult with an endocrinologist or diabetes specialist to perform a comprehensive
review, recommendations and training concerning the management of diabetes, and in
particular, insulin-prescribed diabetes in the IDOC.
11. Implement and utilize current Center for Disease Control (CDC) age-based and diseasebased standards for the administration of adult immunizations.
12. Implement and utilize current United State Preventive Services Task Force (USPSTF)
guidelines for screening adults for cancer and other conditions. The IDOC should adopt
the A and B recommendations of the USPSTF.
13. Calculate and document the ten year cardiovascular risk score on all appropriate adults
to assist with the decision and timing to initiate HMG-CoA reductase inhibitors (statins).
14. Revise the current restrictive criteria and lengthy screening and approval process
utilized to determine in order to expand the number of active hepatitis C patients are
eligible for treatment and when treatment is initiated.

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15. Particularly given the current configuration of physicians, when a physician has not been
trained in residency training to manage an illness, the physician should refer that patient
to a physician who is trained in managing that condition.
16. Increase access to specialty care throughout the IDOC by increasing the number of
onsite specialty consultants, expanding the existing telehealth specialty program to
include additional medical specialists to assist facility providers with the management of
complex and common medical conditions including diabetes, hypertension, cardiology,
dermatology, neurology, and non-HIV, non-hepatitis C infectious diseases, and
establishing an e-consult program that would allow providers to readily consult with
specialists about diagnostic and treatment questions.
17. Develop a plan to shift anticoagulation treatment from vitamin K antagonists (warfarin)
to new types of anticoagulants that do not require frequent ongoing lab testing and
frequent dose modifications to achieve an adequate state of anticoagulation.

Urgent/Emergent Care
First Court Expert Recommendations
1. All facilities must track urgent/emergent services through using a logbook maintained by
nursing which includes patient identifiers, the time and date, the presenting complaint,
the location where the patient is seen, the disposition and when the patient is sent out,
the return with the appropriate paperwork including an emergency room report, and
appropriate follow up by a clinician. We agree with this recommendation. All facilities,
except NRC, provided a list of patients sent to the ED, but did not provide a log that
contains a list of all unscheduled urgent/emergent encounters. Patients seen urgently,
but not sent to the ED, are not consistently tracked on a log. The current list does not
include the location the patient was seen (cell front, sick call area, trauma room, yard
etc.), whether a report was returned with the patient, and the date the patient was seen
by a provider for follow up after receiving offsite services. Existing logs should be
modified to include this data.
2. Assessments must be performed by staff appropriately licensed to be responsible for
that service. We agree with this recommendation. The use of CMT and LPNs to respond
to medical emergencies is not within their scope of practice. Only registered nurses have
a scope of practice that allows them to make independent decisions about whether to
contact a clinician. There should be sufficient registered nurse staffing so that an RN is
assigned to respond to evaluate patients with urgent/emergent complaints.
3. Guidelines should be developed for nursing staff with regard to vital signs reflecting
instability that require contacting a clinician. We agree with this recommendation. We
note that the IDOC issued a revised set of nursing treatment protocols in March 2017.
The document does provide guidance to nurses on vital sign results among the
determinants in contacting a provider. Ongoing review of urgent/emergent clinical
performance using the criteria in the protocols would aid in improving nursing
performance and is also useful in identifying revisions or additions that should be made
to the protocols.

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4. When patients are sent offsite, work with hospitals to ensure that the emergency room
report is given to the officer to return to nursing with the patient. We agree with this
recommendation. We found many examples of patient discharge instructions but few
actual records from emergency room visits or hospitalizations. This was particularly true
of hospitals in the local community. The First Court Expert recommended developing an
understanding that payment for services included receiving at least the discharge
summary from a hospital. We agree that this is one way to accomplish this.
5. Patients returning from an emergency trip must be brought to a nursing area for an
assessment and if not placed in the infirmary, scheduled for an assessment by an
advanced level clinician. We agree with this recommendation. The follow up by an
advanced level clinician needs to be within three days (see recommendation #7 below).
We found many instances of patients returning from offsite services who were not seen
promptly upon return or not seen at all. We also found instances of patients returning
from offsite services who should have been put in the infirmary, but instead were housed
in general population.
6. The Office of Health Services should provide guidance with regard to the types of clinical
problems that require services beyond the capability of the infirmary, thus sending
patients to the local hospital. We agree with this recommendation.
7. Insure that after the patient returns, he is seen by a clinician within three days where
there is documentation of a discussion of the findings and plan as described in the
emergency room report. We agree with this recommendation. However, given the
number of hospital visits where the patient is never seen, we suggest IDOC consider
requiring patients sent off site in an emergency be admitted to the infirmary upon return
to the facility until evaluated by a provider and a plan for ongoing care established.
8. The QI program should monitor timeliness and appropriateness of professional
responses. We agree with this recommendation. All unscheduled urgent/emergent
encounters should be reviewed by a nurse manager as soon as possible after the
encounter but no longer than the next business day. The review by the nurse manager
should include review of the nursing assessment for compliance with the relevant
treatment protocol as well as timeliness of the response. These reviews should be
documented, and an analysis given to the QI committee monthly, including
recommended areas of improvement. The QI committee should direct corrective action
or performance improvement plans and monitor implementation. In addition, a sample
of patients sent to the ED should be reviewed at least quarterly to evaluate whether the
care of the patients in the months preceding the offsite could have better addressed the
clinical reason the patient required unscheduled urgent/emergent care. Examples of
conditions which should be considered for review are seizures, hypoglycemia,
ketoacidosis, infection, etc. The results of chart review should be analyzed to identify
individual clinicians who would benefit from coaching or other performance
improvement measures as well as systemic factors that would improve care. The analysis
should be presented to the QI committee and the systemic factors discussed to identify
corrective action to be taken.
9. As an aspect of the QI program, review nursing and clinician performance to improve it.
We agree with this recommendation. See discussion of #8 above.
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Additional Recommendations
10. The Office of Health Services should standardize the equipment and supplies that are at
the facilities for emergency response. This should include specifying the contents of the
emergency bag, identifying the minimum number and location of AEDs and other
equipment (oxygen tanks, suction, cervical collars, etc.) for each site, and whether one
or more trauma or disaster bags are kept in addition to the emergency bags. The
contents of the emergency bag (and if kept on-site, trauma and disaster bags) should be
listed on the outside of the bag and include the expiration date of any medicine or other
supplies. Every opening on the emergency bag (and trauma or disaster bags) should be
sealed with a numbered, plastic seal or lock to indicate that the contents are
undisturbed.
11. Emergency equipment and supplies should be checked each shift and documented on a
standardized log. The log should list what specifically is to be checked (i.e., the
expiration date of the electrodes on the AED, the pressure in the oxygen tank, etc.) and
include the numbers of the tags on the sealed emergency bag. If the locks are intact, the
bag does not have to be opened and checked. If the bag has been opened, it is removed
from service until it has been replenished and a new seal applied. The log is checked
daily by a nurse manager to ensure that equipment is being checked and is functional.
12. The Office of Health Services should monitor to ensure compliance with expectations for
emergency response equipment and that drills are conducted per the AD. The Office of
Health Services should also develop a template with criteria to be considered in the
review and analysis of emergency response and mass disaster drills, and monitor the
reporting and corrective action pursued through the facility CQI committees.
13. The Office of Health Services needs to incorporate in its quality improvement program
review of sentinel events.267 These should be reviewed consistent with methodology
used for mortality review in an attempt to discover correctible process errors or other
errors.

Specialty Consultations
First Court Expert Recommendations
1. The entire process, beginning with the request for services, must be tracked in a
logbook, the fields of which would include date ordered, date of collegial review, date of
appointment, date paperwork is returned and date of follow-up visit with clinician.
There should also be a field for approved or not approved, and when not approved, a
follow-up visit with the patient regarding the alternate plan of care. We agree that
offsite specialty care needs to be tracked and this system of tracking should continue if a
prospective review process is continued. This tracking should be standardized across all
IDOC facilities and directed and/or managed by IDOC.
2. Presentation to collegial review by the Medical Director must occur within one week.
See Key Recommendation #5 above. We believe the collegial process should be
abandoned as a patient safety hazard. Doing so makes this recommendation mute.
267

Sentinel events are unexpected events involving death or serious physical harm or risk of harm.

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3. When a verbal approval is given, the authorization number must be provided within one
business day to the onsite scheduler. See Key Recommendation #5 above. We believe
the collegial process should be abandoned as a patient safety hazard. Doing so makes
this recommendation mute.
4. When a scheduled routine appointment cannot be obtained within 30 days, a local
resource must be utilized. We generally agree with this recommendation. But we note
that some referrals are meant to be longer than 30 days out. This recommendation
relates to UIC referrals presumably and we agree that for routine appointments that are
meant to occur as soon as can be reasonably scheduled local resources should be used
when UIC cannot provide a timely appointment.
5. Scheduling should be based on urgency. Urgent appointments must be achieved within
10 days; if emergent, there should be no collegial review and there should be immediate
send out. Routine appointments should occur within 30 days. We agree with this
recommendation. But we note that some referrals are meant to be longer than 30 days
out (e.g., a patient is referred by a cardiologist to be seen in follow up in six months)
6. When the patient receives the service, the paperwork and the patient must be returned
to the appropriate nursing area so that the nurse can identify what the needs are. We
agree with this recommendation.
7. When the patient returns without a report, a staff member should be assigned to
contact offsite services and obtain a report. We agree in principle with this
recommendation. However, it is our opinion that the root cause of this problem is a
failure of the vendor to negotiate with contract hospitals and consultants in order to
obtain reports. To force line staff to attempt to obtain reports is misplaced and is
unlikely to succeed. The vendor must correct this problem systemically.
8. Either a nurse or the scheduler must be assigned responsibility for retrieving offsite
service paperwork timely and this should be documented in the offsite service tracking
log. We agree in principle with this recommendation. However, it is our opinion that the
root cause of this problem is a failure of the vendor to negotiate with contract hospitals
and consultants in order to obtain reports. To force line staff to attempt to obtain
reports is misplaced and unlikely to correct the problem. The vendor must correct this
problem.
9. Nurses should contact clinicians for any orders. We agree with this recommendation.
10. When patients are scheduled for appointments, they should be put on hold for as long
as clinically necessary to complete the appointment before being transferred. We agree
with this recommendation.
11. When the paperwork is obtained, an appointment with the ordering clinician or Medical
Director must be scheduled within one week. We agree with this recommendation.
12. That encounter between the patient and the clinician must contain documentation of a
discussion of the findings and plan. We agree with this recommendation.
Additional Recommendations
13. See Key Recommendation #5 above.
14. We recommend that IDOC investigate and negotiate for expanded specialty coverage
via telemedicine with UIC or SIU. Given the degree of underutilization, additional
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specialty care resources will be indicated. To the extent possible (onsite providers,
onsite radiography, etc.) IDOC will need to increase specialty care resources to attain
adequacy. The extent to which unqualified doctors continue to be used, the expansion
of specialty care necessary to attain adequacy will be considerable.

Infirmary Care
First Court Expert Recommendations
1. It is our opinion a registered nurse should be readily available to address infirmary
patient issues as needed. We agree with this recommendation.
2. In the large facilities, such as SCC, Pontiac, and MCC, where medical staff is assigned to
work in multiple buildings/cell houses outside the main health unit where infirmary is
located, it is recommended that at least one registered nurse is assigned at all times to
the building where the infirmary is located. We agree with this recommendation
provided the analysis called for in Key Recommendations #3 and #8 are completed and
this level of coverage is sufficient to ensure the safety and meet the needs of patients in
the infirmary. We also have concerns that nurses in the building but not on the infirmary
will not hear the alarm unless they are present on the infirmary unit.
3. At all other facilities, it is recommended at least one registered nurse is assigned to each
shift. We agree with this recommendation.
4. The infirmary policy should include specific clinical criteria which are appropriate for
infirmary care, and those criteria which exceed the level of care which can safely be
provided in an infirmary setting and would indicate referral to the hospital. We agree
with this recommendation.
5. The infirmary policy should provide criteria outlining when patients are stable enough to
be discharged from the infirmary and require follow up after infirmary discharge. We
agree with this recommendation.
6. Develop and implement a plan to open and operate the NRC infirmary. The NRC
infirmary was opened in 2016 and this recommendation is no longer necessary.
7. Develop and implement a plan to insure a constant security presence in the infirmary.
We agree with this recommendation. Security staff are stationed at desks outside the
SCC and Dixon infirmaries. During the day shifts, correctional officers were observed
inside both of these infirmaries.
8. Develop and implement a plan to insure each infirmary patient is provided a nurse call
device. We agree with this recommendation. Nurse call devices are in place in all patient
rooms at the NRC and LCC infirmaries and in some infirmary rooms at SCC and Dixon.
MCC’s infirmary has not placed nurse call devices in any infirmary patient rooms.
9. Develop and implement a plan of teaching/continuing education for nursing staff which
addresses accurate and informative documentation. We agree with this
recommendation.
10. The inconsistencies between IDOC and Wexford Infirmary policies should be rectified,
specifically regarding the issue of 23-hour admissions/temporary placements. We agree
with the recommendation. Wexford policies were no longer in use at the time of our
visits
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11. The infirmary policy should clarify for nursing staff those criteria that are appropriate for
temporary observation vs. those that require evaluation by a provider prior to release
from the infirmary. It is our opinion that if a nurse believes that a patient needs to be
placed on the infirmary for observation, a physician should examine the patient the
following day. The rationale is that if a nurse judges a patient to have an urgent medical
condition requiring infirmary admission, a physician should see the patient.
12. Ensure that institutions with infirmaries have at least one registered nurse available
onsite 24 hours a day. We agree with this recommendation. See also recommendation
#2 above.
13. The infirmary policy should require follow up after discharge from the infirmary. We
agree with this recommendation.
14. Develop and implement a plan to insure sufficient quality and quantities of infirmary
bedding and linens. We agree with this recommendation. We note that with the
exception of NRC, a sufficient quantity of bedding and linens in reasonably good
condition were available in the infirmaries inspected. This does not address the
laundering of linens which is addressed in the Infection Control Recommendations below.
Additional Recommendations
15. Health care leadership and the quality improvement committee should develop,
monitor, and report quality indicators that measure and track provider and nurse
adherence to the infirmary policy and the quality of the acute and chronic care provided
to infirmary patients.
16. Problem lists in the infirmary charts must be complete and accurate.
17. Provider infirmary notes must be legible, communicate the rationale for modifications in
treatment, list reasonable differential diagnoses, document pertinent physical findings
and symptoms, record clear treatment plans, and include regular comprehensive
progress notes that update the status of each and every acute and chronic illness.
18. Provider infirmary admission notes and progress notes should be performed in accord
with the timeframes detailed in IDOC policy 04.03.120, Offender Infirmary Services.
19. Physical therapy services must be provided in the infirmary for those patients who
cannot be readily moved to the physical therapy treatment rooms.
20. Patients whose clinical needs and support for their activities of daily living exceed the
capability of the infirmaries must be transferred to a licensed skilled nursing facility in
the community or to an infirmary in the IDOC that meets all the State of Illinois
standards for licensure at a skilled nursing facility. See Key Recommendation #8.
21. Educate, encourage, and direct infirmary providers to expeditiously consult with surgical
and medical specialists to address the care of complex infirmary patients.

Pharmacy and Medication Administration
First Court Expert Recommendations
1. Following patient ingestion of medication, security staff should be responsible to check
the mouth for contraband. We agree with this recommendation. Some officers we
observed do check for ingestion, but it was sporadic. See also Key Recommendation #12
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which recommends that the IDOC develop, in collaboration with the Office of Health
Services, an Administrative Directive that provides standardized guidance to custody
staff on the expectations for safe delivery of medications. The IDOC should translate this
into post orders at each site that explicitly detail correctional officers’ responsibilities
during medication administration. This should ensure that nurses are safe and can
administer medication in accordance with established nursing standards.
2. A security staff member must be assigned to accompany the nurse who performs
medication administration. We agree with this recommendation. See Key
Recommendation #12. Correctional officer support is essential to complete medication
administration swiftly and safely. This includes not just escort but also controlling
movement and distractions in the environment (television, fights, etc.), accounting for
missing inmates, and ensuring that inmates ingest medication that has been
administered. Many facilities identify these duties in the officers’ post orders as
discussed in the recommendation above.
Additional Recommendations
We provide detailed recommendations in the facility reports for improvements needed in
pharmacy and medications services. They are so numerous and basic that they are not restated
here. The five recommendations below are overarching and require the concerted and
immediate attention of IDOC.
3. Pharmacy and medication services need to be completely redone to bring practices into
conformance with standards of care. This should be accomplished by leadership from
the Office of Health Services and managed as a comprehensive plan of change with clear
targets, steps to proceed, timeframes, and outcomes.
4. IDOC Office of Health Services needs to establish more detailed operational guidance
(See Key Recommendation #6) that specifies how medication is prescribed, how and by
when treatment is initiated, how medication is to be administered safely and timely,
including support to be provided by the facility, and establish how and by when
documentation of medication administration takes place. At a minimum this should
include:
a. Nurses should timely transcribe medication orders onto a MAR;
b. Nurses should have the MAR present at all times medication is administered to
patients;
c. Nurses should administer medications to patients directly from pharmacydispensed containers and contemporaneously document administration on the
MAR.
5. Computerized provider order entry should be implemented at all facilities. This will
resolve problems with legibility and, if a template is created, assist providers to write
complete orders. The MAR should also be automated. Automation of the MAR will make
information on medication orders and treatment available to providers, who can use
this information to guide decisions about subsequent care. Automation will provide
detailed and accurate statistical measures of medication administration and of
compliance of medication by individual inmates. Automation will also provide staff and

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managers with information which directs work and identifies outliers, which can be
immediately resolved. See also Key Recommendation #9 above.
6. Facility operations need to provide sufficient access to inmates so that medications are
administered safely. This may mean that schedules need to be renegotiated or
additional personnel or equipment must be obtained. The compromise of widely
accepted practices to administer medication is unacceptable. See Key Recommendation
#12 above.
7. Health care programs at each facility should be expected to monitor the extent practices
comply with the expectations of the Office of Health Services (as described in
recommendation #4) and to report these results to the CQI committee. CQI committee
meetings should document the analysis of root causes of systemic problems, develop
corrective action plans, and monitor the results of corrective action. The Office of Health
Services needs to monitor facility compliance with the comprehensive plan of change as
well as performance criteria outlined in the operational guidelines.

Infection Control
First Court Expert Recommendations
1. Each facility is to do the following:
a. Develop a position description and name an Infection Control (IC)/Quality
Improvement (QI) registered nurse (IC/QI-RN) and provide training on
communicable and infectious disease recognition, monitoring and reporting, and
the Quality Improvement process.
We agree, but would modify the recommendation as follows: The IDOC should
develop the position description for an infection control nurse that includes the
duties listed by the First Court Expert on page 35 of his report as well as responsibility
for coordination of clinics and care for patients with HIV and HCV; the initiation and
follow up of treatment for patients with tuberculosis; monitoring and managing
vaccination programs for inmates and staff; managing and providing surveillance of
infectious and contagious disease screening programs; monitoring and resolving
problems with conditions of confinement that are known risks for communicable
disease transmission; monitoring and managing Occupational Safety and Health
Administration (OSHA) requirements to provide protection from infectious disease by
delivering training, overseeing the availability and use of PPEs, and screening with
vaccination of staff and inmates; and conduct surveillance, manage and report on
resolution of communicable disease outbreaks in collaboration with the Illinois
Department of Public Health. Each facility should be expected to fill this position and
operate an infection control program consistent with the position description
adopted by IDOC. This model is in place at MCC and should be used as a model for
other facilities. It needs to be a dedicated position but does not have to be a nursing
supervisor. We note that the First Court Expert recommends combining the infection
control and quality improvement responsibilities. It is our recommendation that

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each of the infection control positions be a dedicated full time position and not
combined with quality improvement responsibilities.
In addition, the IC-RN should report to the statewide Communicable and Infectious
Diseases Coordinator for clinical performance.
b. Develop and implement a plan for the IC/QI-RN to conduct monthly documented
safety and sanitation inspections, focusing at a minimum on the healthcare unit,
infirmary, and dietary department, with monthly reporting to the Quality
Improvement Committee (QIC).
We agree with this recommendation and would amplify it as follows: Safety and
sanitation inspections should monitor the condition, function, and annual
certification of clinical equipment, the cleanliness and sanitation of clinical rooms,
the integrity of all flat surfaces for sanitation, functionality of the negative pressure
rooms, integrity of bed and chair upholstery including on infirmaries and ADA units,
completion of medical cart and emergency response bag logs and ensuring proper
sealing of these bags, the safety of shower areas used by special needs populations,
the training of health care unit porters, and other health care issues. Reporting
should include request and completion dates of all repair or replacement requests.
Delays longer than 30 days should be reported to IDOC Office of Health Services for
further efforts at resolution.
c. Develop and implement a plan for the IC/QI-RN to monitor food handler
examinations and clearance for staff and inmates.
We do not agree with this recommendation. A medical examination of persons to
work as a food handler is not necessary because it only represents that individual’s
condition on the day of the exam and is not predictive of future illness or disease that
would contradict working as a food handler. Instead, we recommend that staff and
inmates working in food service be trained and pass an examination on proper food
handling techniques, sanitation procedures, and what health conditions need to be
reported to the food services supervisor. This training should be approved by the
IDOC Communicable and Infectious Diseases Coordinator. In addition, food service
supervisors should be trained and certified by IDOC or the IDPH in supervision of food
handlers and prevention of food borne illnesses. The food services supervisor’s job
description should include responsibility to prevent food borne illnesses by
monitoring workers’ compliance with policy and procedures for food safety, and
vigilance for health conditions that should exclude workers from food preparation
and serving.
d. Develop and implement a plan for the IC/QI-RN to monitor compliance with
initial and annual TB screening, with monthly reporting to the QIC and facility
administration as needed.
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We agree with this recommendation and would amplify it to include the following:
Monitoring shall include observation of TB screening practices as well as chart
review. In addition, we recommend that IDOC replace skin testing with interferon
gamma testing to screen for TB. We also recommend that each facility IC-RN
complete training in TB control offered through the Southeastern National TB Center
or online at the Centers for Disease Control.268 The statewide Communicable and
Infectious Diseases Coordinator should work with the Tuberculosis Control Section of
the IDPH to determine rates of TB infection in the state correctional centers and
establish parameters to monitor the quality and efficacy of TB screening, prevention
and treatment.
e. Develop and implement a plan to aggressively monitor skin infections and boils,
and work jointly with security and maintenance staff regarding cell house
cleaning practices, with monthly reporting to the IC/QI-RN, QIC and facility
administration as needed.
We agree with this recommendation. Only one of the facilities we visited had
implemented this recommendation. Given the poor conditions of the physical plant,
particularly the showers and sinks, as well as the sanitation issues we observed with
water temperatures and poor surface cleanliness, skin infection should be a major
area of focus for infection control. Detailed records of each case should be kept on a
log that identifies the housing and work assignments and places frequented by the
inmate for programming. The log should be surveilled by the infection control nurse
to identify cells and other locations to receive targeted deep cleaning. Finally,
vigilance for skin infection referral needs to be broadly disseminated throughout the
institution. Identification of possible skin and soft tissue infection needs to originate
from sick call visits, provider visits, and use of urgent care, not just from the lab
(culture) or pharmacy (antibiotics). Referrals from correctional officers to infection
control of inmates with possible skin infection should be supported by the facility and
health care program.
We also recommend that this tracking and monitoring include scabies and lice, two
types of skin infection readily transmissible in correctional facilities and easily
contained with astute and early intervention.
f. Develop and implement a plan to daily monitor and document negative air
pressure readings when the room(s) is occupied for respiratory isolation and
weekly when not occupied.

https://www.cdc.gov/tb/education/professional-resources.htm, specifically the online course “TB 101 for Health Care
Workers” and the Self Study Modules 1-9 as well as https://sntc.medicine.ufl.edu/home/index#/catalog, which provides a
course “Arresting TB: Best Practices for Controlling TB in Corrections” and other seminars.
268

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We agree with this recommendation and would amplify it to include the following:
Negative pressure rooms or alarm systems that are not functional after five days
shall be reported to the Office of Health Services and a plan for correction
established with the approval of the Office of Health Services. In addition, the
statewide Communicable and Infectious Diseases Coordinator should establish, in
consultation with the TB Control Section of the IPHD, the number of negative
pressure isolation rooms that are needed and the location for each of these rooms
based upon the population served.
g. Develop and implement a training program for healthcare unit porters which
includes training on blood-borne pathogens, infectious and communicable
diseases, bodily fluid clean-up, proper cleaning and sanitizing of equipment,
infirmary rooms, beds, furniture, toilets, and showers.
We agree with this recommendation and would supplement it with the following:
Inmates shall not be assigned to work in the health care area until such training has
been documented as received in the inmate’s institution record. We would add that
inmates will not be assigned work in the health care area until vaccinated for
hepatitis A and B, a record of such vaccines has been documented in the inmate’s
record, and clearance for assignment to the health care area provided by health
services is placed in the inmate’s institution file.
In addition to the training, each facility should have procedures for the cleaning and
sanitation of each area in the health care area to include proper use of PPEs. The
policies and procedures at MCC should be considered an example once they have
been updated.
h. Monitor all sick call areas to insure appropriate infection control measures are
being used between patients, i.e., use of paper on examination tables which is
changed between patients or a spray disinfectant is used between patients,
examination gloves are available to staff, and hand washing/sanitizing is
occurring between patients.
We agree with this recommendation but would expand it to include all health care
areas.
i.

Develop and implement a plan to monthly monitor all patient care associated
furniture, including infirmary mattresses, to assure the integrity of the protective
outer surface, with the ability to take out of service and have repaired or
replaced as needed.

We agree with this recommendation and would supplement it with the following:
Such monitoring shall include the condition, function, and annual certification of
clinical equipment, the integrity of all flat surfaces for sanitation, integrity of bed,
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chair, and other upholstery. Additionally, a record of each item found in disrepair, the
date taken out of service, and the date repaired or replaced should be documented
on a log. We would also recommend that IDOC establish the practice of recording the
expected useable life and replacement date for each piece of patient care equipment
with a replacement cost greater than $50 on a capital repair and replacement log.
This log should be used to plan and requisition replacement equipment and furniture.
j.

Interface with the County Department of Health and Illinois Department of
Health, and provide reporting as required by each.

See our Key Recommendation #7 above. We agree with this requirement and found
that an individual at each facility had been designated with this responsibility. We
did not evaluate if reportable conditions were being reported as required to the
county and state health departments. There was evidence of collaboration between
IDOC facilities and the county/state health departments.
However, this interface should be for more than just reportable conditions, as it is
now. The relationship with county health departments and the state should include
establishing prevalence rates for certain communicable diseases, validation of
communicable disease screening processes and results, access to the state vaccine
registry and to vaccines, assistance with monitoring environmental safety and
sanitation, and so forth. The statewide Communicable and Infectious Diseases
Coordinator should be principally involved in establishing these relationships and
developing organizational relationships that translate Illinois’ interests and goals for
the health and safety of its citizens into the state prisons.
k. Develop and implement a plan for the proper sanitizing of healthcare unit linens.
We agree with this recommendation. IDOC has known that linens are not adequately
sanitized since at the least the First Expert’s report and has not corrected it. This is an
example of how pervasive and systemic the conditions for transmission of infection
with communicable disease are in IDOC. The same could be said for the lack of
protection provided during dialysis of patients with chronic hepatitis B. The fact that
at SCC birds still fly through the kitchen and roost over the dining area today, after
an outbreak of histoplasmosis at the Danville facility in 2013, is unfathomable except
as a reflection of deliberate indifference to the health and safety of inmates.
These are problems that require the attention of infection control personnel who are
trained and qualified in measures to prevent and control transmission of
communicable disease in the prison setting. In addition to training and qualifications,
the infection control nurse must have the authority to drive change in both
institution and health care practices, with accountability to the Office of Health
Services. In addition, a schedule for sanitation and disinfection for each area of the

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institution should be established. The IC-RN should monitor compliance with the
schedule as part of Safety and Sanitation rounds.
2. The Office of Health Services to fill the position of statewide Communicable and
Infectious Diseases Coordinator.
We agree with this recommendation. See Key Recommendation #7. There are obvious
areas of infection control that should be dealt with at a statewide level. The first and
most obvious is that the Administrative Directive related to communicable disease
screening is not current with articulated policy, the Infection Control Manual is out of
date, and the facility policies and procedures vary widely and are not up to date. Other
areas of primary responsibility include establishing the job expectations and
performance criteria for infection control at each of the state facilities, ensuring
vaccination rates are compatible with age and disease related expectations,
implementing policy for robust communicable disease screening, the standardization of
policy and procedures for infection control practices, monitoring surveillance activities,
acting as a point person with IDPH on contagious disease outbreaks, and analyzing
statistics to identify and address areas of disease progression and infection control that
are problems.
A problem cited at every facility was that the infection control reports made to the CQI
committee did not contain any analysis of disease prevalence or trends in disease
identification. In addition, we found at one facility that a TB conversion was not
identified as such in the monthly report. The statewide Communicable and Infectious
Diseases Coordinator must be responsible for establishing the methods and means for
IC-RNs to analyze and trend infectious disease data correctly and meaningfully. This
information needs to be reviewed and further analyzed at a statewide level by the
Communicable and Infectious Diseases Coordinator. It should be used as a basis for
decision making by the IDOC Medical Director on policy and program direction.
The statewide Communicable and Infectious Diseases Coordinator should be a masters
prepared public health nurse and should be guided and supported by a part-time
infectious disease physician specialist to advise on policy and updated recommendations
for prevention and control of communicable disease. For example, while the IDOC does
inconsistently offer pneumococcal 23 vaccine to a few individuals with high-risk
conditions, it does not offer the pneumococcal vaccine 13 in accord with the CDC’s aged
and illness-based adult vaccination guidelines. IDOC also fails to provide meningococcal
vaccine to individuals with immunodeficiency (e.g., HIV, etc.).269 The infectious disease
specialist would also design and carry out prevalence studies to monitor disease rates,
269

2018 immunization
adult-combined-sched

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train and monitor quality of the work performed by the IC-RNs, evaluate the
performance of disease monitoring clinics provided by UIC, and consult in treatment and
prevention of communicable disease. We suggest that IDOC consider establishing this
position within the IDPH. This would provide access to resources of the IDPH and support
collaboration with the IDOC.

Mortality Reviews
First Court Expert Recommendations
1. All mortality review should be performed by an independent clinician. A regional nurse
could do the initial review; those cases identified as potentially problematic and
therefore requiring a secondary review should be evaluated by the central office
regional physician, and not a “like” (i.e., Wexford) employee. We do not completely
agree with this recommendation. It is our opinion that under current circumstances an
independent physician should review all deaths. Under circumstances of adequate IDOC
central office staff (when and if that occurs), it is our opinion central office IDOC
physicians and nurses can perform this review. We do not believe that regional nurses
should be responsible for reviewing physician clinical care with respect to mortality
review. That is currently what is occurring and as we note, regional nurses find no
problems when significant problems exist. Physicians should review physician care in
mortality review and nurses should review nursing care. Nurses should not review
physician care. We agree that IDOC physicians, not vendor physicians should conduct
mortality review.
2. Policy should provide more specific guidance for end of life care. Specifically, this should
clarify the important differences between “DNR,” palliative care and hospice/end-of-life
care. We agree that that an end-of-life policy needs to be developed. This policy needs to
ensure that informed consent is specifically given and that when a person is not
competent to provide informed consent that reasonable legal options are taken. This
policy also needs to address the current practice of palliative sedation to ensure that it is
not used merely to hasten death or engage in euthanasia. Palliative sedation also needs
to follow strict guidelines with respect to informed consent. The policy should also
address end of life pain management as this appears to be an area of deficiency in the
medical program.
Additional Recommendations
3. Morality review should be completed for all deaths. We recommend that this be done at
a central office level when the central office is adequately staffed.
4. We recommend that the Office of Health Services (OHS) make a determination of
preventability and track preventable, possibly preventable, and non-preventable deaths.
5. Mortality review should be structured and include:
a. A brief summary of the care of the patient;
b. A list of all of the patient’s medical conditions;
c. A list of all the patient’s most current medications;
d. The age, date of incarceration, current housing unit, and the location of death;
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e.
f.
g.
h.
i.
j.

The preliminary cause of death;
The coroner’s cause of death;
A psychological autopsy in the event of a suicide;
Inclusion of any administrative or custody reports of the death;
A list of all problems identified on review of the death; and
A summary of any corrective actions or referrals taken with respect to identified
problems.
6. All deaths should include an autopsy.
7. All deaths should be tracked by the OHS and a summary report made at the end of the
year. This report should be forwarded to the Director of the IDOC and reviewed at the
statewide medical meeting. This should include reporting on the numbers of
preventable deaths. Analysis of recommendations based on deaths should be provided
at an annual statewide meeting.

Dental Program
First Court Expert Recommendations
1. Screening [initial] examinations at the reception center should include a thorough,
documented, intra and extra-oral soft tissue examination. We note that per
Administrative Directive 04.03.102, the examination performed at the R&C center should
be a complete examination; however, it is not complete at all.
2. The screening [initial] exam should not be used to develop treatment plans.
3. The examination should include radiographs diagnostic for caries, a periodontal
assessment, a soft tissue exam, and accurate charting of the teeth.
4. Appropriate medical conditions should be red-flagged, and medical consultations and
precautions should be documented in the dental record.
5. The health history should be more comprehensive, and appropriate conditions redflagged. We note that the health history form should be expanded in scope and reside on
a separate page.
6. Proper area disinfection and clinician hygiene should be implemented.
7. Proper radiology hygiene should be put in place. We note that this includes, at a
minimum, using a lead apron with a thyroid collar,270 and posting radiological hazard
signs in the areas where x-rays are taken.
8. Routine comprehensive care should be provided from a thorough, comprehensive
examination and treatment plan.271
9. Hygiene care and oral health instructions should be provided as part of the treatment
process.
While radiation exposure from dental radiographs is low, it is F to follow the ALARA Principle (As Low as Reasonably
Achievable) to minimize the patient’s exposure. Dentists should follow good radiologic practice and (inter alia), use protective
aprons and thyroid collars. Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation
Exposure. ADA and FDA (2012), 14. Emphasis added.
271 IDOC agreed that “[r]outine comprehensive care should be provided for through a comprehensive exam and treatment
plans.” The exam [should include] radiographs diagnostic for caries, a periodontal assessment, a soft tissue exam, and accurate
charting of the teeth,” and “hygiene care and oral health instructions be provided as part of the treatment process. IDOC
Response, ¶XIII (5).
270

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10. Removable partial dentures should be provided as the last step in the comprehensive
care process.
11. All teeth should be restored, and the periodontium should be stable before partial
denture impressions are taken.
12. A proper diagnosis should be part of the treatment process. We note that except for
NRC, the diagnoses were appropriate in most of the charts we reviewed.
13. Inmates with urgent care needs should be provided care within 24-48 hours.
14. The SOAP format should be used to document emergency and urgent care contacts. We
note that the SOAP format was used consistently, except for NRC and SCC.272
15. A proper diagnosis should be part of the treatment process. We note that except for
NRC, the diagnoses were appropriate in most of the charts we reviewed.
16. The IDOC should develop a policy to ensure that each institution has a meaningful
orientation manual to instruct inmates how to access acute and routine care.
17. The IDOC should insure that all institution dental programs have well-developed and
thorough policy and protocol manuals that address all areas of the dental program.
18. All dental staff should be familiar with these policies and protocols.
19. Policies should be reviewed annually and amended as necessary.
20. An administrative dentist should be available to oversee the IDOC dental program. This
person could remain in the field as a part-time practicing dentist.273 We feel the position
should be 0.5 FTE. See Key Recommendation #10.
21. The IDOC should insure that all dental programs follow current infection control
guidelines as well-defined by the Centers for Disease Control, to include documented
weekly spore testing of autoclaves.
22. Bulk biohazardous waste be properly stored outside the dental clinic.
23. Biohazard and radiology warning signs should be in place.
24. Patients should wear protective eyewear during treatment.
25. Every dental program should develop a robust and meaningful CQI program to include
ongoing studies and corrective measures that address identified program weaknesses.
26. The IDOC should develop a clinically oriented peer review system and dentists should be
available to provide these reviews, such that deficiencies in treatment quality or
appropriateness can be corrected.
27. A systemwide evaluation of existing equipment should be performed and old, badly
and
non-functional
units,
equipment,
and
worn,
rusted,
corroded,
cabinetry/countertops should be replaced. We agree and note that this should be part
of a systemwide capital equipment replacement plan.

IDOC agreed with the First Court Expert that “the SOAP format be used to document emergency and urgent care contacts.”
IDOC Response to First Expert Report, ¶ XIII (2).
273 We note that Dr. Meeks, the IDOC Medical Director, opined that while he is responsible for oversight of the dental program,
he relies on the Wexford Dental Director, which is not a good arrangement. He prefers a Chief of Dentistry, who is a state
employee and part of his management team. Meeks Interview ¶¶35-36. Note that IDOC stated (in 2014) that it is committed to
filling the statewide position of Dental Director, who would spend 25 percent of his time on statewide administrative duties and
75 percent of his time on facility dental practice. IDOC Response, p. 31.
272

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28. Dental hygienists be hired ASAP at Henry Hill274 and Dixon Correctional Centers. While
we did not visit Henry Hill Correctional Center, we note that all prisons should have
dental hygienists on staff.
We agree with these recommendations.
Additional Recommendations
29. Valid oral hygiene instructions should be provided, and if they are not, the dental chart
should not record that they have been provided.
30. All inmates should have a comprehensive examination within 30 days of intake. This
exam should use the criteria of the ADA Procedure Code D0150 (Comprehensive Oral
Examination–New or Established Patient) and biennial exams should use the criteria of
Procedure Code D0120 (Periodic Oral Examination).
31. Treatment performed should be reported using standard (ADA) definitions and
procedure codes, or entries that can be mapped to the treatment codes. Similarly,
dental statistics reported to the CQI Committee should use profession-standard
definitions.
32. The health history should be updated at every examination and treatment.
33. The consent form should specify the tooth to be extracted and the reason for the
extraction (i.e., the diagnosis).
34. When an antibiotic is prescribed for a tooth-related infection, the tooth should be
extracted within the therapeutic window of the antibiotic. A follow-up appointment for
the extraction should be made so that the tooth is extracted within 10 days.
35. When an antibiotic is prescribed, the reason for the prescription (i.e., the diagnosis)
should be recorded.
36. The panoramic x-ray units and film processor at NRC should be replaced immediately. It
is strongly recommended that all dental x-ray units be digital.
37. The dental CQI program (as well as all other components of the dental program) lacks
guidance from a dentist with experience in corrections. This expertise should reside
centrally at IDOC and not from a Wexford employee or contractor. IDOC should retain a
0.5 FTE dental director. See Key Recommendation #10.
38. IDOC should develop protocols for periodontal diagnosis that include the use of
periodontal screening and recording, and appropriate intraoral radiographs.
39. All routine dental examinations should include a sequenced treatment plan.
40. All dental assistants should be capable of taking intraoral x-rays.
41. Nurses should triage all requests for dental care. Non-urgent requests (cleaning, routine
exams, fillings, etc.) should be sent to the dental clinic for scheduling. All other dental
complaints should be assessed at nursing sick call, treated for pain as needed, and
referred to the dentist based upon clinical urgency.
42. Diabetics should be referred for a periodontal assessment that includes periodontal
probing every six months, and those diagnosed with periodontal disease should be
offered an oral prophylaxis every six months and non-surgical periodontal treatment
Since we did not visit Henry Hill Correctional Center, we express no opinion about its staffing. However, as a general
principle, all IDOC prisons should have a dental hygienist assigned.
274

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(i.e., scaling and root planing) if clinically indicated. This should be part of the chronic
care program.

Internal Monitoring and Quality Improvement
First Court Expert Recommendations
1. A trained Quality Improvement Coordinator must be assigned to each facility. We agree
with this recommendation. This should be a dedicated position.
2. Training for members of the line staff should also be provided. We agree with this
recommendation.
3. Each facility’s program should develop a calendar in which every major service is
reviewed at least once a year. This strategy is reasonable but it is more important that
high priority problems be identified and resolved. See Key Recommendation #11. Instead
of annual review of each area of service the program should develop standardized
metrics that measure major areas of service on an ongoing basis. These should be
regular reports to the QIC. We note that these metrics are difficult to attain with a paper
medical record. Examples of these types of metrics could include:
a. Percent of new medication orders that the patient receives within 24 hours.
b. Percent of medications that are received by the patient. We note that this item is
only possible if there were an electronic medical record.
c. Percent of preventable hospitalizations.
d. Percent of patients who fail to show up for a scheduled appointment.
e. Percent of patients transferring from an intake facility who do not have a
thorough therapeutic plan based on a list of all patient problems.
f. Number and percent of nursing and physician clinical care episodes that are of
poor quality- based on professional performance evaluations.
g. Number of items remaining uncorrected on sanitation and safety inspection.
h. Number of unfilled positions.
i. Intake opt-out screening results.
j. Emergency bags which are not in compliance.
k. The number of examination rooms that are out of compliance with respect to
space, equipment, supplies or sanitation as evidenced on monthly environmental
inspections.
4. When reviews are performed, they must utilize one or more of the eight quality
performance measures.275 We agree that these measures are important and can form
the basis of reviews. However, it is more important that the program focus on high
priority deficiencies whether or not they include one of these eight measures.
5. Each local quality improvement program should be measured on the basis of the extent
to which the program facilitates improving the quality of services. We agree with this
recommendation.

These Joint Commission on Accreditation of Healthcare Organizations include Accountability, Availability, Effectiveness,
Efficiency, Quality of Providers, Safety of Environment, Continuity and Timeliness.

275

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6. The State should contract with one or more external quality reviewers for the mortality
review process since the current process was extremely ineffective at identifying
significant lapses in care and therefore ineffective in helping improve the quality of
services provided. Under current circumstances, we agree with this recommendation.
Ultimately, mortality review can be conducted by IDOC OHS as described in
recommendations 3-7 under Mortality Review above.
7. Where the external reviews identify one or more lapses in care, the institution should
be responsible for developing a corrective action plan which is provided to a regional
nurse and the Medical Director. We agree with this recommendation.
Additional Recommendations
8. The IDOC needs to develop a system of identifying key problems. Mortality review and
sentinel event reviews should be included in that system. See Key Recommendation
#11.
9. The IDOC should hire a statewide CQI leader who has training qualifications in quality
improvement (e.g., systems engineer, six-sigma blackbelt, etc.). See Key
Recommendation #1.

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Chart Review Details
Area of Record Review

Dixon

Medical Reception/
Intrasystem Transfer
Nursing Sick Call
Chronic Care
Urgent Care
Hospitalization and Specialty
care
Infirmary Care
Medication Administration
Infection Control
Totals
Death Reviews (12 Facilities)

LCC

MCC

NRC

SCC

Totals

8
29
14
5

10
22
14
4

15
15
14
5

26
11
3

12
27
13
8

71
104
58
22

7
7
12

9
8

11
7
11
7

7

9
6
6

43
28
29
7
362

Totals

33

33

Total Medical Records
Reviewed
Dental Records Reviewed
Dental Comprehensive Care
Dental Biennial Exams
Dental Outside Oral Surgery
Dental Medically
Compromised Patients
Dental Extractions
Dental Scheduled Extractions
Dental Prosthetics
Dental Sick Call
Dental Nurse Sick Call
Dental Peer Reviews
Dental Intake (initial
examination)
Total Dental Records
Reviewed

October 2018

362

395
Dixon
12
10
2

LCC
10
10

12
11

8
10

8
10

6
32

MCC
16
8
5
8
11
15
4
5
7

NRC
1

SCC
10
4

5

10
9

5

6
10
7

20

10

5
11

20

10

Total
49
28
11
38
46
15
24
62
14
5
71
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Dixon Correctional Center
2nd Court Appointed Expert Report
Lippert v. Godinez

Visit Date: April 2, 2018 – April 5, 2018

Prepared by the Medical Investigation Team
Mike Puisis, DO
Jack Raba, MD
Catherine Knox, MN, RN, CCHP-RN
Jay Shulman, DMD, MSPH

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Table of Contents
Overview............................................................................................................................... 2
Executive Summary ............................................................................................................... 2
Findings................................................................................................................................. 6
Leadership, Staffing, and Custody Functions.............................................................................. 6
Clinic Space ............................................................................................................................... 10
Sanitation .................................................................................................................................. 16
Medical Records........................................................................................................................ 18
Reception Processing and Intrasystem Transfer ...................................................................... 20
Nursing Sick Call ........................................................................................................................ 22
Chronic Care .............................................................................................................................. 26
Urgent/Emergent Care.............................................................................................................. 46
Specialty Consultations ............................................................................................................. 58
Infirmary Care ........................................................................................................................... 65
Pharmacy and Medication Administration ............................................................................... 72
Infection Control ....................................................................................................................... 77
Radiology Service ...................................................................................................................... 80
Dental Program ......................................................................................................................... 82
Internal Monitoring and Quality Improvement ........................................................................ 95
Recommendations ............................................................................................................ 100
Leadership, Staffing, and Custody Functions.......................................................................... 100
Clinic Space ............................................................................................................................. 100
Sanitation ................................................................................................................................ 101
Medical Records...................................................................................................................... 101
Reception Processing and Intrasystem Transfer .................................................................... 102
Nursing Sick Call ...................................................................................................................... 102
Chronic Care ............................................................................................................................ 104
Urgent/Emergent Care............................................................................................................ 106
Specialty Consultations ........................................................................................................... 107
Infirmary Care ......................................................................................................................... 107
Pharmacy and Medication Administration ............................................................................. 108
Infection Control ..................................................................................................................... 110
Radiology Service .................................................................................................................... 111
Dental Program ....................................................................................................................... 111
Internal Monitoring and Quality Improvement ...................................................................... 116
Appendix A........................................................................................................................ 118

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Overview
From April 2, 2018 through April 5, 2018, the Medical Investigation team visited the Dixon
Correctional Center (DCC) in Dixon, Illinois.
DCC has a capacity for 2529 inmates. On the day of our visit there were 2298 inmates, with an
occupancy of 90.4%. DCC is a low security prison. Only 5.5% of inmates are maximum security
inmates, with 39% minimum security and 55% medium security. Sixty-seven percent of inmates
have a sentence of five years or less. Thirty-one percent of inmates have a sentence of less than
a year. DCC has a significant mental health mission and a significant elderly population. There
are 761 (33%) inmates with a severe mental illness.
The nationwide average of inmates over 50 years of age in state and federal prisons is 19.2%.1
In the IDOC, the percent of inmates over the age of 50 is 17.6%. At DCC, 26% of inmates are
over 50 years of age. DCC has a 23-bed American Disabilities Act (ADA) unit, an 84-bed geriatric
unit, and a 28-bed infirmary. Most of the ADA, geriatric, and infirmary units (135 beds) are filled
with elderly. The remainder of the elderly population (472) is housed in general population. The
health program at DCC is served by two local hospitals and one remote hospital. Katherine
Bethea Hospital is within three miles and CGH Medical Center is in Sterling Illinois, about 14
miles away. University of Illinois Chicago (UIC) is used for the majority of hospitalizations and is
over 100 miles away.
This report describes our findings and recommendations. During this visit, we:
• Met with custody and medical leadership
• Toured the medical services area
• Talked with health care staff
• Reviewed health records and other documents.
We thank Warden Varga and staff for their assistance and cooperation in conducting the
review.

Executive Summary
Based on a comparison of findings as identified in the First Court Expert’s report, we find that
the intrasystem transfer and sick call processes have improved since the First Court Expert
Report but clinic space, medication administration, and the infirmary processes are worse, and
the remainder are the same. Access to specialty care and physician quality of care were so poor
that overall, we find that Dixon Correctional Center (DCC) is not providing adequate medical
care to patients, and that there are systemic issues that present ongoing serious risk of harm to
patients and result in preventable morbidity and mortality. The deficiencies that form the basis
of this opinion are provided below.
1

Prisoners in 2015, Bureau of Justice Statistics, US Department of Corrections.

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Although a competent Health Care Unit Administrator (HCUA) is now in place, the remainder of
the leadership team is either new or not in place. Leadership staff is still deficient. The Director
of Nursing (DON) position is vacant but is to be filled by a State supervisory nurse. When that
happens, two of three nurse supervisor positions will be vacant. The remaining nurse supervisor
is deemed ineffective and spends considerable time on managing the onsite personnel matters
for Wexford as opposed to actual nursing supervision. The Medical Director position is recently
filled but the staff physician position is vacant. The HCUA acts as the HCUA, CQI Coordinator,
supervisor of medical records, infection control coordinator, and as a supervisory nurse,
including taking call. The new DON will also act as a supervisory nurse. Even if all positions were
filled, it is our opinion that additional nursing staff is needed on the infirmary to provide the
necessary level of care. Three supervisory nursing positions are inadequate given the
population size and mission of this facility. Given the complexity of clinical care at this facility, it
is our opinion that an additional physician is needed. Also, our opinion is that the lack of
consistently filled physician positions over the years and lack of physicians with primary care
training has contributed to preventable morbidity and mortality.
The physical plant is not well maintained. On the initial day of our visit both elevators in the
three-floor medical unit were not functioning, and patients needed to be evacuated for safety
reasons. Nursing examination rooms do not all have a standardized set of equipment, including
examination tables. Privacy and confidentiality is not yet ensured for all nursing examination
rooms. The ADA unit needs to be remodeled and refurbished, and beds need replacement.
Equipment for the disabled needs to be present in shower areas. Infirmary beds are not all in
acceptable condition. The infirmary needs to be refurbished by replacing cracked tiles, repairing
missing and cracked plaster, removing peeling paint, and repainting. The geriatric unit needs
refurbishing. Cracked and missing tile needs replacement to prevent falls in the elderly. Vents
need to be cleaned. Showers need refurbishing to improve ventilation and remove mold.
Otherwise, clinical areas were generally clean. The negative pressure room unit was functional
and regularly inspected. Medical equipment is mostly regularly inspected.
Problem lists are not up to date in medical records. The medical record jackets are still too large
to be effectively used; they come undone. Thinning records has been problematic due to lack of
availability of funds to purchase medical record folders. Hospital and consultant reports are
obtained for only about 10-15% of offsite visits. This adversely affects clinical care.
All inmates transferring into DCC are now brought to the dispensary for evaluation, which was
not occurring during the First Court Expert’s visit. Nurses are identifying new needs, taking vital
signs, updating problems, and reconciling medications. The establishment of this process
resolved a finding of the First Court Expert. However, chart reviews indicate that performance
could be improved but is not being monitored effectively through the quality improvement
program.
With respect to nursing sick call and access to care, we found that some of the problems
identified by the First Court Expert have been resolved. Boxes have been put in place to receive
health care requests and these are picked up daily. A log has been established. We found that
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sick call requests were timely triaged. Because licensed practical nurses (LPNs) work in close
proximity and under supervision of an RN, nursing sick call now conforms to the Illinois Nurse
Practice Act requirements. Sick call is no longer done in the hall. Rooms are designated for this
function, but rooms are not all equipped adequately. Other problems identified by the First
Court Expert remain and there are new problems. Sick call requests are still not filed in the
medical record. Nurse documentation is inconsistent or absent, and did not consistently give an
indication of the assessment or plan of care. Quality review of nurse performance is not done.
Medical records are not available in X house; patients there are seen without a medical record.
Provider follow up on nurse referrals was not timely. Segregation inmates only have access to
sick call once a week. We noted that care of dental patients with pain have their pain addressed
inconsistently by medical staff until a dentist can evaluate the patient. This process should be
standardized so that pain is timely addressed.
Emergency response equipment and supplies were available, properly sealed, and maintained.
Equipment is regularly checked. Mass casualty drills are performed and are thorough, although
critiques of the drills seldom find any problems. No strengths or weaknesses are found, and the
quality improvement minutes do not reflect any discussion of these drills. Two of five patients
sent out on an emergency basis had problematic care as described in the report.
Our review of records of persons hospitalized identified preventable hospitalization and
preventable morbidity. It is our view that this is a result of systemic issues, including the
inadequate physician staffing and inadequate credentialing of physicians.
There has been no improvement in management of specialty care. The tracking log does not
accurately record the date of referral. Referrals, collegial reviews, and approvals are not
consistently documented in the medical record. Providers do not update the status of the
patient after consultations. There are significant and unacceptable delays in getting patients
scheduled at UIC, which accounts for approximately 80% of specialty consultations. Delays to
gastroenterology average 239 days and all UIC consultations average about six months. When
significant delays occur, alternate consultants are not used. This results in harm to patients.
Consultation reports were frequently unavailable, making it difficult to determine the clinical
status of the patient. Record reviews identified that doctors did not document knowledge of
the patient’s status or condition after consultation visits. Care of patients before and after
consultations was poor, as described in the specialty care section, and placed patients at
significant risk of harm and possibly caused harm for several patients.
Medication rooms were clean, secured, and uncluttered. Medication refrigerators were well
maintained. Narcotic counts were accurate. However, medication administration practices are
unsafe and outdated. Medication orders are incomplete, and providers do not consistently
document the decision to order medications or the rationale. There were problems with
handwritten transcription of orders to medication administration records (MAR). Only 37% of
MARs reviewed had complete documentation. Only 70% of new medication orders had the first
dose administered within 24 hours. Nurses pre-pour medications. On the STC, mental health
unit nurses use unsanitary envelopes to administer medication and do not have the MAR when
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they administer medication. Medication administration is inconsistently documented at the
time medication was actually provided. Continuity of medication for persons with chronic
disease is not ensured and compliance with medication in chronic illness patients is not
assessed. Reported medication errors are not analyzed to identify systemic causes or subjected
to corrective action in order to improve care.
There have been no improvements in the infection control program since the First Court
Expert’s visit. There is no person with leadership and responsibility to effectively manage
infection control. Safety and sanitation inspections are performed monthly, but deficiencies
reported since September of 2017 have not yet been corrected. Infirmary porters were not
offered hepatitis A vaccination and only one of two porters completed vaccination for hepatitis
B. Communicable disease data collected for continuous quality improvement (CQI) is not
analyzed or discussed. We noted, for example, four occupational exposures to blood borne
pathogens in 2017. Three of these were needle stick injuries. There was no discussion of this in
the CQI minutes. We were told that Wexford has not responded to address this issue. Not
addressing this issue is an OSHA violation, as an employer must evaluate environmental and
engineering controls to reduce exposure to blood borne pathogens.
Radiology services are inspected and current. Access to plain film x-rays is acceptable and
turnaround time is good. The x-ray technician does not wear a dosimeter to measure radiation
exposure, which may not be in accord with State regulations.
We found infirmary services worse than in the First Court Expert’s report. Patients housed on
this unit have needs that exceed the capacity of the program to manage. There are insufficient
nurses and equipment to manage the population of patients requiring total or partial assistance
with activity of daily living care or to manage those with skilled nursing care needs. There is no
physical therapy on the unit. Provider notes contain limited clinical information or rationale for
treatment plans and fail to document key history, physical findings, or treatment plan
components. Provider admission notes and progress note timeliness and frequency do not
meet IDOC policy standards.
Dental staffing is inadequate. A dental hygienist and an additional dentist should be hired
immediately. The clinic is closed on Mondays due to inadequate dentist scheduling and should
be open five days a week. Routine treatment is inadequate since it is not informed by a
comprehensive oral examination (i.e., intraoral x-rays, a periodontal assessment, and a
treatment plan). The failures of the dental program documented in this report place patients at
risk of preventable pain and tooth loss by fostering widescale underdiagnosis and treatment of
dental disease. Dentists consistently fail to update health histories, which is particularly
problematic since the dental chart is separate from the medical record. The dental program has
not changed materially since the First Court Expert Report, and the treatment provided to IDOC
inmates remains substantially below accepted professional standards and is not minimally
adequate.

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The First Court Expert found an inactive CQI program. We found that the CQI program was in
place but had not yet become effective. There is no CQI coordinator. The program does not
have a CQI plan specific for DCC. The CQI program is not performing all IDOC required studies.
Monthly meeting minutes are brief and lack discussion about existing problems. Most studies
measure only that care was provided, not whether it was effective, of good quality, or whether
it could be improved. Peer review was ineffective. Mortality review does not occur. There were
26 deaths over a two-year period of 2016-2017. We asked for charts for 13 deaths and
reviewed six of these deaths. Of the six deaths reviewed, four were preventable in our opinion,
and two were possibly preventable. We found systemic failures and grossly and flagrantly
unacceptable clinical practice resulting in preventable death. This is an extraordinary number of
preventable and possibly preventable deaths.

Findings
Leadership, Staffing, and Custody Functions
Methodology: We interviewed medical and custody leadership, reviewed staffing documents,
and other pertinent documents.
First Court Expert Findings
At the time of the First Court Expert’s visit to DCC, the HCUA, DON, and Medical Director
positions were all vacant. The Medical Director position was filled by a traveling Medical
Director, but this person was not performing all duties typical of a Medical Director. The lack of
a Medical Director dedicated to the program resulted in no continuity of medical authority.
Both supervisory nurses were new to their positions, so there was a significant leadership gap.
Because of the lack of leadership, there was a lack of monitoring of program effectiveness. The
First Court Expert recommended prioritizing filling the Medical Director, HCUA, DON, nurse
practitioner (NP), and seven RN positions. The First Court Expert also recommended
reevaluation of total nursing positions to determine whether additional RNs should be added.
He made this recommendation because non-RN nurses were involved in conducting sick call,
which was outside the scope of their license.
Current Findings
There have been changes since the First Court Expert’s report, but the net result is only a
minimal change in overall staffing and leadership. Currently, the HCUA position has been filled
since 2015. The DON position is vacant. One of the current state nurse supervisors will fill this
position beginning on 4/16/18. In 2014 the DON was vacant, but two of three nursing
supervisor positions were filled. Now the DON will be filled but two of three nursing supervisor
positions are vacant. In 2014 the Medical Director position was vacant, but the staff physician
was filled. Currently, the Medical Director is filled, and the staff physician is vacant. The net
effect of all these changes is not much change except for the HCUA, which will be discussed
below. In comparison to the First Court Expert’s report, there have been some improvements,
but these are insufficient to create an adequate program. We agree with the First Court
Expert’s recommendations to reevaluate nursing positions.

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We identified additional findings or confirm First Court Expert findings, including:
• There has been no effective change in budgeted staffing since 2014 with the exception
of three additional staff assistants for medical records.
• The effective vacancy rate (long-term leave of absence and vacancies) is 23%, which is
an improvement from the 28% vacancy rate in 2014. However, a 23% vacancy rate is an
unacceptably high vacancy rate.
• There is a deficiency of nurse supervisory positions. The existing nurse supervisory
positions are not filled, resulting in the DON and HCUA undertaking nurse supervision
roles that detract from their ability to manage the program.
• The only consistent elements in physician staffing have been continual change of
physicians and moving of physicians to other facilities. Quality of physician care has
been poor. Insufficient time has passed to evaluate clinical quality of the new physician.
Care we reviewed showed preventable morbidity and mortality.
• There are insufficient nursing staff managing patients on the infirmary unit.
• Given the population and numbers of complex geriatric patients, there needs to be an
additional physician.
We provide a staffing table in Appendix A. What appears to be an increase in staffing as
compared to the 2014 Court Expert’s report is not really a staffing increase. There were always
two state nursing supervisors and one Wexford nurse supervisor, but only one State nurse
supervisor and one Wexford nurse supervisor were documented in the First Court Expert’s
report. There has been no increase in nurse supervisor positions since 2014. Also, we list 48 RN
staff. This appears to be a significant increase in nurses compared to the 26 RNs in the 2014
report. But the total complement of RN staff has not changed. Twenty-two mental health
nurses were moved to the medical program, making it appear as an increase when there was
no increase. These 22 nurses were responsible for mental health programming and
administration of medication to mental health inmates and will still be responsible for those
tasks. This change was done to allow the DON to be more flexible in using nurses for various
assignments. Thus, mental health nurses can work on medical units and medical nurses can
pass medication on mental health units. Whether this will adversely affect nurse staffing for
medical tasks is uncertain. The only increase in staffing from 2014 to 2018 is a permanent
increase of a 0.5 FTE phlebotomy position and an increase of three staff assistants who assist in
the medical records department.
One significant change is that the State has filled the HCUA position with a very capable person.
She appears to have led changes that have resulted in improvements noted in this report. The
HCUA has been in her position since 2015. This person has provided leadership, but she lacks
nursing supervisors and a consistent Medical Director, and therefore the program still does not
have adequate medical leadership. Also, because of staffing shortages, the HCUA serves as the
CQI coordinator, supervisor of medical records, infection control coordinator, and acts as a
supervisory nurse, including taking call. One person is incapable of effectively performing all of
these roles.

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Supervisory nursing positions are deficient. It is our opinion that three nurse supervisory
positions (two state and one Wexford) are inadequate given the large population and mission
to care for the elderly. There is one Wexford supervisory nurse who is also the Wexford Site
Manager and supervises 10 LPNs and six CNAs. The HCUA and the Assistant Warden of
Programs believe this individual is ineffective and is not performing at a level expected of a
supervisory nurse. Wexford will not replace this person. Because this person is ineffective and
because only one of three State supervisory nurse positions (DON and two nurse supervisors)
are filled, the DON will be the only effective supervisory nurse responsible for the performance
of 48 registered nurses. Therefore, the HCUA, who is a nurse, acts as a supervisory nurse,
including taking call, and this detracts from her effectiveness as a HCUA. Because the DON has
to act as a supervisory nurse, she too will be less effective in her role as DON, which includes
establishing policy and procedure, response to grievances, monitoring of nursing practice, and
implementing program improvement. Given the sizeable population of vulnerable patients in
the mental health program, infirmary, ADA unit, and geriatric unit, additional nursing
supervision is needed. It is our opinion that there should be a daytime inpatient and swing shift
supervisor for the infirmary, ADA, and geriatric units; an outpatient daytime nursing supervisor;
and an evening outpatient nursing supervisor. Given the large mental health population, it is
our opinion that daytime and swing shift mental health nursing supervisors are needed. The
lack of nursing supervision is significant and negatively affects the program.
The Medical Director position was not filled from the time of the First Court Expert’s review in
February of 2014 until July of 2015. It was then filled from July of 2015 until May of 2017. The
position was unfilled from May of 2017 until a traveling Medical Director filled the position
from July to October of 2017. Since October 2017, a new Medical Director has been in place.
The new Medical Director works four 10-hour days. Because there is no staff physician, there is
no onsite physician on Fridays. The Medical Director covers the infirmary and has
administrative duties, leaving most of chronic care management to the nurse practitioners (NP).
Also, the second physician position has not been consistently filled over the past four years.
When this second physician position has been filled, according to the HCUA, it has been filled
by less than qualified doctors. On multiple occasions Wexford was asked to replace these
doctors on the basis of quality of care.
The infirmary and geriatric units in combination require more than a full-time physician,
particularly if the Medical Director covers these units in addition to the other Medical Director
duties. Currently, all medical care outside of the infirmary is managed by the two NPs. While it
is uncertain what the situation would be like if all four medical provider positions (Medical
Director, physician, two mid-level providers) were filled, it is our opinion that for a population
of 2300 with a significant elderly population, an additional budgeted physician is indicated.
The frequent changes and lack of primary care trained physicians appears to have continued
since the First Court Expert’s report. We note that the new Medical Director has primary care
training but has not been in place long enough to determine if quality will improve. The past
lack of qualified physicians has resulted in a significant absence of quality of medical leadership
and physician coverage. Based on chart reviews and death reviews we performed, we identified
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preventable morbidity and mortality, which will be described later in this report. The lack of
adequate and qualified physician coverage is causing harm and is the single most important
factor in preventable morbidity and mortality in our opinion.
There are 93.8 health care employees.2 There are 19 (20%) vacancies. Three staff are on longterm leave of absence. If these are added to the vacancies, the effective vacancy rate is 23%.
This is a significant vacancy rate and contributes to an inadequate program. More than half of
the state vacancies (52%) are RN positions. There are more RN vacancies now than there were
in 2014, although it is uncertain what the effect has been with respect to combining mental
health and medical nursing staff. There are 57 state employees and 36.8 Wexford employees in
the medical program. The vacancy rates for state employees is 28% and for Wexford employees
17%. However, because the Wexford employees include physicians, the Wexford vacancies in
the Medical Director and physician positions, over recent years, impact the program
significantly more than any other position.
It is our opinion that there are insufficient numbers of budgeted positions in the nursing
categories even if vacancies were filled. The infirmary unit is understaffed with nurses and
nursing assistants. The geriatric unit on the third floor has people who should be on the
infirmary and require a higher level of nursing care than is now being provided. These units
attract elderly patients from all IDOC facilities, yet these units have insufficient staff to provide
care at a necessary level based on our review of services on that unit. Inmates provide
considerable assistance on these units. Services that require health trained personnel are either
not provided or are provided at a level inadequate for the designed purpose of these units.
During this visit we were also able to interview the Wexford Regional Manager. This individual
manages seven facilities. He has a background in criminal justice and has no formal training in
any aspect of health care. He worked for the IDOC beginning in the 1990s and left IDOC in 2004,
when he was a warden at Pontiac Correctional Center. He said that though he had no training in
health care or health care management, he felt his administrative experience with the IDOC as
a warden was sufficient to warrant his being a manager of a health care program. We disagree.
Criminal justice training is not a sufficient background to obtain a high-level health care
management position.
The Wexford Regional Manager said that he was not aware of any persistent problems at any of
the sites we had visited. The problems at the three sites that he manages and that we visited
are considerable. Failure to be aware of these ongoing problems demonstrates a level of
disinterest or failure to understand how to manage a health care program. Both the Assistant
Warden of Programs and the HCUA detailed year-long problems that they had brought to his
attention, mostly involving the performance of physicians, filling positions, and performance of
the Wexford supervisory nurse. The Wexford Regional Manager perceived his role as only
administrative, which was difficult to understand. He stated that he referred any clinical issues
to other clinical staff. However, as a manager of a health program he must be involved in
2

See Appendix A.

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clinical issues, as the program is a clinical medical program. He also has not meaningfully
participated in quality improvement efforts at any of the facilities he manages. His lack of
knowledge of ongoing problems at the facilities he manages and his lack of involvement in
attempts to improve the program are demonstration of why a person with a criminal justice
background should not be involved in managing a health care program.

Clinic Space
Methodology: Accompanied by a correctional officer, the acting Director of Nursing, and the
Wexford site administrator, we inspected the three-story medical building. Accompanied by the
HCUA and the Assistant Warden, we separately visited the nurse sick call rooms and medication
rooms in the X-building (Segregation Unit).
First Court Expert Findings
The First Court Expert found the clinical areas at DCC reasonably clean and well maintained. The
expert raised concerns about the metal beds on the third floor being taken apart to make
weapons, contributing to musculoskeletal problems for the third floor’s geriatric population,
and being difficult to clean and sanitize.
Current Findings
• The three provider exam rooms in the medical building are insufficient to accommodate
the four budgeted clinical providers.
• The telehealth room used for UIC HIV and hepatitis C care, renal specialty consultation,
and telepsychiatry is clean and adequately sized. The telehealth room is not shared with
the clinical providers and thus there is no competition for this space.
• Nurse sick call rooms are not all properly equipped, and all do not provide for patient
privacy and confidentiality.
• One of the two dedicated nurse sick call rooms on the first floor of the medical building
has two exam tables; the other only a desk and chairs. Having two exam tables in one
room and none in the other is a barrier to the delivery of care and does not allow for
adequate patient privacy and confidentiality.
• When not in use, the optometry and telehealth rooms are used as backup nurse sick call
rooms; neither of these backup rooms have an exam table.
• The location of a satellite nurse sick call room in a housing unit of the X building
maximizes the segregated patient-inmates’ access to sick call.
• The infirmary beds, ADA unit beds, and the geriatric beds were not all in acceptable
condition. Broken beds need to be properly repaired or replaced.
• The low height and limited mattress support of the metal beds in the geriatric unit make
it difficult for this aging patient population to effectively and safely utilize them.
• The negative pressure unit in the infirmary is regularly inspected. The unit was fully
functional. The unit has documented inspections on a weekly basis. The unit should be
regularly checked during the environmental rounds and the condition noted in the
monthly Medical Safety and Sanitation Report.

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•
•
•
•

•

Both elevators in the three-floor medical building were non-functional on the first day of
the site visit.
Most but not all of the medical equipment and devices in the medical building had
documentation of annual inspection by biomedical engineering.
Multiple air vent covers were missing. Many air vents and air vent covers were rusted
and cannot be fully sanitized.
All three floors of the medical building had cracked and missing floor tiles. This is a
safety, sanitation, and infection control concern for patient-inmates and staff who use
these areas. This is a special concern for the high-risk-for-fall population that is housed
on the second and third floor.
All the showers in the medical building were poorly ventilated, had peeling ceilings, had
musty odors, and evidence of mold. There were an insufficient number of shower
chairs; the existing shower upholstery needs to the repaired or the chair replaced.

The medical unit contains three floors. The first floor outpatient clinical unit houses medical
exam rooms, nurse sick call rooms, an urgent care center, physical therapy, dental clinic,
telehealth rooms, x-ray suite, optometry clinic, mental health interview rooms, nurse
medication preparation room, the pill call/KOP medication pick up window, medical records
department, storeroom, health care administrative offices, provider and nurse work areas, and
a conference room. The second floor houses the infirmary, the ADA housing unit, and mental
health offices. The third floor houses the geriatric housing units.
With the exception of the nurse sick call held in the X building (segregation unit), all medical
health care is provided on the first and second floors in the three-story medical building that is
located in the central area of the expansive DCC campus. There are two elevators in the medical
building. One has not been functional for a long time. On the day before the experts’ site visit,
the only operational elevator broke down. Patients housed on the second and third floor who
were ambulatory were moved to backup housing in outlying buildings on the DCC campus. Nonambulatory patients in the ADA unit and the infirmary were not moved. One elevator was fixed
and operational by the end of the first day of the experts’ visit. The second elevator remained
non-operational during the entire visit and there was not a repair team working this elevator.
Both elevators need to be operational, assuring that all patients residing on the second and
third floors of the medical building can be safely and readily relocated in the case of
environmental and medical emergencies. This is a significant life-safety and fire-safety issue.
The first floor of the medical building is the hub of the health care delivery services provided at
DCC. It is separated into two sections, with the patient-inmate entrance to the building in the
middle of the two sections. Inmates walk approximately 200-1000 feet to the medical building
from multiple housing units located on two divided sides (general population and mental
health) of the campus to pick up keep-on-person (KOP) medications and nurse administered
medications just inside the entrance, and to receive ambulatory reception, medical, dental,
limited specialty, diagnostic, and urgent care services. Mental health patients have their
medication administered dose-by-dose in their housing units.

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The west side of the first floor houses the medication preparation and medication storage
areas, and the pill call window and medical supplies.
The east end of the first floor has three interconnected corridors. The main/central corridor
houses the urgent care and procedure room, two centralized nurse desks, three provider exam
rooms, a three-chair dental suite, three observation bays, physical therapy unit, medical
records, conference room/backup telehealth room, and a waste disposal room. The north
corridor has the plain film x-ray suite, an optometry suite, a telehealth room, and two nurse
sick call rooms. When not in use, the optometry and telehealth rooms are also used by the sick
call nurses. The north corridor houses the health administrative and provider offices, medical
supply storeroom, and a conference/breakroom.
Although generally clean, there were cracked and missing floor tiles in all three corridors on the
first floor of the medical building. This is a safety, sanitation, and infection control concern for
patient-inmates and staff who use these areas.
The treatment and procedure room has one adjustable table with an intact mattress and paper
barrier, a new ECG machine, oxygen tanks in racks, an AED with a current inspection sticker and
pads that do not expire until 2019, a Gomco suction machine, nebulizers, three backboards,
medical supplies, and an emergency response bag. The handwashing sink in the room is clean.
The space is adequately sized to provide treatment and urgent care. The counters in this
treatment room are congested with supplies, and the two alcoves used for storage are
cluttered, with 10-15 wooden crutches leaning against one wall, and staff bags and coats. The
slop sink in one alcove is crusted and not able to be fully sanitized.
Two desks in the main corridor serve as a nursing station where pre-visit interviews and vital
signs are performed, and reception screening and transfer forms are completed by nursing
personnel. This layout does not allow optimal audiovisual privacy for patient interviews.
Despite having four budgeted providers, there are only three provider exam rooms in proximity
to the nursing desks. All three are clean, adequately sized, and similarly outfitted with exam
tables with intact upholstery, a desk, two chairs, functional oto-ophthalmoscopes, medical
supply cabinets, a handwashing sink, gloves, and paper towels. One exam table did not have a
paper barrier, one sink was crusted with mineral deposits, a few paper memos without
protective sleeves were taped on the walls, and a single box of fecal occult blood testing cards
had expired in October 2017. A 23-year-old Physician Desk Reference (PDR) was found in one
room; however, it was reported to the experts that the three providers had access to
UpToDate® electronic medical reference on the computers in their offices in the adjacent
administrative corridor.
Three curtained observation bays with flat beds are located in the main corridor. They are used
for short term observation and nebulization treatments when the treatment room is occupied.
There is no equipment or supplies kept in these bays. The bays are a few steps away from the
nursing desks and in voice range but not in line of sight of the nurses. A large conference room
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in the main corridor is used as the chronic care nurse office/computer workstation and serves
as a backup telehealth room on the occasion when overlapping tele-specialists are scheduled.
The telehealth unit in the conference room does not have an electronic stethoscope.
A three-chair dental suite is situated off the main corridor and will be described in the dental
section of this report.
The physical therapy (PT) room with multiple stations, mats, and equipment is located at the
west end of this corridor. Visual inspection did not identify any notable deficiencies. Every bit of
space in the PT room is utilized; although crowded with equipment and mats, it is well
organized.
On the north side of the central patient-inmate entrance is the T-shaped north corridor. The
top section of this T houses four clinical rooms. Two rooms are designated exclusively for nurse
sick call service. One nurse sick call room has two exam tables and two desks; the other has a
desk and two chairs but no exam table or sink. The other two rooms house the telehealth room
and the optometry service. The telehealth unit is located in a large room with the telehealth
unit along one wall with a desk and a chair facing the monitor. The unit has an electronic
stethoscope. Three part-time services (HIV/hepatitis C, renal, and psychiatry) use the telehealth
room. The fourth room is the generously sized optometry clinic with storage cabinets, a variety
of optometry instruments (none of which had inspection labels), a sink, a desk, and a chair. The
optometry clinic is only in session eight hours per week. When the optometry and telehealth
rooms are not in use, the rooms are used as additional nurse sick call rooms. Since only one of
the four dedicated or part-time nurse sick call rooms has an exam table, nurses interview
patients and bring them over to the room with two exam tables if further physical evaluation is
required. This could result in a breach of privacy if two patients are examined in the same room
at the same time. Two of the other rooms could readily accommodate an exam table and this
should be done. Handwashing gel was noted in the rooms without a sink, or if not is brought in
by the nurses when they use these rooms.
The x-ray suite is in the long arm of the north corridor. During the expert’s visit, the existing and
aging plain film radiology unit was removed and a used but updated non-digital unit was being
installed. The interior space was adequate but could not be walked through due to the
construction. The radiology technician has a work space at the entrance to the suite that is
separated from the corridor by a floor-to-ceiling metal screen. There is limited foot traffic on
this corridor.
The second floor of the medical building has three separate units: mental health staff offices,
the medical infirmary, and an ADA housing unit for inmates with ambulatory deficits, including
those requiring wheel chairs. There is a security station staffed by a correctional officer in front
of the entrances to these three units on the second floor.
The mental health staff offices are used almost exclusively for administrative duties and
functions. Only on a rare occasion are selective patients interviewed in this area.
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The ADA housing unit is a 23-bed housing unit for patient-inmates with significant difficulties
with ambulation. Many of the men on this unit use ambulation aides, including wheel chairs.
On the day that this unit was toured, there were only eight men on the unit; 15 had been
temporarily relocated to buildings 31 and 41 until the elevator was repaired. The men housed
on this unit must be able to provide for all their activities of daily living. Some get intermittent
limited assistance from inmate health aides. There are no nursing personnel assigned to this
unit and clinical providers do not make rounds on the ADA area. Individuals seeking medical
attention must submit a sick call request sheet to access non-urgent care. The ADA unit is a
housing unit located with good proximity to 24-hour medical services in the building, but it is
not a medical treatment unit. The beds are almost universally metal bed frames with metal wire
mattress supports. Some of the wire supports have been separated from the metal legs and
struts and held together with strands of ripped sheets. The separated metal wires had sharp
ends and constitute a potential safety hazard. These beds are less than optimal for individuals
with heightened risk for decubitus ulcers. Unoccupied metal beds were turned on end and this
presented a notable safety risk. There are three showers on the ADA unit. Only two of the
showers are functional; the ceiling paint in all three showers is peeling, and the ceiling light in
front of the showers is not functioning. The single shower chair has ripped upholstery and
needs to be sealed or replaced. The showers cannot accommodate wheelchairs; we were
advised that some men are moved to the infirmary to bathe and shower. There are cracked and
missing tiles in the patient rooms, the hallway, and in front of the showers; this is a significant
safety hazard for this high-risk population and for staff. Many of the ceiling air vents are dirty
and/or missing covers. The slop sink in the janitorial closet was dirty, rusty, and had constant
running watering that could not be turned off. The floor in this closet was dirty. A correctional
officer was on the unit at the time of the inspection.
The 28-bed U-shaped infirmary is located across from the ADA unit. The patient rooms have
two to three beds per room. Most rooms appeared to have two beds per room. There were a
few individuals who were housed alone. At the time of the expert visit 18 beds were occupied.
Most of the beds were hospital beds with intact mattresses and adjustable heads. There were
no electrical beds in the infirmary. Most of the hospital beds have been acquired from local
hospitals as they upgraded their beds.
A central nursing station with glass on both sides has doors to each of the two side corridors. A
shower and tub room also can be accessed from both sides of the unit. A dayroom with a TV is
situated in the middle of each side of the infirmary; this room is also used for meals for some of
the patient-inmates. A biohazard room is located on the unit; waste material is removed one to
two times per day. There is a restraint room with a single impervious covered, cushioned fourpoint restraint bed; the room was clean, and the bed was intact. Call buttons were available in
the patient rooms. Four were tested and the warning monitor in the nursing station
appropriately lit up.
The restraint room (room 35) also serves as the negative pressure room; the exhaust was
turned on and the tissue paper test demonstrated a high level of negative pressure. The
negative pressure monitor in the nursing station has been non-functional for a long time; the
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monitor is old, and it was reported that replacement parts are no longer available. The negative
pressure log in the nursing station verified that the room was tested weekly for functionality. It
was reported that the negative pressure had recently failed due to a blown fuse; the problem
was corrected that day by the engineering team. The restraint room is directly across from the
nursing station, allowing a moderate degree of direct observation.
The infirmary nursing staff checks and logs the results for the three glucometers on a daily basis
and the negative pressure room functionality (tissue paper method) and the emergency
response bag on a weekly basis. Inspection of the infirmary logs verified that these devices and
equipment were being monitored as described. Oxygen tanks were full and kept in safety racks.
Review of the equipment in the storage room or the nursing station identified that one of the
three oxygen concentrators, one of three nebulizers, two of two IVAC pumps, two of two
Gomco suction units, and the AED had a current bioengineering stickers. No explanation was
provided on why some of the devices had not been inspected within the last year.
There are cracked and/or missing floor tiles throughout the infirmary, including the nursing
station, the hallways, the patient rooms, the biohazard room, and the patient bathrooms. This
creates a safety hazard for this very high-risk-for-fall patient population. A patient with
dementia was occupying a broken bed in Room 33. Unrepaired cracks and missing plaster were
noted in some of the patient rooms. Peeling paint was noted on the ceiling of the shared
shower room. Room 29 had a dirty sink and a cracked electrical outlet cover with exposed live
electrical connections. A number of ceiling vents were missing and/or rusty. The ceiling in the
nursing station had rust stained tiles.
The third floor of the medical building is divided into two wings and serves as an 84-bed
geriatric housing unit. Seventy-six patients were assigned to the third floor on the day of the
inspection, but 26 had been temporarily relocated to building 41 due to the non-functional
elevators. Patient rooms have two to three beds and a toilet with a sink. Similar to the ADA
unit, the vast majority of the beds on the geriatric housing unit had non-adjustable fixed metal
frames with an intertwined wire mattress support. The wires provide limited mattress support
for this geriatric population. The wires on some beds were separated from the metal and were
tied with ripped sheets to the frame. Unoccupied beds are flipped on end in the rooms,
creating a risk for injury. The men must be able to independently manage their activities of
daily living. Each room has a call buzzer next to the door. Inmates in three separate rooms were
knowledgeable about the use of the call buzzer and demonstrated competency in its use. Many
patients have their own TV sets at their bedside. There are dayrooms that are also used to eat
meals and these have a TV.
Each side of the third floor had a shared five-cubicle shower room. One shower cubicle on each
side was not functional. The showers emanated a musky odor, mold was noted in some of the
showers, ceilings in both showers were peeling, the vents were rusty, and the shower space
was humid and steamy when in use. The showers were poorly ventilated. Only one shower
chair was noted in each of these two shower rooms. Cracked and missing floor tiles were noted
throughout all areas of the third floor. This creates a safety risk for this aging population and is
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a barrier to the effective cleaning and sanitation of the units. Missing and/or rusted ceiling vent
covers were noted throughout the third floor. Some of the vents were blocked with medical
chucks, others were clogged with dust.
There are no nurses assigned to the geriatric unit. Patients place a request in locked boxes on
the floor to seek medical attention. Patients reported that their requests are screened by a
nurse within 24 hours and, if needed, they are seen in two to three days in nurse sick call on the
first floor.
There is a staging kitchen area on the west end of the third floor; food is served by inmate
workers. Dirty trays are placed in different carts than those used to bring food to the floor. The
temperature in the food refrigerator is checked and logged on the day and evening shifts; the
recorded temperature was always less than or equal to 41°F.
In summary, the medical building was generally clean and organized; the exceptions are the
infirmary, ADA, and geriatric units, which need refurbishing, including providing functional
shower equipment, installing ventilation in the showers, fixing broken tiles, and fixing plaster
and painting. This can be a safety issue for elderly and disabled patients. There are insufficient
provider examination rooms. A number of physical plant and maintenance deficiencies were
identified that have created safety, sanitation, and infection control risks. The metal beds used
in the geriatric unit are not appropriate for use in this population. The nurse sick call rooms are
not all adequately equipped nor do these rooms allow for patient privacy and confidentiality.
All of the beds in the infirmary must be hospital-quality beds with adjustable sections.
We agree with the recommendations of the First Court Expert. We have additional
recommendations found at the end of this report.

Sanitation
Methodology: We inspected the infirmary rooms, the ADA unit, the geriatric floor, the firstfloor health care unit, and the sick call rooms in the medical building and the X building. We
interviewed nurses, correctional officers, infirmary patient-inmates, health care leadership, and
inmate porters. The Safety and Sanitation reports for the months of September 2017 to
February 2018 were reviewed.
First Court Expert Findings
The First Court Expert reported that the clinical spaces were generally well-maintained and
made no specific recommendations about sanitation.
Current Findings
• Monthly safety and sanitation inspections and reports are being done by the health care
team at DCC.

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The safety and sanitation reports fail to address the condition of the patient beds in the
infirmary, ADA unit, and geriatric floor; the compliance with annual inspections of all
clinical equipment and devices; and the lack of exam tables in all nurse sick call rooms.
The clinical areas in the medical building and in the X building and the patient rooms in
the infirmary, ADA unit, and the geriatric floor were generally clean.
It is not possible to fully sanitize areas with rusted vents, broken or missing floor tiles,
and cracked walls and peeling paint.

Safety and sanitation inspections (environmental rounds) are performed by the health care
team on a monthly basis and reported by the HCUA to the Assistant Warden. September 2017
to February 2018 reports were reviewed by the experts. These rounds identified concerns,
some of which appear to have been corrected or are being addressed. However, the inspection
reports repeatedly noted a number of deficiencies, including cracked and missing tiles, mold in
the showers, non-functional ceiling light fixtures, peeling paint, rusty ceilings, and nonfunctional showers that have not been corrected. During this site visit, the experts noted the
same not yet addressed defective conditions throughout the entire medical building and in all
the housing areas in the medical building. In addition, the experts identified missing and rusty
vent covers and vents, a few sinks crusted with mineral deposits, 10-15 crutches leaning the
treatment room wall, the shower chair in the ADA unit had torn upholstery, a broken bed being
used by a demented patient in the infirmary, and oxygen concentrators and nebulizers that had
not been inspected in the last year.
Sharps boxes, gloves, handwashing sinks, or sanitizing gel was found in all clinical areas. Inmate
porters sweep and mop the floors of the infirmary rooms two to three times a week. They
report that they spray and clean the toilets, sinks, and showers on a regular basis. They
reported that they clean and spray beds of discharged patients prior to another patient being
placed in that bed. Two infirmary porters were interviewed.3 The first floor medical unit was
generally clean. The rusty vents and vent covers noted in almost all areas of the medical
building cannot be fully sanitized. As previously noted, the shower rooms on the second and
third floor were poorly ventilated, and subsequently, musky odors and mold were noted in all
the shower rooms, and the ceilings in the shower rooms had peeling paint. Although most sinks
were clean, at least one sink on each floor was found be dirty or crusted with mineral deposits.
We noted the broken and missing tiles on multiple areas in the Clinic Space section of this
report. Broken and missing tiles make proper sanitation difficult.
In summary, although the First Court Expert had no findings with respect to sanitation, we
noted several problems as described above. Overall, the cleanliness of the health care unit and
patient housing areas is generally good except for the infirmary, ADA, and geriatric units.
Monthly safety and sanitation inspections are being done in the health care areas. The rounds
have appropriately identified problems with the maintenance of the physical plant but these
problems are not consistently corrected. These inspections also must focus more attention on
the beds and clinical equipment.
3

Infirmary Patients #6 & 7.

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Medical Records
Methodology: Interview medical records staff, inspect the medical records room and filing
system, and by way of record review, identify any problems.
First Court Expert Findings
The First Court Expert noted that medical records were “overstuffed and in dire need of
thinning.” Because the paper records were so large, they were difficult to use and were
deemed an obstacle to efficient delivery of care. Medication Administration Records (MARs)
were often missing, making it difficult to determine if patients were receiving ordered
medication. There were large backlogs of MAR documents that had not been filed. Also, the
infirmary charts were on clipboards even when infirmary patients were permanently housed on
that unit. This would make it difficult to follow the care of the patient because the paperwork
was not organized.
The First Court Expert recommended that charts should be thinned regularly, MARs should be
promptly filed, and problem lists should be kept up to date. He also recommended timely filing
of all offsite medical reports.
Current Findings
Since the First Court Expert’s report, MARs appear now to be timely filed in the medical record.
Three additional medical record staff have been added since the First Court Expert’s visit in
2014, which has helped in this regard. However, the remaining problems identified by the First
Court Expert have not been resolved. Our key findings include the following, which confirm
problems identified by the First Court Expert and include an additional finding.
• We confirmed that problem lists are not up to date. This is a pervasive problem and has
not been fixed.
• The infirmary use of clipboards as the medical record makes it harder to track paper
documents relevant to each patient.
• The paper medical charts are too large to be effectively used. They come undone
frequently. Chart thinning sometimes results in critical documents to be missing from
active records.
• Consultant and hospital reports are obtained for only approximately 10-15% of offsite
visits. In most cases, it is not clear what the status of the patient is from the perspective
of the consultant. This makes it extremely difficult to impossible to provide adequate
continuity of care.
Medical records are stored in a single room that connects the main and the administrative
corridors. The medical record system is entirely paper. The records are stored on multi-tiered
shelves in two double sided aisles with a central counter. The space is extremely cramped but
well organized. The experts received every chart that was requested during the four-day visit.
A medical record director position and health information assistant position are vacant. The
medical record director position has been vacant since 2005 and the HCUA serves as the
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supervisor. There are now three additional staff assistant positions for medical record filing.
The filing backlog, including for MARs, was negligible and total backlog of filing was less than a
few inches. However, there are backlogs in copying records for legal purposes and when
inmates request a copy of their medical record. This has been an improvement since the last
visit.
However, the remaining findings of the First Court Expert are the same. Clipboards holding
medical documents are still used on the infirmary. These clipboards contain documents that are
periodically moved to the formal paper medical record binder. Documents in the clipboard are
not in any sorted order. This makes it more difficult to manage patients.
Charts at DCC tend to be large. Thirty-three percent of the inmates at DCC have serious mental
health conditions and 26% of inmates are over 50 years of age. This results in a large number of
medical documents, as these populations are more frequent users of the medical program and
have increased medical or mental health documents to file. Recent changes in the mental
health program have resulted in a large increase in mental health documents to maintain.
Patients at DCC, therefore, have large charts consisting of many medical record documents.
Chart folders consist of an accordion-like pressboard folder with a fixed plastic binder. The
binder consists of two flexible plastic tubes of about an eighth of an inch in diameter that fit
into a forked clip. The paper record documents have two holes punched that fit over the
flexible plastic tubing. The plastic tubing can easily become dislodged from the plastic fork and
papers can come loose from the binder. The accordion pressboard folder is approximately one
and three quarters of an inch wide. But the volume of paperwork in most charts far exceeds
this amount, so the charts become distended and put pressure on the plastic tubing, and it
comes undone frequently when staff leaf through the record and when progress notes are
written. Charts we reviewed were difficult to use without dislodging the plastic tubing from the
paper documents. The program has not been able to adequately thin excessively large records
because they are short of funds to purchase additional pressboard folders.
A chart is thinned when a nurse notifies medical records to thin the chart or when a medical
record clerk believes the chart is too large for use. Chart thinning is also dependent on the
availability of medical record folder stock. When a chart is thinned, the forward volume is
required to contain the following information from the previous chart:
• One year of AIMS testing
• Any psychosexual evaluations
• All problem lists
• All intake and yearly physical evaluations
• Two years of documents in the “Lab” section
• Approximately a year of progress notes
• At least six months of mental health documentation
• Chronic illness flow sheets
• The general medical consent sheet if the inmate is under 18 years old

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Any existing living will
A month of medication refusals
One year of other refusals

Critical consultant reports and specialized tests (EEGs, pulmonary function tests, CT scans, etc.)
are not required to be moved forward, but are often critical in understanding the clinical status
of the patient. Without these documents, clinicians have a much more difficult time
determining the existing problems of the patient, particularly since physicians change so
frequently. In our own chart reviews, we frequently had to ask for a prior volume to obtain
necessary information about the patient. Not having critical information readily available may
be a reason for some of the problems with following clinical care that we identified on chart
review. Also, this carry forward volume of documents can be substantial and newly thinned
records therefore start with a fair-sized volume. Most patients have multiple chart volumes.
Any clinician attempting to understand the clinical course of care would need to go back and
review multiple old volumes to obtain necessary information about the existing problems of a
patient, particularly since problem lists are so out of date. This lack of maintaining critical
information in the existing volume in use and the difficulty in using the paper record make the
paper record system a significant barrier to adequate care. An electronic medical record should
be used.
Nurses in X house see patients without a medical record. When this occurs, they write their
note on separate documents and present these documents later to medical records for filing.
This is inappropriate and supports the implementation of a fully electronic medical record.
Unlike most IDOC facilities, DCC maintains its dental charts in the dental clinic, and not as a
component of the health record.4 While there are some advantages to this practice, it makes
documenting a patient’s health history in the dental chart critical, since the medical problem
list will not be available unless it is requested.

Reception Processing and Intrasystem Transfer
Methodology: To evaluate the medical screening of inmates received at DCC as transfers from
other Illinois DOC facilities we interviewed health care staff, toured the dispensary where
transfer screening takes place, reviewed the IDOC health status form, DCC Admission Checklist,
the Health Care Unit (HCU) Operations Policy and Procedure P-118 Transfer Screening, and
health records of inmates received at DCC.
First Court Expert Findings
The previous Court Expert found that transfer screening was either not done at all or was
significantly delayed, and when done was completed incorrectly. Inmates were not brought to
medical for transfer screening; instead, nurses interviewed inmates on the housing unit
(without the medical record or transfer summary) and attempted to address any critical
4

DCC received a variance from AD 04.03.102 10/21/16.

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medication needs they learned about from the interviews. Nurses were not familiar with the
requirements for intrasystem transfer screening. There was no process in place to log and track
intrasystem transfers so that the timeliness and appropriateness of this health care encounter
could be monitored, and feedback provided to improve performance.5
Current Findings
The previous Court Expert’s recommendation has been achieved. All transferred inmates are
brought to the dispensary upon arrival at DCC. Nursing staff (RNs) review the transfer summary,
take vital signs, and conduct a brief screening interview to identify any immediate medical
needs and reconcile prescribed medications so that treatment can be continued. Each inmate
receives an individual explanation from the nurse about how to request health care attention
for urgent and routine medical needs. The next day these inmates are seen again by nurses who
complete a lengthier interview using the intake screening questions and review the medical
record. At this encounter the nurse checks to make sure the problem list is up to date,
completes any screening not done at intake, and identifies any pending referrals or
appointments. Inmates who have chronic diseases are enrolled in chronic care clinic, and
medication, treatments, and labs are ordered. At this second encounter, the nurse answers any
questions and confirms the inmates’ understanding of how to request care, procedures to
receive KOP and pill line medications, and obtain refills.
We reviewed eight charts of inmates arriving as an intrasystem transfer between May 19, 2017
and April 4, 2018. These eight charts were selected from lists of patients prescribed
medications that cannot be missed. The transfer summary and documentation of continuing
care (medication administration, enrollment in chronic care clinic, pending appointments, etc.)
was reviewed. In two cases, the transfer summary did not include the name of the sending
facility and information on tuberculosis screening.6 In two cases the inmate was not scheduled
for a chronic care appointment within 30 days of arrival for an initial evaluation.7 Five patients
had medications which were provided without dose interruption when received at DCC.8
However, one of these ran out two weeks after the transfer and was not re-ordered.9 It was a
KOP medication. It was not possible to ascertain if the discontinuity was because the inmate did
not know how to request a renewal, or the patient was lost to follow up. Two others were not
taking medication at the time of transfer but were referred, and medication was ordered and
administered within 24 hours.10
It appears that problems with intrasystem transfer at DCC that were identified by the First
Court Expert have been resolved. However, the quality of these evaluations is not uniformly
good quality. Given the number of errors and omissions in the information found in the chart
review of intrasystem transfers that affect patient care, we recommend that health care
Lippert Report DCC pp. 7-9.
Intrasystem Transfer Patients #1 & 2.
7 Intrasystem Transfer Patients #2 & 3.
8 Intrasystem Transfer Patients #1, 2, 5, 6, 7, & 8.
9 Intrasystem Transfer Patient #1.
10 Intrasystem Transfer Patients #3 & 4.
5
6

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leadership establish a process to monitor and provide feedback as part of the CQI program.
When facilities send inaccurate or incomplete information on the intrasystem transfer form
they should hear about the mistake from the receiving facility. Errors and omissions should be
subject to focused study to improve the accuracy of transfer information and continuity of
patient care.

Nursing Sick Call
Methodology: Nursing sick call was evaluated by reviewing DCC Institutional Directive
04.03.103K Offender Health Care Services, HCU Operations Policies and Procedure P 103 NonEmergency Health Care Requests and Services, and IDOC Treatment Protocols. We observed
the boxes on the housing units where inmates put their health care requests, and observed
nurses conducting sick call. We inspected the rooms used for sick call in the dispensary and Xhouse. We also reviewed tracking logs and used them to select records to review. Twenty-nine
sick call requests were reviewed. Fifteen were selected from sick call logs from July 2017
through March 2018, with complaints of potentially serious conditions (chest pain, acute
infection, shortness of breath, seizures, etc.), and their charts reviewed; three were observed at
sick call on Tuesday April 3, 2018, and charting was reviewed. Eleven requests were selected for
review because of complaints of dental pain; six were obtained from the dental clinic and five
were selected from sick call logs for February 2018.11
First Court Expert Findings
The previous Court Expert found that original sick call requests were discarded after triage and
that no log was maintained to evaluate timeliness or responsiveness of nursing sick call. There
also were significant breaches of medical confidentiality because sick call requests were
handled through the general mail system. Unqualified personnel (LPNs) were assigned
responsibility for sick call triage in the X-House and because these encounters took place “cellside,” an adequate examination of the inmate’s complaint was impossible. In other parts of the
facility the areas used for sick call were not adequately equipped, lacking an exam table;
sometimes a hallway or other open area was used, with insufficient privacy. Also, inmates were
limited to only one complaint per sick call request, which limits access. Nursing documentation
was absent (times, dates, etc.) or not in SOAP format. Nursing treatment protocols were not
used consistently. In segregation, nurses did not have access to the inmates’ medical record
and so left progress notes made during sick call encounters in the segregation log until they
were released from segregation. Referrals to providers often did not take place, were not
timely, were not documented, or the problem for which the patient was referred was not
addressed at the provider appointment.12
Current Findings
Our review found that some of the problems with sick call described in the previous Court
Expert’s report have been resolved. DCC has put specific boxes on each of the housing units
11
12

Sick Call Patients #1-26.
Lippert Report DCC pp. 9-15.

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designated for inmates to put their sick call requests into. These requests are picked up by
nursing staff seven days a week and triaged, so problems with confidentiality and delay have
been resolved. DCC has also implemented a sick call log, so it is possible to monitor the
timeliness and appropriateness of nursing triage and referral decisions. Documentation of
timeliness in responding to sick call requests was evident from review of the sick call logs. Of 15
medical sick call requests, all were triaged within 24 hours and all were seen within 48 hours of
receipt. Four urgent requests were seen the same day the request was received.13 DCC nursing
staff are assigned to monitor that the log is filled out. Undoubtedly, this helps to ensure that
the log is current and timelines are being met.
For the month of March 2018, staffing assignments for nursing sick call were in accordance with
the Illinois Nurse Practice Act. An LPN was assigned to do sick call along with an RN on two of
the four Fridays in the month. The minimum number of staff assigned to sick call is two. Some
days, three or four RNs are assigned to sick call. Practices at DCC are to assign an LPN to sick call
only when it cannot be staffed with two or more RNs. When an LPN is assigned sick call, he or
she works under the direction of the RN assigned to sick call. This information was verified by
nursing staff who were interviewed while observing sick call. However, the use of LPNs to assist
in conducting sick call risks patient harm and is an example of how RN vacancies (23%) affect
quality of patient care.
Sick call assessment is no longer done in the hallway, cell side, or in rooms without access to an
exam table. Rooms have been designated and equipped in the dispensary and in X-House to see
patients requesting sick call attention. See the description of these areas in the previous section
on Clinic Space. These rooms are not adequately equipped, lacking exam tables and
examination equipment.
Four rooms in the dispensary area are used to perform nursing sick call. These are adjacent to
each other or across a small hallway. One of the rooms has an exam table with paper. There
also are two alcoves down the hall with beds and curtains that were also used for unclothed
examination. The nurses share an otoscope and two weight scales. Each room has hand
washing capacity and equipment to take vital signs. Forms and treatment supplies are kept in a
locked medication cart in one of the rooms, which all of the nurses performing sick call can
access. Nurses share the examination table and otoscope, which promotes lack of
confidentiality and is disruptive of nursing services. Our opinion is that the sharing of
examination tables is inappropriate and unreasonable. We do not endorse that practice for
physicians and likewise do not endorse that practice for nurses. Each nurse should be afforded
the equipment and supplies necessary to conduct their work.
The day sick call was observed (4/4/2018), an officer was stationed at a table in the hallway and
managed inmate movement from the cell blocks to the waiting area and to the sick call nurses.
The nurses had the inmate’s sick call request and their health record at the time of the
encounter. Nurses used the IDOC treatment protocols; assessments were appropriate to the
13

Sick Call Patients #4, 7, 10, 12.

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complaint and responsive to the patients’ medical issues. Inmates were not limited to one
complaint in the encounters we observed, or the records reviewed. Four registered nurses saw
29 patients from general population and four from the Special Treatment Center (STC).
In X-House, sick call requests are picked up daily and triaged by registered nurses. Registered
nurses see patients for sick call Monday through Friday. Patients are seen for sick call in an
examination room located at the front of the segregation unit. The room has an examination
table with paper, a desk, chairs, scale, and examination light. Examination equipment and hand
wash is brought to the room when sick call is conducted. This room is also used when the
provider sees patients housed in this building.
Problems with sick call identified in the initial Lippert report that were still evident include:
• Original sick call requests are not filed in the inmate’s medical record. It is an
improvement that the nurse has the actual request at the time the patient is seen.
However, there is no record of the patient’s actual request for health care attention.
Documentation of the patient’s complaint on the nursing note is not verbatim; it is often
shortened and interpreted by the nurse. This is not an accurate reflection of the
patient’s request for medical attention. Sick call requests should be filed in the patient’s
medical record.
• Nursing documentation was absent (times, dates, etc.) or not in SOAP format, and
nursing treatment protocols were not used consistently to guide the assessment and
plan of care. In the charts of 15 medical requests reviewed, there were 12 that resulted
in a face-to-face nursing assessment. Of these, only six (50%) were adequately assessed
and an appropriate plan of care developed. Either the assessment was incomplete,14 the
nursing protocol was not used,15 the nurse did not address the complaint,16 or did not
follow up on significant symptoms.17 A rate of 50% inaccuracy in the nursing assessment
and follow-up of medical requests for potentially serious complaints (unexplained
weight loss, numbness, chest pain, infection, etc.) puts patients at significant risk of
harm.
• A quality improvement study of the use of nursing treatment protocols was included in
the 2016 CQI Annual Review.18 This QI tool only monitors whether nurses used a
protocol, identified their credentials, and documented the date and time the patient
was seen. There is no evaluation of the quality or completeness of the nursing
assessment or the appropriateness of clinical decision making. In addition, the DCC
Medical Director reviews two records of every nurse assigned sick call each month and
reports these findings at the monthly CQI meeting. Performance of less than 80% on
criteria used to evaluate sick call was reported month after month in CQI minutes
reviewed.19 The only corrective action was counseling and progressive discipline. No
14 Sick Call Patient #14 complained of “bladder issues,” and a urine dipstick was not done per the IDOC Nursing Treatment
Protocol for Urinary Tract Symptoms.
15 Sick Call Patients #4, 13.
16 Sick Call Patients #4,10, 11.
17 Sick Call Patients #10, 11, 15.
18 Dixon Correctional Center Annual Governing Body Report, September 21, 2016 p. 19.
19 Criteria include whether a full set of vital signs were taken, was the assessment thorough, was a treatment protocol used,
etc. DCC CQI Minutes May 2016, July 2016, August 2016, January 2017, March 2017.

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attempt has been made to trend problem areas or to analyze systemic factors that
contribute to poor performance; instead, individuals are blamed.
Medical records are not available in X-House. The IDOC Nursing Treatment Protocols
state that “sick call evaluation using these protocols should be performed with a
medical record.”20 Patients with medical complaints are evaluated without
consideration of their problem list or medical history, which contributes to inadequate
assessments and plans of care. Nurses document the sick call encounter on IDOC
medical record forms which are kept in the nurses’ office. This loose filing is
incorporated into the inmate’s medical file eventually.
Inmates who were referred from nurse sick call were not seen or not seen timely by
providers. Providers failed to follow up at intended intervals and treatment orders were
not completed.
In the charts of 15 medical requests reviewed, nine were referred to a provider. Two
additional patients should have been referred by the nurse and were not.21 Of those
referred, three were referred urgently and all were seen within 24 hours (100%). Of the
other six patients referred to a provider non-urgently,22 only one was seen in less than
72 hours for higher level medical attention (16%).23
Health Care Unit Policy and Procedure P-103 states that provider sick call for general
population and the special treatment program takes place Monday through Friday from
8 a.m.to 4 p.m. However, in segregation, provider sick call only takes place once a week.
The frequency of provider sick call and scheduling practices results in patients not being
seen timely. Patients’ medical conditions are at risk of deterioration when medical
attention is untimely, and can result in harm.

A new problem identified by the Court Appointed Experts is a practice variation in how
complaints of dental pain are handled. Sometimes nurses forward complaints about dental pain
directly to the dental department and other times the patient is seen by nursing staff in sick call
and then referred to the dentist. The problem with forwarding complaints about dental pain
directly to the dental program is that it may be several days before the patient is seen. In the
meantime, the patient’s pain is untreated. The pain may also mask other more serious
conditions, such as infection, that needs to be attended to immediately to prevent more
serious consequences.
We were told by both nursing and dental staff that requests for dental care are routed to the
dental program for triage and appointment. We used six sick call requests found in the dental
clinic from patients who complained of having dental pain and looked at their medical records
to see if the request had been triaged and assessed by nursing staff.24 None of these patients
had their complaint of dental pain triaged or assessed by nursing staff; instead, the request was
routed directly to the dental program.
IDOC Nursing Treatment Protocols p. 6.
Sick Call Patients #4 and 11.
22 Sick Call Patients #1, 8, 10, 13, 14, 15.
23 Sick Call Patient #1.
24 Sick Call Patients #24-D through 29-D.
20
21

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The IDOC Nursing Treatment Protocols provide instruction to nurses in the assessment and
treatment of dental complaints.25 A toothache without fever or swelling is to be referred to the
physician or dentist for evaluation within 24 hours. Using the nursing sick call log, we found five
patients who had dental complaints in February 2018. Each of these patients had been triaged
by nursing and a progress note written in the chart. Three patients agreed to be seen at nursing
sick call and the nursing protocol was used to guide the assessment, urgency of referral, and to
provide care in the interim until seen by the dentist.26 In two of the three referrals, the patient
was not seen for evaluation by a dentist or physician within 24 hours as specified in the
protocol.27
We brought this practice variation to the attention of the IDOC Nursing Supervisor and did not
receive any clarification about what nurses were expected to do when triaging complaints of
dental pain. We recommend that an expectation be established that complaints of dental pain
are assessed in nursing sick call, then referred to the dentist based upon urgency, and interim
treatment options considered (use of OTCs or obtain a provider order).
The nursing treatment protocol for toothache/dental complaints should be revised by the IDOC.
Separate protocols for dental decay, infection, and trauma to the oral cavity should be
developed. Expectations for the assessment, directions on determining the urgency of referral
provided, and the timeframe in which the dentist or physician is to see the patient should be
specified. A review and revision of the treatment protocol can also delineate options for nurses
to treat pain while the patient awaits appointment.
In summary, some of the problems with sick call identified in the previous Court Expert’s
reports have been corrected. Problems with sick call currently include:
• Sick call requests are not filed in the patient’s medical record.
• Nursing assessments and documentation of sick call encounters are not adequate.
• Rooms used by nurses for sick call are not adequately equipped or supplied.
• Patient medical records are not used for evaluations in the X-House and cannot be used
to reference the problem list, medical history, or orders when seeing patients.
• Patients referred to providers from sick call are not seen timely.
• Complaints of dental pain are not consistently triaged and assessed by nursing staff.

Chronic Care
Methodology: The Chronic Care Nurse was interviewed about the chronic clinic processes and
scheduling. The 2016-2017 and 2017-2018 chronic care clinic statistics, the current chronic care
clinic annual schedule, and the chronic care patient lists were reviewed. The medical records of
14 patients with chronic medical illnesses and conditions were reviewed. The Office of Health
Services Chronic Illness Treatment Guidelines dated March 2016 were reviewed as needed.
IDOC Nursing Treatment Protocols p. 80.
Sick Call Patients #20-D through 22-D.
27 Sick Call Patients #21-D and 22-D.
25
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First Court Expert Findings
The previous court expert noted that it was difficult to determine how many patients were
enrolled in chronic care clinics, that the chronic care tracking system was inadequate, that
patients with chronic illnesses were not all enrolled in a chronic care clinic, and some without
chronic illnesses were erroneously registered in chronic care clinics. The expert stated that the
chronic care clinic process was fragmented and disjointed. The absence of a single chronic care
nurse to coordinate the chronic care clinics was a prominent contributing factor to the lack of
an effective chronic care program. It was noted that DCC has established multiple illness clinics
(MIC) that allows patients to have more than one chronic illness assessed and managed in a
single visit.
Current Findings
DCC now has a single dedicated nurse coordinating chronic care. Patient are assigned and seen
in chronic care clinics and patients are tracked and reported. The remaining problems identified
by the First Court Expert have not been corrected. In addition, we identified additional findings
and confirmed some of the First Court Expert’s findings as follows:
• DCC now has a single, designated nurse to staff and coordinate the chronic care clinic
program.
• Patients assigned to chronic care clinics are regularly seen in these disease specific clinic
sessions. Chronic care patient lists identify the next scheduled appointments of the
patients.
• Chronic care clinic statistics are tracked and reported.
• The names of patients enrolled in one chronic care (HIV) clinic list was compared to the
HIV medication list. With the exception of four patients who had recently been
transferred and one patient who had not yet been started on HIV medications, the two
lists were in accordance.
• DCC has established biannual MIC clinics (two non-diabetes chronic illnesses) and MIC
diabetes clinics (diabetes and at least one other chronic illness). This allows patients
with more than one chronic illness to have their multiple chronic conditions managed in
a single comprehensive clinic visit.
• The handwritten notes in the chronic care visits are generally legible; this is a notable
improvement from the previous site visits.
• The current practice of not rescheduling chronic care patients who refuse to attend
their scheduled appointment until the next chronic care clinic, which may be as long as
six months later, is not in the best interest of the patient or the institution.
• Providers are primarily documenting changes in warfarin anticoagulation dosages on the
INR lab report sheet but not in the progress notes. This important, even life affecting,
information is inappropriately filed in the wrong section of the medical chart where it is
likely to be undiscoverable.
• The chronic care clinic notes inconsistently contained needed clinical information, did
not always indicate that needed examinations had been performed, did not universally
document the rationale for clinical decisions and therapy modifications, and did not
clearly outline the patient’s treatment plan.

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•

•

•
•

•

•
•

•

The care of chronic illnesses (diabetes, hepatitis C, seizure, asthma, hyperlipidemia) and
the provision of age-based routine health maintenance screenings are not in full accord
with both the Office of Health Services Chronic Illness Treatment Guidelines and
national standards of care.
Asthmatic and COPD patients do not have documentation in their medical record that
they have been educated and have demonstrated competency in the use of metered
dose inhalers (MDI). Poor technique in the use of MDIs contributes to poor control of
asthma/emphysema and increased morbidity.
Asthmatic and COPD patients who present with respiratory symptoms to nurse sick call
do not routinely have their peak expiratory flow rates (PEFR) measured. This is not in
compliance with IDOC Asthma Treatment Guidelines.
Diabetics at DCC were seen regularly, had HbA1C and urine microalbumin creatinine
ratio testing performed at reasonable intervals, and received annual optometric
screening for diabetic retinopathy. However, detailed foot exams, preventive
pneumococcal vaccinations, and evaluation of 10-year heart disease and stroke risk
scores that are recommended in the IDOC diabetes treatment guidelines and in national
standards of diabetes care fail to be performed.
The one chart of a patient 65 years of age or older whose chart documented a past
history of tobacco use had no documentation in his record that he was offered one-time
screening for aortic abdominal aneurysm as recommended by national standards of
care.28 DCC failed to screen all patients over 50 for colon cancer and repeat the
screening at intervals based on the results and the methodology of screening utilized.
The charts of seven patients 50 years of age or older were reviewed; six (86%) of the
seven eligible patients had not been screened for colon cancer.29 The one patient
credited for being screened was not routinely screened for colon cancer but had a
colonoscopy performed when he was 49-year-old to evaluate bloody stools.
Nationally recommended vaccinations for adults are not consistently administered.
Pneumococcal and meningococcal vaccinations were not offered or given as
recommended by national age and disease-based guidelines.30
Warfarin is the anticoagulation therapy provided at DCC. The monitoring of this
modality of anticoagulation is staff intensive and logistically complicated, which makes it
extremely difficult to maintain a safe level of anticoagulation. Patients are not
adequately anticoagulated for a significant percentage of the time that they are on
treatment.
Uncontrolled chronic illnesses with problems that appear to be beyond the expertise of
the DCC providers are not referred for specialty consultation.

USPSTF AAA 2014.
Chronic Care Patients #2,4,5,8,9,12,13.
30 In references, CDC Recommended Immunization Schedule for Adults 19 Years or Older by Medical Conditions or Other
Indications, 2018).
28
29

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•
•

•

The chronic care providers did not document any review of the MAR, the CBGs, the
nursing and provider sick call notes and blood pressure readings when they saw patients
in the disease-specific chronic care clinics or in the intervals between chronic care visits.
The Medical Director reported that the providers have access provided by Wexford on
their administrative office computers, but not in the infirmary or clinic exam rooms.
Nurses do not have access to electronic medical references in the sick call exam rooms.
This lack of ready access to current clinical diagnostic and therapeutic information is a
barrier to the delivery of comprehensive, quality care at DCC.
Chronic care scheduling in separate clinics for each individual disease is wasteful,
without basis in contemporary medical primary care practice, and may be harmful to
patients. On the basis of patient safety we recommend this practice be discontinued.

Two advanced practice nurses are assigned to staff the chronic care clinics. The single physician
at DCC provides care to the infirmary patients and does administrative duties, but does not staff
chronic care clinics.
Chronic care clinics at DCC are scheduled to be seen at specific monthly intervals that are
inflexible.31 These schedules are not based on the degree of control of the patient’s illness.
Patients need to be seen as frequently as is necessary to obtain control for their illness, not
based on an inflexible schedule. The practice of seeing patients in disease specific chronic
illness clinics encourages providers to ignore the implications of any one disease on another
disease and to ignore the multitude of drug-drug interactions that exist in the practice of
medicine. Many chronic illness are clinically interrelated. Metabolic syndrome, for example, is a
condition that consists of obesity, diabetes, high blood lipids, and hypertension. Yet in the
IDOC, each of these diseases (diabetes, high blood lipids, and hypertension) may be evaluated
in a separate chronic clinic. In the IDOC, these disease specific clinics also do not include
documentation that the provider evaluating the patient is aware of the patient’s other clinical
conditions. Each individual illness is documented on a separate medical record document,
which makes it impossible to obtain a unified perspective with respect to therapeutic treatment
planning. This redundant documentation is wasteful of time, unnecessary, and is clinically
inappropriate. Unless a specialist is managing an individual disease, there is no legitimate
clinical basis for this practice, which we believe should be discontinued on the basis of patient
safety and elimination of waste.
For these reasons, patients with chronic medical conditions should be seen for all of their
chronic medical conditions each time they are evaluated unless a specialist is managing their
care. A patient in a primary care practice with six chronic conditions might be seen four times a
year or more frequently if clinically indicated. In the IDOC, a patient with six chronic illnesses

31

At DCC, asthma chronic clinic is scheduled in January and July. Diabetes chronic clinic is scheduled in April, August, and
December. MIC/DM is scheduled in April, August, and December. Hepatitis C clinic is scheduled in June and December. High
risk/HIV clinic is scheduled monthly. Hypertension/Cardiac clinic is scheduled in March and September. Seizure clinic is
scheduled for February and August. Tuberculosis clinic is scheduled monthly. General Medicine clinic is scheduled May and
November. Renal clinic is scheduled monthly via telehealth by a consulting nephrologist.

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can have up to 24 chronic care documents in the medical record each having been developed in
a separate clinic session.
The chronic care clinic enrollment and scheduling processes were reported as follows:
1. Within 24 hours of admission, the admitting RN documents names of patients and their
chronic illnesses in the clinic log.
2. The chronic care nurse reviews the clinic log on a daily basis, adds patients to the
appropriate chronic care list, arranges for the next chronic clinic visit based on the due
date and the date of the previous visit, and arranges lab testing if the patient is to be
seen within the next 30 days.
3. Within one week, an advanced practice nurse (APN) reviews the charts of all newly
admitted individuals, identifies missed chronic illnesses, orders any needed labs, and if
needed, sees patient within 30 days if a chronic illness baseline is required.
4. During the interval before the first chronic care visit at DCC, APNs will renew expiring
medications.
5. The chronic care nurse reviews all patients to be seen in the upcoming month’s chronic
clinic, and arranges required lab tests to be drawn in advance.
6. Medical record staff generate the passes no less than the day before the clinic and a
movement list/clinic schedule is printed and sent to the correctional staff. The chronic
care nurse arranges the passes/list for the telehealth specialties (HIV, hepatitis C, renal).
7. Refusals for chronic care appointments (and treatments, dressings, nebulizer
treatments, insulin injections) must be documented in person in the health care unit.
Medications will be renewed if needed for patients who refuse a chronic clinic appointment.
But the patients who refuse an appointment will then be rescheduled at the next chronic illness
clinic, which could be as long as six months later. This places the patient at risk for having a
sustained period of lack of control without any clinical intervention unless their condition
deteriorates to the level of causing clinical symptoms. We view this as indifferent. Patients at
DCC include the mentally ill and many geriatric patients who have mental challenges. Refusals
of care, particularly in this group of patients, must be viewed with the perspective that this
group may have cognitive challenges. IDOC must therefore establish procedures that ensure
that high-risk, non-cooperative, or non-compliant patients who refuse visits are rescheduled
promptly based on their existing clinical need. In all other respects, monitoring of these
patients must continue as ordered. On the other hand, as opposed to refusals, all no shows due
to lockdowns, NP call-ins, offsite site writs, and hospitalizations are currently automatically
rescheduled and seen shortly after the missed appointments.
There were 2,560 chronic care visits at DCC from July 2016 through June 2017. In the first eight
months of FY 2017-18 (July 2017 to February 2018), 1,781 chronic care clinic visits were
provided; this projects to a slightly higher annualized volume than the previous year.

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Chronic Care Clinic Statistics
July 2017 – June 2018
Table 1

Clinic
HTN
Average Pt. Roster
307
Annual Visits
605
Visits per patient/year
2
% of DCC Population

DM
28
85
3

Sz Asth/COPD Gen Med
59
173
238
113
356
501
1.9
2.1
2.1

13.4% 1.2% 2.6%

7.6%

10.4%

Hep C
129
256
2.0

HIV
27
80
3.0

5.7%

1.2%

INH MIC* MICDM Total
1 96
128
1185
12 196
368
2560
2
2
2.9
0

4.2% 5.6%

*MIC includes patients with ≥2 conditions: hypertension, seizures, asthma/COPD, gen med. MIC DM includes
patient with diabetes and ≥1 of these conditions: hypertension, seizures, asthma/COPD, or gen med.

Over 50% of all the patients at DCC have a chronic illness. Based on the data noted in Table One
and the review of the medical records of 14 chronic care patients, most patients with chronic
illnesses at DCC are seen by a provider approximately twice a year.
At the time of the site visit to DCC, 11 patients were receiving chronic anticoagulation using
warfarin (Coumadin or Jantoven). Patients receiving warfarin treatment must have frequent
International Normalized Ratio (INR) testing to assure that the level of anticoagulation is within
a recommended therapeutic range. Lower than therapeutic range results predispose the
patient to recurrent clots and possible pulmonary emboli; elevated levels create risks of serious
bleeding. The experts had difficulty evaluating the care provided to this patient population who
were at high risk for serious complications. The progress notes and chronic care clinic notes had
limited if any documentation of INR results and clinical decisions to modify warfarin doses.
Ultimately, the experts identified, albeit inconsistently, scribbled annotations at the bottom of
lab reports buried amidst multiple lab results noting a change in warfarin dosage. This vital
clinical decision and the rationale for dose modification must be documented in progress notes
which providers and nurses commonly use to comprehend and verify the care provided to a
patient. This must be expeditiously addressed by IDOC and DCC medical leadership. The
utilization of INR testing was tracked on two patients receiving warfarin for chronic
anticoagulation. One patient had 24 INRs in 16 months; nine (38%) were in the recommended
therapeutic range, 11 (46%) above this range, and four (17%) below the therapeutic range.32
The other had 43 INRs over 41 months; 31 (72%) in the therapeutic range, three (7%) above this
range, and nine (21%) below the therapeutic range.33 The varying levels of anticoagulation in
these two patients resulted in multiple increases and decreases in the dosage of warfarin. Given
the logistical difficulty in maintaining therapeutic levels of anticoagulation in the correctional
setting, IDOC must strongly consider switching to the use of newer anticoagulants that do not
require INR testing and the subsequent frequent adjustments of the anticoagulant dosages.

32
33

Chronic Care Patient #7.
Chronic Care Patient #10.

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The documentation in the chronic care clinic notes does not consistently contain sufficient,
pertinent clinical information needed to clarify and understand the status of a patient’s chronic
illness or justify a change in the treatment plan. This lack of consistent clinical documentation
creates a barrier to the continuity and quality of care delivered to the DCC patient population.
The experts found limited documentation that the chronic care providers had reviewed the
MAR (refusals, compliance with prescribed medications), the CBGs, the previous nurse and
provider sick call notes, and the blood pressure readings taken in the previous sick call visits
when they assessed patients in the disease specific chronic care clinic visits. This failure to
review and document the data and information that had been gathered between chronic care
visits contributes to inappropriate clinical decisions for DCC’s patient population.
The chronic care clinic notes are handwritten but were, for the most part, legible. The legibility
of the chronic care handwritten notes was a notable improvement from the Experts’ site visits
to the previous two correctional facilities.
It was reported that the providers have access to the UpToDate® electronic medical reference
on their administrative office computers, but this important access to current diagnostic,
treatment, and clinical information is not available to providers or nurses in their clinical work
areas (infirmary, nursing stations, exam rooms), making access to this information not available
when it is needed.
Most of the chronic care patients had completed problem lists. However, four (29%) of the 14
charts reviewed had important diagnoses missing from the problem list and one had diagnoses
that were either incorrect or no longer active problems.
The care provided to diabetics and patients on chronic anticoagulation, antihypertensive, and
asthma/emphysema medications had deficiencies. The Office of Health Services Chronic Illness
Treatment Guidelines were not fully adhered to: diabetics did not receive pneumococcal
vaccines or have documented detailed foot examinations. Asthmatics did not receive
pneumococcal vaccination and did not have pulmonary function tests performed when there
was uncertainty about their diagnosis. Seizure patients did not have documentation of the
occurrence of their most recent seizure. Hepatitis C patients did not have a baseline HCV RNA
measured. Some diabetics, hypertensives, and patients on warfarin anticoagulation remained
uncontrolled for lengthy periods of time, and detailed foot and lower extremity sensory exams
are not documented in the diabetes chronic care notes. Recommended vaccines are not
universally provided to patients whose age or disease warrant such vaccination. Compliance
with prescribed medication is important for all chronic illnesses and the impact of not taking or
receiving diabetic, hypertension, anticoagulation, and seizure medications can result in rapid
deterioration and morbidity. There was no documentation in the chronic care provider notes
that they were reviewing the MAR’s or nursing notes to assess compliance with medication and
initiating appropriate interventions as needed.
All 14 (100%) of the patient records had some degree of problems identified in the provision of
care. The following patient summaries highlight the concerns and the findings noted above.
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Chronic Care Patient Summaries
• This patient is a 49-year-old male with diabetes, hypertension, obesity, ETOH abuse, and
paranoid schizophrenia, whose medications included glipizide 5mg, metformin 1000mg
BID, fenofibrate 54mg/d, metoprolol 50mg BID, hydrochlorothiazide 25mg/d, and
aspirin EC.34 There was no documentation in the database of pneumococcal vaccination,
which is recommended for all diabetics. He was followed in DCC’s combined chronic
(MIC DM) clinic. Lab testing in 2013 revealed cholesterol 206, LDL 95, TG 343 (45-150),
and HbA1C 8.6%. In 2015, simvastatin was discontinued and fenofibrate was started due
to an elevated TG (343). This is a questionable clinical choice, with only a mildly elevated
TG. The national guidelines recommend statins for patients with high risk of
cardiovascular disease. This patient’s 10-year cardiovascular risk score was not assessed
by the DCC providers, but we calculated his risk to be 20.5%, which warranted
prescription of a statin.35 His diabetic control improved and his HbA1C was maintained
between 5.4 and 5.7%. He has chronic kidney disease (creatinine 1.77) but his urine
microalbumin was within normal range. The optometry visit in March 2017 identified no
findings of diabetic retinopathy. His blood pressure was controlled; however, in 2016 a
prescription for lisinopril, an antihypertensive that is strongly indicated in diabetics with
early kidney disease, was discontinued. The rationale for this decision was not noted. At
none of his chronic care visits was there documentation that a detailed foot exam had
been performed. At the 8/6/17 annual exam, his cognition was felt to be somewhat
impaired, but the provider did not list any reasons or possible etiologies for the
assessment of mild cognitive impairment. The patient lost 51 pounds over six years (311
lbs. in 2011 and 260 lbs. in October 2017). This may be due to exercise and better food
choices, but there was no documentation by the provider that a wider differential
(hyperthyroidism, cancer, malabsorption, etc.) was considered. This patient will be 50
years old later this year and consideration should be given to additional age-based
screening (e.g., colon cancer screening). A review of recent MARs showed good
administration and compliance with medications.
In summary, for the most part, this patient’s diabetes (HbA1C’s consistently in the 5
range) and hypertension have been well controlled for the last two years. The
improvement in his diabetes may be due to his weight loss. Although the repeated
HbA1C’s in the 5 range put the patient at risk for hypoglycemia, the provider did not
reassess the diabetes medications and did not consider discontinuing at least one of the
two anti-glycemic medications (for example glipizide). His 10-year risk of heart disease
and stroke was greater than 7.5%. Based on current standards and on the IDOC Chronic
Illness Guidelines, this patient should have been prescribed a statin to lower his risk of
cardiovascular events. Also, the providers failed to comply with the IDOC guidelines by
not documenting a foot examination, and not ordering a pneumococcal 23 vaccination.
The providers failed to identify, monitor, and evaluate the reason for the patient’s

34
35

Infirmary Patient #1.
ACC/AHA Heart Risk Calculator.

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notable 51-pound weight loss during his incarceration. This puts the patient at risk from
potentially preventable morbidity and even mortality.
•

This patient is a 53-year-old male with HIV infection, hyperlipidemia, hypertension,
asthma, substance use disorder, and a past history of positive TB skin test.36 His
medications included lisinopril 20mg, QVAR MDI, albuterol MDI, pravastatin, Genvoya,
and darunavir. The patient was transferred in September 2017 from Northern Reception
Center (NRC) to DCC. He was followed in the UIC HIV telehealth clinic and the MIC
chronic care clinic. In the past 21 months he has been seen three times in the UIC HIV
clinic while at NRC and DCC, three times in the hypertension chronic clinic at NRC, and
two times at the MIC clinic at DCC. His HIV has been stable on Stribild/darunavir and
then Genvoya/darunavir, with viral loads <20 and CD4s ranging between 680 and 838.
His HIV medications included protease inhibitors. The patient was on simvastatin from
June 2016 to March 2017. Simvastatin is contraindicated in persons on protease
inhibitors, which this patient was on, yet this contraindication was not recognized for 10
months. He had been seen three times in the NRC hypertension chronic care clinic
before this contraindicated medication was discontinued. There is no documentation in
the chart that he was offered or administered the pneumococcal 13 or 23 or the
meningococcal vaccinations. His asthma was well controlled with no exacerbations
noted in the medical record, and his PEFRs ranged between 600 and 750 L/min. His
blood pressure was controlled over the last 21 months. On 3/21/17, when simvastatin
was discontinued at SCC, gemfibrozil was ordered without a rationale documented in
the medical record. Gemfibrozil is not recommended for lipid lowering in the absence of
high triglycerides. An elevated triglyceride level was not identified in the medical record.
A different statin drug other than simvastatin should have been chosen. Labs on
7/20/17 showed a cholesterol of 251, LDL 173, TG 156. The patient transferred to DCC in
late 2017. In March 2018, gemfibrozil was discontinued and an appropriate statin
(pravastatin) was finally initiated. The decision to appropriately start statin medication
was delayed by the providers’ failure to calculate the patient’s 10-year ASCVD risk score
as is mandated in the IDOC diabetes treatment guidelines.37 This patient’s estimated 10year cardiovascular risk was 9.7%; the national and IDOC guidelines recommend
starting a statin when the 10-year risk is >7.5%.38 This 53-year-old has not yet been
screened for colon cancer; all individuals should be screened for colon cancer beginning
at the age of 50.39
In summary, this patient was continually seen in HIV and chronic care clinics. His HIV,
asthma, and hypertension were adequately controlled. Even though this patient was
seen three times in an NRC/SCC chronic care clinic, for seven months he was left on a
type of statin that has serious drug interactions with HIV medications before this
contraindicated statin was recognized and discontinued. This delay put the patient at

Chronic Care Patient #2.
IDOC Chronic Illness Treatment Guidelines, Diabetes 2016.
38 ACC/AHA Heart Risk Calculator.
39 USPHS Taskforce.
36
37

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risk and supports a recommendation that chronic care clinic providers need to be
engaged and knowledgeable about the care provided in other chronic care and specialty
clinics and in sick calls. There was no rationale documented in the medical record for
starting gemfibrozil after the contraindicated statin was stopped; triglycerides were
never more than mildly elevated. The providers failed to comply with the IDOC and
national guidelines by not calculating the 10-year ASCVD risk and delaying the ordering
of another statin that was not contraindicated for use with HIV medications. The
providers failed to comply with national guidelines to offer screening for colon cancer to
all individuals at the age of 50 years and to offer pneumococcal and meningococcal
vaccination to this patient with HIV.
•

This patient is a 29-year-old male with asthma. His only medication is levalbuterol MDI.40
His database noted a negative PPD and hepatitis B vaccination series being administered
in 2017. There was no documentation of pneumococcal or flu vaccines. In 2016, he was
seen three times in nurse sick calls for upper respiratory infections and asthma
exacerbations. The nurses did not measure peak expiratory flow rates (PEFR) but did
measure oxygen saturations. The patient improved with increased use of the
levalbuterol inhaler. The patient was seen in asthma chronic care clinics four times
between July 2016 and January 2018. In the asthma clinic his peak flows ranged from
450 to 500 L/min. The providers did appropriately document the frequency of
levalbuterol usage as one to three times per week when the weather was cold. There
was no documentation in the medical record by nurses or providers that the patient’s
inhaler technique was reviewed and found to be appropriate. MARs reviewed in 9/2017
and 11/2017 documented the distribution of the KOP inhalers to this patient.
In summary, the patient had very stable asthma that only required intermittent use of
his rescue inhaler. He was seen regularly in the asthma chronic care clinic. There was no
evidence in the medical record that he had been offered pneumococcal vaccination, as
is nationally recommended for all asthmatics. The nurses did not measure PEFRs when
the patient was seen in nurse sick calls for breathing issues. Nurses should measure and
record PEFRs before and after treatment on all asthmatics who are evaluated in sick call
or in the urgent care treatment rooms. Oxygen saturation testing has a place in the
evaluation of symptomatic patients in respiratory distress or those not responsive to
treatment, but does not replace the measurement of PEFRs. Asthmatic and COPD
patients should have documented ongoing training and documented observation of
their inhaler technique. This is not being done at DCC and should be incorporated into
the standard care provided to all users of inhalers. Failure to do this puts the patient’s
health at risk.

•

40
41

This patient is a 81-year-old male housed on the geriatric floor with diabetes,
hypertension, hyperlipidemia, and decreased vision.41 His medications include

Chronic Care Patient #3.
Chronic Care Patient #4.

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simvastatin, metoprolol, furosemide, aspirin, lisinopril, and metformin. The patient was
seen regularly in the diabetes/hypertension MIC chronic care clinic. His HbA1Cs have
ranged from 5.4 to 5.7 for the last 2¾ years. His blood pressure was 178/90 on 1/12/16
and furosemide was added to this anti-hypertensive regimen. His blood pressure was
also elevated (158/80) in December 2017, but no treatment modifications were made at
this visit. There was no documentation in the medical record that this patient received
the pneumococcal vaccines, which are indicated for all diabetics and every patient 65
years of age or older. He also was not screened for colon cancer, which is indicated for
all patients 50 years of age or older.
Since 2015, this patient has been followed by the DCC optometrist for failing vision,
worse in the right eye. He was referred the UIC cataract clinic in February 2017. On
3/8/17, the optometrist documented that the patient could only count fingers at five
feet with his right eye and had visual acuity of 30/40 on the left. On 4/26/17, the
optometrist noted that he was still looking into the request to get approval for cataract
surgery. On 5/4/17, the optometrist found that the patient’s vision deteriorated to a
visual acuity of 20/100 on the left, and only finger counting on the right at five feet. The
optometrist submitted another request for referral to UIC. On 10/11/17, eight months
after the initial referral, the patient was seen at UIC, where retinal swelling was noted
and drops in both eyes continued for glaucoma. A two week follow up was
recommended. On 11/8/17, the optometrist found the patient’s vision to be only finger
counting at two feet in both eyes. The optometrist added a second eye solution and
wrote “need to get back to retina specialist…will refer again.” On 12/13/17, the
intraocular pressure of both eyes was normal. The optometrist noted that the patient
had a history of retinal swelling due to diabetic retinopathy and advised that the patient
keep the eye appointment with the retinal specialist. No further visits to the UIC eye
specialists were located in the medical record. The patient’s MAR indicated compliance
with all medications.
In summary, the patient was seen regularly in the chronic clinics and his diabetes
appeared to be over treated because his HbA1C level was significantly below goal. The
risk of hypoglycemia should have prompted reevaluating the need for metformin in this
elderly patient. Failure to offer and administer pneumococcal 13 and 23 vaccines is not
in compliance with community practice nor with IDOC diabetes treatment guidelines.
Failure to screen this patient for colon cancer is also not in accord with national
standards. The patient’s vision was rapidly deteriorating. It took eight months before
the visit to the UIC eye specialist was arranged. The optometrist had to submit a second
request three months after his initial request. The patient was seen in October 2017 at
UIC and was to return in two weeks; the optometrist wrote on 11/8/17 that the patient
needed to see the retina specialist and re-submitted a referral request. As of 12/13/17,
the patient had not yet been seen back at UIC. The patient’s vision has notably
deteriorated. There have been delays with the initial and follow-up appointments at UIC
that may have contributed to his failing vision. The delays in obtaining specialty

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ophthalmology consultation at UIC should have prompted DCC to consult with a local
ophthalmologist. These delays place the patient at risk of loss of vision.
•

This a 53-year-old male with hepatitis C, asthma, hyperlipidemia, and a psychiatric
disorder.42 His database noted PPD negative in 2017 and hepatitis A and B vaccination
series in 2013-14. He was followed in the asthma and hepatitis C chronic clinics. His
medications were levalbuterol and ciclesonide MDIs. There was no evidence in the
medical record that he received the pneumococcal vaccine as is recommended for
persons with asthma or emphysema. His last asthma attack was documented as
occurring in 2013. Given he had infrequent asthma exacerbations, he had questionable
need for inhaled steroid medication. His PEFRs ranged from 325 to 520 L/min, but the
PEFR was not always recorded when he was seen at his chronic care visits. There was no
evidence in the medical record of pulmonary function testing. This testing was needed
to identify if this patient had asthma as opposed to emphysema. His lipid profile in
September 2015 noted cholesterol 263, HDL 61, and LDL 159. His 10-year ACC/AHA
cardiac risk was not assessed by the DCC providers, but we calculated this risk to be
10.8%. In spite of this elevated risk, his statin medication was discontinued without a
clinical explanation in 2016. The patient was followed for hepatitis C infection since at
least 2013. His liver enzymes were slightly elevated, and his platelet counts were within
normal ranges. He was treated for oral thrush with Diflucan (fluconazole). There was no
rationale given for why this patient developed an oral candida infection. Although the
cause might have been the use of an inhaled steroid, oral thrush is rarely seen in
patients who do not have AIDS or diabetes. He was not tested for HIV. His APRI was
calculated to be 0.418, which is below the IDOC criteria for treatment. We were not able
to identify lab testing for HCV quantitative RNA testing as is required in the IDOC
Hepatitis C Guidelines 2017.43 There was no documentation in the medical record that
this over 50-year-old patient has been screened for colon cancer.
In summary, this patient was seen four times over 31 months in the asthma clinic. His
respiratory condition was stable. He failed to receive necessary pulmonary function
testing. There was no clinical justification in the medical record indicating that this
patient needed to continue to use inhaled steroids. There was no documentation in the
medical record that this patient was trained on the use of the MDI or successfully
demonstrated proper technique during any of this asthma clinic visits. There was no
evidence in the medical record that hepatitis C virus (HCV) RNA testing had been
ordered as directed in the hepatitis C guidelines. The cause of oral thrush was not
identified; HIV testing was clearly needed but was not ordered. This poses a significant
risk to this patient. This patient was over 50 years old, yet has not received colon rectal
screening, which is indicated by both national and community standards of care.

42
43

Chronic Care Patient #5.
Hepatitis C Guideline, December 2017.

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•

This patient is a 38-year-old male with hepatitis C infection, seizure disorder, and
depression.44 His database noted that he had received hepatitis A and B vaccination
series in 2016-17. His medications included valproic acid 500mg BID. He was followed in
the hepatitis C and seizure clinics. He was admitted to IDOC in July 2016 and was seen
three times in the hepatitis C clinic. His liver enzymes were slightly elevated, his
platelets were normal, and his APRI scores was less than 0.46, which meant that the
patient could have significant fibrosis but was unlikely to have cirrhosis. There was no
documentation in the medical record that he had been tested for HCV RNA as directed
in the hepatitis C guidelines.45 Based on current institutional criteria, he was not a
candidate for hepatitis C treatment. In the 5/15/17 seizure clinic, it appeared that he
had stopped or had not received his seizure medications and valproic acid was restarted. On 2/27/18, he was examined in the seizure clinic. His valproic acid level was
low 27.4 (50-100) and the ALT test result was 53. There was no mention about when he
had his last seizure. Review of the MAR documented that he had received his KOP
monthly supply of valproic acid from September 2017 to December 2017, but there is
no documentation that he received valproic acid in January and February 2018. There is
no indication or documentation that the provider in the seizure chronic care clinic
reviewed the MAR and documented the most recent failure to receive his valproic acid.
None of the seizure clinic notes document when the patient had his last seizure.
In summary, there is no evidence in the medical record that this patient has ever had
HCV RNA testing; this is not in accord with the system’s hepatitis C guidelines. If the test
showed that there was no active infection, the patient would no longer need to be
followed and repeatedly examined and tested with respect to treatment of hepatitis C.
The seizure clinic notes fail to document if the patient had any epileptic seizures since
the previous visit. The failure to record this key clinical information poses a health risk
for this patient. There was a question about the patient’s ability or willingness to take
his seizure medications, but he continued to be allowed to self-medicate his seizure
treatment instead of placing him on nurse administered medication.

•

This patient is a 44-year-old male whose problem list includes DVT since 2016 on chronic
warfarin anticoagulant treatment, seizure disorder, NIDDM, congestive heart failure,
and migraine headaches.46 His medications include warfarin, levetiracetam, phenytoin,
haloperidol, and levalbuterol and ipratropium MDIs. The problem list included no
documentation that the patient had a mental health disorder yet, he was noted as
receiving haloperidol, a psychotropic medication. The patient was receiving a rescue
bronchodilator, but neither asthma nor COPD were noted on the problem list. Heart
failure and diabetes were on his problem list, but he was not prescribed any
medications for the treatment of either condition. During the past two years, the
patient had no asthma attacks or emphysema exacerbations. Based on the inhalers

Chronic Care Patient #6.
Hepatitis C Guidelines.
46 Chronic Care Patient #7.
44
45

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being prescribed, it appears likely that this patient was being treated for emphysema,
yet pulmonary function testing was never performed to verify the patient’s actual
diagnosis. His PEFRs ranged between 270 and 400. He attested to using his inhalers two
to three times per week. There is no documentation in the record that this
asthma/emphysema patient was offered pneumococcal vaccination in accord with
national guidelines. While housed at Pontiac Correctional Center, his carbamazepine
level was 2.6 (4-12) and his phenytoin level was 9.4 (10-20) both of which were below
therapeutic levels. There was no comment in the clinical notes made about recent
seizure activity nor about these low drug levels. The patient’s history and physical exam
notes were extremely limited to the point of being non-contributory. The patient was
transferred to DCC and was seen in the asthma/seizure clinic on 6/2/16. A more
thorough history noted that his last seizure was in May 2016 and that he was using his
rescue MDI two to three times per week. His carbamazepine and phenytoin levels were
now within therapeutic range; carbamazepine was discontinued and levetiracetam was
started. At the 12/15/16 MIC clinic, he reported having a seizure one week ago; he was
reported to have been noncompliant with his anti-seizure medication. At the 1/17/18
asthma/seizure clinic, the provider documented that there had been no seizures since
the last visit and his phenytoin level was found in the therapeutic range. The
management of this patient’s chronic anticoagulation was complicated by the failure of
the NPs providing chronic care to clarify in the medical record why this patient had to be
prescribed long-term anticoagulation with warfarin or any other anticoagulant. From
8/14/15 through 12/21/16 (16 months), 24 INR tests were performed. Only nine (38%)
were in the recommended therapeutic range; 11(46%) were high and put the patient at
risk for serous hemorrhage; and four (17%) were low, creating the potential of new clot
formation. Due to these varying levels of anticoagulation, the warfarin dosage had to be
changed at least eight separate times. Warfarin was eventually discontinued because of
the patient’s propensity to self-mutilate. At one point, the patient developed anemia
from bleeding from self-inflicted lacerations. At two clinical visits (7/30/17, 1/17/18),
the provider’s plans were “see orders” and “see RX.” These short cut plans are an
impediment to the effective communication to nurses and other providers about the
treatment of this patient.
In summary, this patient’s likely diagnosis was COPD, but the patient failed to have
pulmonary function testing to make that determination. The patient was never offered
or administered the pneumococcal vaccines; this is not compliant with the standard of
care in the community. The patient’s anticoagulation treatment was in the therapeutic
range only 38% of the time in 2015-2016. The provider’s documentation at the 7/30/17
and 1/17/18 chronic care clinics to “see orders or RX” instead of documenting a
therapeutic plan of care has the potential to disrupt the continuity of care for this
patient and put the patient’s health at risk.

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•

This patient is a 51-year-old male with hyperlipidemia.47 He was followed in the general
medicine chronic clinic. He was not on medication; simvastatin was discontinued in
2012 due to non-compliance. In 1/8/2007, initial labs showed cholesterol 280, HDL 33,
LDL indeterminate and TG 461. One month later on 2/19/2007, repeat lipid testing
revealed cholesterol 196, HDL 23, LDL 128, and TG 224. We were not aware whether the
patient was on statin medication when this test was taken. At the general medicine
clinic on 6/10/15, the patient’s dyslipidemia was controlled with diet. There was no
documentation in the record why and when the statin had been discontinued. The
patient was subsequently seen four times in the general medicine clinic between
November 2015 and November 2017. His weight decreased from 230 in 2014 to 219 on
11/12/17. He continued to be advised by the providers to exercise, increase dietary
fiber, and eat a healthy diet. There was no documentation in his chart, as recommended
in the IDOC Hyperlipidemia Guidelines 2016, that his 10-year risk for heart disease or
stroke was calculated.48 Using his most recent lipid profile, we calculated his 10-year
ASCVD Risk to be 4.7% which does not meet the criteria for treatment with a statin
medication. In 2015, the patient had an episode of bright red blood per rectum (BRBPR).
He was evaluated twice by DCC providers and the bleeding was thought to be caused by
an external hemorrhoid. He had a colonoscopy done at UIC on 9/2/15; a sessile polyp
was removed. The patient is to have a repeat colonoscopy in 2020. He was not told
about the colonoscopy results until eight months later, when he asked for this
information.
In summary, this patient was followed regularly in the general medicine chronic care
clinic. He has had six chronic care clinic visits in the last 29 months. Although the 10-year
ASCVD risk score was below the threshold to initiate anti-cholesterol medication, the
providers failed to follow the IDOC hyperlipidemia guidelines by not regularly calculating
this risk. The colonoscopy performed in 2015 to evaluate BRBPR fulfilled the age-based
screening for colon cancer in this over 50-year-old patient.

•

This patient is a 70-year-old male with COPD and a previous 50-year history of smoking
tobacco. 49 His database noted a flu shot on 9/20/17 and a pneumococcal 23 vaccine. His
medications included fluticasone and vilanterol inhaler, levalbuterol inhaler and
ipratropium, and albuterol inhaler. He was seen seven to eight times in the asthma
chronic care clinic from July 2015 through January 2018. His medications were modified
on a number of occasions to address his respiratory status. His PEFRs were consistently
low, 110-130 L/min, and his oxygen saturations ranged from 95 to 97%. He was
admitted to the infirmary on two occasions (1/8-22/2016, 4/4-20/16) for exacerbations
of his COPD. The patient was referred to UIC pulmonary clinic on 1/20/17, but there was
no evidence in the medical record that this has been accomplished. His weight dropped
from 125 on 7/17/15 to 116 on 2/21/17, but has remained stable through 1/17/18 at

Chronic Care Patient #8.
IDOC Treatment Guidelines Hyperlipidemia.
49 Chronic Care Patient #9.
47
48

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115 lbs. He initially refused cancer screening and lab screening on 2/21/17. A lipid
profile performed in October 2017 showed cholesterol 179, HDL 59, LDL 103. We
calculated the patient’s 10-year ASCVD risk as 16.3% which warrants treatment with a
statin. There is no documentation in the medical record that he has been offered or
received pneumococcal 13 vaccine. Though the patient had COPD, a pulmonary function
test was not evident in the medical record. Though the patient was a 70 year old exsmoker, abdominal aortic ultrasound testing was not done to screen for an aortic
aneurysm.50 It is unclear which cancer screening he refused on 2/21/17. Given that the
patient was recently allowing lab testing again, colon cancer screening should be
revisited. There is no documentation in the medical record that colon cancer screening
has been offered in the last 12 months.
In summary, this patient has been seen regularly in the COPD clinic and his medications
have been adequately modified to include a corticosteroid, short-acting beta agonist,
long-acting beta agonist, and an anticholinergic bronchodilator. He has never had a
pulmonary function test to fully verify the clinical diagnosis of emphysema. His COPD is
quite severe, and it is in his best interest that the pulmonary specialty appointment
requested in January 2017 be resubmitted. Per IDOC hyperlipidemia guidelines, the
providers should have (but have not been) calculating his 10-year ASCVD risk. His 16.3%
10-year risk indicates that he should have been offered a statin medication. This patient
is not being offered nationally recommended age and risk-based tests to screen for
abdominal aortic aneurysm and colon cancer. He also has not been offered and
administered the pneumococcal 13 vaccine. The failure to offer these preventive and
early detection screenings puts this patient’s health at risk.
•

50
51

This patient is a 43-year-old male with asthma, DVT on chronic anticoagulation with
coumadin, psychiatric disorder, past history of seizure disorder (no longer on
antiepileptic medications), traumatic brain injury (TBI) in 1999 due to MVA, and
blindness in one eye.51 His database noted a flu shot and HIV Ab negative test in 2017.
His medications included levalbuterol and ciclesonide inhalers, and warfarin. He was
followed semi-annually in the asthma chronic care clinic, with eight chronic care visits in
the last 40 months. His PEFRs have ranged been 300 and 650 L/min, with a mean of 380400. He has had no urgent care or ED visits for asthma attacks. The patient was
prescribed warfarin for the past treatment of DVT. We could not find a comprehensive
note in the medical record explaining why he is receiving chronic anticoagulation. On
8/13/17, the lead physician wrote that the NP primary care provider needed to
determine if there was clinical justification to continue anticoagulation; the NP then
only noted in the 10/16/17 progress note that a history of multiple DVTs was the reason
for the ongoing warfarin treatment. Forty-three INR tests were done in the last 41
months: 31 (72%) were in the therapeutic range, nine (21%) below, three (7%) above
this range. Warfarin doses were modified six times during this timeframe. The patient’s

USPSTF AAA 2014.
Chronic Care Patient #10.

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weights were recorded as 301 lbs. on 2/6/15, 291 on 8/11/15, 281 on 12/8/16, and 228
on 1/29/18. He lost 73 lbs. in 36 months. On 5/13/17, lab tests revealed a normal HbA1C
and TSH, ruling out diabetes and hyperthyroidism. There is no documentation in the
chart that discusses this notable weight loss. This patient needs to be fully evaluated to
determine that the weight loss is not caused by an underlying medical condition.
In summary, the patient was seen regularly in the asthma chronic care clinic; he has not
had any exacerbations and his PEFRs are stable. There was no evidence in the chart that
he has been trained about the use of an inhaler and his technique verified to be
competent. The patient continually received INR testing to assess the adequacy of
anticoagulation for his past history of DVT(s). The patient was therapeutically
anticoagulated only 72% of the time. The providers need to thoroughly review this
patient’s history of DVTs to ensure that anticoagulation was still necessary, as an
adverse side effect of warfarin is serious risk of bleeding. The frequent lab testing and
medication adjustments needed when warfarin is prescribed are logistically complicated
and put patient-inmates at risk for poor outcomes. Utilizing newer anticoagulation
medications that do not require frequent ongoing measurement of the level of
anticoagulation should be strongly considered by the IDOC. The patient’s significant
weight loss has not been fully and comprehensively evaluated. The providers have not
taken a careful history, performed a thorough physical exam, and ordered additional
laboratory and diagnostic tests to evaluate the unexplained weight loss. This must be
initiated immediately.
•

This patient is a 40-year-old male with hypertension and a history of anemia.52 His
database noted a diphtheria/tetanus vaccine in 2013. His medications included
diltiazem 240mg ER, metoprolol 50mg bid, losartan, and hydrochlorothiazide 12.5mg/d.
He has been followed in the hypertension and general medicine chronic care clinic at
Danville and DCC. From September 2016 through April 2018, he was seen seven times in
the hypertension and general medicine clinics. His blood pressure was controlled until
10/2/17, when he ran out of his medications and his blood pressure was noted to be
165/109; his BP medications were renewed. On 10/20/17, he was transferred to DCC.
His blood pressure at the 11/3/17 hypertension clinic was 150/100. At the 3/20/18
hypertension clinic, even though his blood pressure was 126/80, lisinopril was added to
his blood pressure regimen. At the next hypertension clinic on 3/28/18, his blood
pressure was 142/88. The lisinopril was stopped because of the development of a
cough, and losartan was substituted. Over the next week, blood pressures ranged from
122/74 to 158/98. At the 4/4/18 hypertension clinic, the blood pressure was 130/90,
with a follow-up pressure in two weeks.
On 7/10/17, while housed at Danville CC, the patient presented with a history of rectal
bleeds, and he was found to be significantly anemic, with a hematocrit of 22.4%,
hemoglobin of 6.3g/dl, and an MCV of 57. This was suggestive of an iron deficiency

52

Chronic Care Patient #11.

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anemia. A rectal exam was not performed. No additional workup was ordered or
initiated. He was placed on iron tablets. At a follow-up visit on 7/27/17, his hemoglobin
level had improved to 8.6g/dl, his bleeding had ceased, a rectal exam was deferred but
hemorrhoids were noted as the cause of the blood loss. By 10/2/17, the blood counts
had returned to normal ranges. The patient has voiced complaints of constipation. This
serious bleed should have been but was not fully investigated. It would have been fully
justified to have initially admitted the patient to the hospital to stabilize, monitor, and
evaluate the etiology. The patient’s investigations should have included additional blood
tests and upper and lower endoscopies.
In summary, the patient has been prescribed four hypertensive medications and his BP
control was not yet stabilized. The exchange of lisinopril for losartan was not fully
explainable; both can cause dry cough and the patient’s cough was under control on the
day of the change. The use of four medications at less than optimal dosing is
questionable. The Danville CC providers put this patient at risk by not hospitalizing and
fully investigating his profound blood loss. The patient’s health and life could have been
in jeopardy if he had suffered further bleeding episodes at the prison. Upon transfer to
DCC three months after the anemia had first been detected, the DCC providers should
have initiated the warranted evaluations. They failed to do this even though they had
received transfer information noting that one of his problems included anemia.
•

53

This patient is a 76-year-old male with hypothyroidism, atrial fibrillation, type 2
diabetes, prostatic hypertrophy (BPH), glaucoma, and cataracts.53 His medications
included metformin, levothyroxine, metoprolol, aspirin, and terazosin. He had been in
IDOC for at least seven years. He was not offered pneumococcal vaccination. He was
followed in the diabetes/hypertension chronic care clinic. He had 10 visits to the chronic
care clinic between March 2015 and December 2017. Without any reason being
documented, his statin medication was stopped on 3/20/15. The patient was taking
250mg of metformin for his diabetes and multiple HbA1C’s were between 5.1 and 5.5,
all reflecting totally normalized blood sugars. This indicated that the patient may be too
tightly controlled or might not even require any diabetic medications. Multiple thyroid
stimulating hormone (TSH) tests were documented to be between 1.65 and 3.85 over
the last two years. All of these thyroid tests are so close to normal and the dose of
levothyroxine so low that it would in the best interest of the patient to further lower or
discontinue this medication. Unneeded thyroid supplementation in this elderly patient’s
very mild underactive thyroid disease could stimulate an exacerbation of his atrial
fibrillation. The patient’s blood pressure was usually in the low normal range. He was
taking two medications for reasons other than hypertension that could lower blood
pressure: terazosin (BPH) and metoprolol (likely for heart rate control of atrial
fibrillation). On 12/2/16, his blood pressure dropped to 90/62; the metoprolol and
terazosin were appropriately discontinued. His levothyroxine was decreased to 25

Chronic Care Patient #12.

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mcg/d. Even though this is a very low dose of thyroid medication, the use of this
medication puts the patient at risk of a possible exacerbation of atrial fibrillation.
In summary, this elderly patient should not be taking levothyroxine, metoprolol, and
metformin. This is in accord with the standards of care in the community. His
hypothyroidism does not require treatment, he no longer requires treatment for
diabetes, and the discontinued low dose of metoprolol had very limited benefit for this
patient. The patient’s 10-year risk of cardiovascular disease is extremely high (>30%)
and warrants consideration for the reinstitution of a statin and the continuation of
aspirin. The preventive health maintenance of this patient has been ignored; he had not
received either pneumococcal vaccination, and there is no evidence in his medical
record that he has been screened for colon cancer.
•

This patient is a 60-year-old male with diabetes, hypertension, hepatitis C, and bipolar
disorder.54 His medications included 70/30 insulin, metformin, nifedipine xl, and
losartan. He was followed in the hepatitis C and the MIC diabetes/hypertension clinics.
At NRC his blood pressure was elevated at 174/115, and his antihypertensive
medications were switched to nifedipine xl and losartan. There was no rationale for
these changes documented in the medical record. His initial diabetes medications were
70/30 insulin 40U BID, metformin 1000mg/d, and sliding scale regular insulin before
breakfast and dinner. This insulin regimen contains two short acting insulins. One
component of 70/30 insulin is regular insulin. The patient was also on a sliding scale
insulin, which is regular insulin. There is a risk of hypoglycemia when simultaneously
administering two short acting insulins. He was seen three times in the MIC
diabetes/hypertension chronic care clinic between October 2017 and March 2018. His
blood pressure control was never at goal of 130/80 and his HbA1C results have only
modestly improved (9.85 to 8.8%). Even though his diabetes was not controlled, the
70/30 insulin dosages were lowered in October and December 2017. The reason for
decreasing the insulin doses was not documented in the medical record, which would
have been especially important to document, since the HbA1Cs indicated poor control.
There were no documented instances of hypoglycemia and his capillary blood sugars in
November and early December 2017 ranged between 80 and 354, with a mean in the
mid-100s. The optometrist identified no evidence of diabetic retinopathy and the
patient’s urine microalbumin was normal. The March MAR noted “missed no insulin
injections.”
The patient was seen twice at the hepatitis C clinic in 2017. His liver enzymes, platelet
counts, and coagulation studies were within normal limits. His APRI score was less than
0.3 and did not qualify him for treatment. There was no documentation in the medical
record of HCV RNA testing. If this test were normal, this patient would not have active
hepatitis C infection and would no longer need to be followed in the hepatitis C chronic

54

Chronic Care Patient #13.

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care clinic for purposes of treatment for hepatitis C. The failure to order HCV RNA is not
in compliance with the IDOC hepatitis C guidelines.55
This elderly diabetic patient has not been offered pneumococcal vaccination or colon
cancer screening as recommended in national age and disease-based prevention and
screening guidelines. His 10-year ASCVD risk score has not been assessed by DCC
providers, and was calculated to be 27.1%; but he has not been offered a high intensity
statin medication.
In summary, after six months this patient’s diabetes and hypertension are not yet
adequately controlled. The decision to order two diabetic injections that can rapidly
lower blood sugars puts the patient at increased risk for hypoglycemic episodes. HCV
RNA viral load has not been drawn. If this test was negative, there would be no need for
this patient to be followed in the hepatitis C clinic for hepatitis C treatment. DCC
providers are not adhering to national standards of providing pneumococcal vaccines to
all diabetics and those over 65 years old, and of offering colon cancer screening to
individuals 50 years of age or older. The failure to assess the patient’s 10-year risk of
cardiovascular disease and to administer a statin is not in line with the practice of
medicine in the community.
•

This patient is a 49-year-old male with insulin requiring diabetes, hepatitis C, and
psychiatric disorder.56 His database noted flu shot on 9/27/17 and completion of
hepatitis A and B vaccines, but not the administration of pneumococcal 23 vaccination.
His medications include NPH insulin and sliding scale regular insulin. The patient’s blood
pressure was not elevated during his incarceration at DCC. Since March 2016, he was
seen four times in the hepatitis C clinic; his liver enzymes were normal or minimally
elevated, his APRI scores ranged between 0.258 and 0.519. HC RNA viral load levels had
not been drawn. Per IDOC guidelines, the patient is currently not a candidate for
hepatitis C treatment. He has been seen six times in the diabetes chronic care clinic. His
HbA1Cs have been 9.1, 9.7, 9.2, 8.7, and 8.9%, and have not yet reached adequate
control during his two-year incarceration. Due to early morning episodes of near
hypoglycemic symptoms, his NPH insulin has been decreased from 28U/am and 26U/pm
to 19U/am and 17U/pm. The optometrist visit on 3/2/17 identified trace diabetic
background retinal changes; his creatinine is minimally abnormal (1.6) with a normal
urinary microalbumin. The patient’s morning and evening CBGs widely range from the
50s to 400. The MARs indicate that the patient is compliant with his prescribed regimen.
Pneumococcal 23 vaccination has not been offered or provided to this diabetic as is
nationally recommended.
In summary, after two years of incarceration, this patient’s diabetes is not yet
controlled. His insulin dosages have been deceased in spite of this lack of control. The

55
56

Hepatitis C Guidelines.
Chronic Care Patient #14.

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episodes of near hypoglycemia occurred in the early morning hours and the provider
efforts should have focused on correcting this issue rather than lowering both the
morning and the evening doses. The ongoing difficulty of fully controlling this patient’s
diabetes warrants consultation with an endocrinology/diabetes specialist.
Pneumococcal 23 vaccination should be offered to this diabetic patient. The failure to
perform HCV RNA testing is not in accord with IDOC Hepatitis C Guidelines.

Urgent/Emergent Care
Methodology: We interviewed the Nursing Supervisor (IDOC), toured the medical clinic, and
assessed the availability and functionality of emergency equipment and supplies. We also
reviewed emergency drills, CQI reports, written directives, and medical records. Medical
records were selected from the list provided by DCC of emergency room visits beginning in
January 2017. This list includes the reason for the ED visit. Records selected for review were
those conditions sensitive to ambulatory care, such as seizure, withdrawal, infection, diabetic
complications, abdominal pain, chest pain, etc. A total of five records were reviewed. We also
reviewed six records of patients who were admitted to a hospital for conditions sensitive to
ambulatory care to assess clinical quality of care.
First Court Expert Findings
Emergency room reports or hospital records were absent in all the medical records reviewed.
The emergency care of patients at DCC was inadequate, usually lacking a thorough assessment
and failing to involve advanced level clinicians. Patients referred to a provider either were not
seen or the problem was not addressed at the next provider appointment. No records of
emergency response or transports to the emergency department were kept and there was no
self-monitoring.57
Current Findings
DCC does not have a crash cart. The institution performs basic CPR, applies the AED, and calls
911 for cardiac arrests. This is an acceptable option for responding to codes/cardiac arrests.
DCC also provides first aid. There are two emergency response bags kept in the dispensary
nursing office that contain first aid supplies, personal protective equipment (PPEs),
stethoscope, blood pressure cuff, equipment and supplies to start an IV, and a few medications
(i.e., glucagon, an EpiPen, aspirin). The contents of the bags are standardized,58 and they are
sealed with a lock to indicate that the bag is fully supplied and ready for use. An automatic
external defibrillator (AED), stretcher with backboard and cervical splint, ambu bag, portable
oxygen, EKG machine, suction, nebulizer, and oto-ophthalmoscopes are available in the urgent
care room adjacent to the nursing office. AEDs and emergency equipment are also available in
57
58

Lippert Report DCC pp. 22-23.
Contents of emergency response bags

DCC list of
emergency supplies.p

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the infirmary and in X-House. The Nursing Supervisor (IDOC) said that there was no trauma bag
as described in DCC’s ID #04.03.108. Instead, a staff member is posted in the urgent care area
to collect additional equipment and supplies if radioed from the scene that they are necessary.
The presence and functionality of the first aid equipment is checked each shift and documented
on a log. We recommended to the Nursing Supervisor (IDOC) that the expiration date for each
medication in the bag be added to the log so that it was apparent when it needed to be
replaced. We checked the AED and other emergency equipment listed above and found all
were functional. DCC ID #04.03.108 lists the contents and location of first aid kits available in
housing units, program areas and vehicles, but we did not evaluate the accuracy of this
information.
The DCC ID #04.03.108 and DCC Health Care Unit Policy and Procedure P-112 differ in the
requirements for drills. The ID requires drills twice a year on each shift. One of these is to be a
mass casualty drill involving multiple people with injuries. One is to be an emergency response
drill and an actual emergency can be substituted. The Health Care Unit Policy and Procedure P112 requires only one mass casualty drill annually and one emergency response drill on each
shift annually. Actual practice appears to conform to P-112 rather that ID #04.03.108, in that
one mass casualty drill is completed annually. We recommend revising the ID to conform to
actual practice; it has not been updated since 2011. The mass casualty drills for 2016 and 2017
were reviewed and found to be thorough, with good multidisciplinary participation, and candid
critique of strengths and weaknesses. However, no corrective action or plans to improve were
developed as a result of these critiques. An incident report is written each time there is an
emergency response and sometimes these are reviewed and critiqued. The report and critique
are kept in binders available for review. We reviewed all emergency response reports and
critiques in these binders from January 2017 to the present. Critiques are very complimentary
and seldom identify needed improvement. Of the five medical emergencies selected for chart
review, two were critiqued by DCC Health Care; no strengths or weakness in the response to
either were identified. Emergency response is an item regularly on the agenda of the Quality
Improvement Meetings. The minutes of these meetings do not reflect any discussion, analysis
of issues, or plans for improvement in emergency response.
We reviewed the medical records of five patients sent to the ED in 2017 and found that the ED
visit could have been prevented in two of the cases if the patients’ care had been different in
the preceding months. Information and recommendations from the ED were not obtained, or if
they were, not incorporated into the patients’ subsequent treatment plan. These findings are
detailed in the following paragraphs.
•

59

The first patient is also discussed in the hospital section below; his death was possibly
preventable if care in the preceding months had been better.59 This patient had
returned to DCC on 11/19/17 after nearly a month of hospitalization. A physician
described his discharge problems as COPD exacerbation, hypercalcemia, pleural

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effusion, post-chest tube, pneumonia, anemia, renal failure and DVT. However, what
the doctor failed to acknowledge was that the patient had a large retroperitoneal mass,
likely a malignant lymphoma, which was not addressed in the plan of care. The diagnosis
was pending. While much of the hospital record was available, the physician only listed
diagnostic possibilities and was not clear about the plan of care. The treatment plan
consists of monitoring and comfort care only. The inbound note written by a nurse
describes the patient’s condition based upon a visual assessment only. The nurse did not
document a review of the discharge instructions or contact the facility physician for
orders as required by Health Care Unit Policy and Procedure P-104.60
There was no plan of care in place in the nine days immediately before his last
hospitalization on 11/29/2017. In the meantime, nurses documented clear signs that
the patient’s condition was worsening, including bloody stools, diminished lung sounds,
pitting edema of the legs, poor oxygenation, and low blood pressure (98/62). When the
provider was contacted, the nurses were instructed to continue monitoring the patient
and report if his condition worsens.
On 11/27/17, the physician documented an encounter and that the patient needed to
be more compliant; the patient was demanding a change in his diet. Vital signs are
described as stable and that he had better aeration and his lower legs seemed
improved. The provider took no steps to definitively treat the patient and made no
effort to uncover the diagnosis of the retroperitoneal mass. Instead, the doctor
continued monitoring and comfort care. There is no documentation that the patient
agreed to palliative or hospice care. The patient was not seen by a provider the next day
even though he was bleeding from the mouth and had petechia on his trunk and upper
extremities. This should have prompted immediate concern, since the patient was on
anticoagulation. No action was taken until the following day, 11/29/17, when the
provider saw the patient and mused about whether the dose of anticoagulant
medication was correct. Ultimately, he ordered the patient transferred to the local
emergency room. There is an outbound note written by a nurse on the intrasystem
transfer form, but it does not contain all of the information relevant to the patient’s
ongoing care, and there is no specific statement of the reason higher level care was
being sought. The patient was admitted to the hospital from the ED and died 20 days
later.
Problems with the medical care of this patient post-hospitalization include: an
inaccurate problem list (not updated since 1/2017); the nurse did not adequately
examine and document her findings and did not summarize the discharge
recommendations or contact the Medical Director for orders when he returned from
hospitalization on 11/19/17; the physician did not incorporate information obtained
from the hospital discharge records into the patient’s plan of care; the physician did not
see the patient as frequently as required by DCC Health Care Unit Policy and Procedure
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P-11361 or as indicated by his deteriorating condition; and the note written to
accompany his transfer to the emergency room on 11/29/17 did not contain all of the
information relevant to the patient’s ongoing immediate care.
•

The next patient was hospitalized emergently on 5/31/17 because he was having signs
of a stroke including slurred speech, inability to move or grasp with right arm, tongue
deviated to the right side, and delayed thought processing.62 He was 61 years old at the
time. His problem list dated 6/23/16 included dyslipidemia, insulin dependent diabetes,
CVA (2012), gunshot wound to the head, and degenerative disorder of the thoracic
spine.
There is no nursing treatment protocol for stroke; the nursing assessment included vital
signs and blood glucose and the symptoms described above. The provider was
contacted and ordered a transport to the emergency department. No orders were given
to start O2 or an IV while awaiting transport, and there is no documentation of
subsequent assessment of the patient while awaiting transport. No transfer note was
written.
There is no note summarizing recommendations from the hospital after he was
returned to DCC on 6/14/17 with a diagnosis of cerebral vascular accident (CVA). The
provider admitted the patient to the infirmary as an acute patient, ordered regular
medications, and a physical therapy evaluation. No comment was made about discharge
recommendations from the hospital and there was no documentation of the rationale
for not implementing the recommendations.
This patient’s medical care in the months prior to the emergency room visit was
problematic. First, he was transferred from Big Muddy Correctional Center 18 months
earlier because of increasing blood glucose levels. He was received at DCC on 4/14/16.
The receiving nurse noted that he also was followed in the hypertension clinic (HTN is
not on his problem list), he had a diagnosis of sleep apnea and used a CPAP machine.
Sleep apnea is not on the problem list and neither the diagnosis of sleep apnea nor the
need for a CPAP machine are listed on the transfer summary. The CPAP machine was
not in his property when transferred. The problem of sleep apnea was not identified or
treated, and he never received a CPAP machine in the 18 months after being received at
DCC. This may have been a factor contributing to the stroke this patient had in May
2017.
He was seen in chronic care clinic for diabetes in August 2016, December 2016, and May
2017. HbA1C was elevated in December (9.9), so the provider ordered a nighttime dose
of Lantus in addition to Metformin, with follow up in two weeks. The follow-up
appointment did not take place. His HbA1C was still elevated when next seen in clinic on

61
62

Infirmary Care III. 1. A. p. 25.
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5/4/17 (9.5) and 70/30 insulin twice a day was ordered; the Lantus and metformin were
discontinued. Aspirin 81 mg. was also ordered at this visit. Medication for HTN and
dyslipidemia were continued.
This patient was also being treated for wounds on his buttocks from August through
October 2016. A note written by a provider on 8/9/16 indicates that this is related to the
patient’s paralysis, but the extent of his paralysis is never described. Another episode of
skin breakdown on his left hip was being treated in May 2017. Undoubtedly his skin
wounds affected his diabetes and vice versa, and yet this was never considered by
providers who were treating him. This patient’s diabetes was not managed to obtain
good control and changes in the plan of care were slow and inadequate.
•

Another patient was a 61-year-old man seen in the emergency room on 2/11/17 for
chest pain.63 His problem list contains diagnoses of insulin dependent diabetes with
neuropathic pain in his feet, which is inaccurate given that the problems listed on the
outbound transfer summary include hypertension, chronic obstructive pulmonary
disease, asthma, and hepatitis C. The problem list also does not identify that he has a
pacemaker.
The patient was brought to the health care unit. The nurse used the chest pain protocol
to assess the patient, but did not describe precipitating factors or do an EKG. The
provider was contacted and ordered transport to the ED. Oxygen and an IV were started
before transport. A transfer note was written to give to the ED upon arrival. The patient
was admitted and treated for congestive heart failure and thrombocytopenia until
discharge on 2/14/17.
The hospital summary was reviewed by a physician the day after he was released from
the hospital, 2/15/17. He does comment on the discharge recommendations. He put
lisinopril and Aldactone on hold until the nephrologist approved resumption. There was
no note that the nephrologist was contacted to make this decision. The Lisinopril was
never restarted. He also held the patient’s Lasix for four days. This was a KOP
medication and there was no note that the patient was instructed to do this. He also
ordered labs, which were drawn, but the results were never commented on. At the next
chronic care appointment in April 2017, the provider did not comment on the patient’s
hospitalization in February.
While the emergency response was adequate, the fact that the problem list is grossly
out of date makes treatment of the patient a guessing game. Even after the patient
returned from hospitalization, the problem list was not updated to ensure its accuracy.
There were several aspects of care ordered after the patient’s return to DCC that were
not followed up on, including the medications to be held and restarted, consultation
with the nephrologist, and lab results. The failure to comment on the patient’s recent

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hospitalization at the next chronic care visit is emblematic of episodic treatment rather
than managed chronic care.
A 24-year-old man with no history of health problems was treated in the ED for chest
pain on 7/19/17.64 The emergency response was good, including use of the chest pain
protocol and documentation. However, the patient returned from the emergency room
with no treatment records and was not seen by a provider. While this man appears to
be in good condition, he had been seen in January for chest pain and had an abnormal
EKG at the time of the ED visit in July. Knowing what diagnostic and clinical work was
done at the ED is essential for the provider to ensure that clinically appropriate care is
continued after return to the prison. Not only is a provider visit required by the Health
Care Unit Policy and Procedure P-104, it was clinically indicated.65
In summary, we concur with the First Court Expert’s findings that ED reports were often absent
in the medical records reviewed and the care of patients was problematic before the ED visit
and after the patient’s return to SCC. We agree with the First Court Expert’s recommendations
and make additional recommendations found at the end of this report.
We reviewed six patients who were hospitalized to assess for quality of care at the facility
before and after admission to the hospital. We noted that hospital reports were inconsistently
present in the medical record. We agree with the First Court Expert’s recommendation in the
Emergency Services section that after all offsite emergencies, a provider should see the patient
to document a discussion of findings and a discussion of any changes to therapeutic plans. We
found that while physicians generally evaluated patients after hospitalization, discussion of
findings and a change of therapeutic plan were not well documented. We suspect that this was
because providers do not appear to have the hospital report. Lacking the hospital report,
clinicians do not know what occurred at the hospital and often appeared to be unaware of the
status of the patient’s clinical condition. This makes establishment of a therapeutic plan difficult
to develop.
We found in the review of records of persons hospitalized that clinical care preceding
hospitalization was poor and often resulted in a problem deteriorating and needing to be
addressed on an emergency basis. There were preventable hospitalizations, preventable
morbidity, and preventable mortality. These findings on record reviews are summarized below.
•

One example was a patient with severe coronary artery disease that resulted in prior
bypass surgery and multiple cardiac stents.66 The patient also had peripheral artery
disease, hypertension, high blood lipids, and diabetes, which were all risk factors for
coronary artery disease. The patient had no problems documented on the problem list
until March of 2017. The patient saw a provider on 6/29/16. The provider took no

Urgent/Emergent Patient #5.
Continuity of Care During Incarceration II. F and III. A. pp. 6-7.
66 Hospitalization and Specialty Care Patient #4.
64
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history with respect to angina but did note that the patient was to see the cardiologist
soon. The patient saw a cardiologist at UIC on 7/6/16. There was no report. Brief
comments on the referral form noted increased angina over the past two months. The
cardiologist recommended titrating up nitrate medication (Imdur) for angina and noted
that the patient needed “aggressive” medical management.
The patient did not see a physician timely after this appointment. On 7/22/16, a nurse
saw the patient for chest pain and used an “Indigestion/Heartburn” protocol despite the
patient complaining of three months of chest pain, “like getting stabbed in the chest
[after] eating + when walking.” This description is typical of angina. The nurse should
have used a chest pain protocol. The nurse should also have obtained an EKG and
should have immediately referred to a physician. Instead, the nurse noted that the
patient had been on Pepcid and switched to Zantac, both of which are for acid reflux
disease and neither of which were working. The nurse initially referred the patient to a
physician urgently, but this was scratched out and a routine appointment was made.
This was a serious error. This patient had significant angina, but a nurse assumed his
complaint was for acid reflux disease. The patient was not properly referred, which
placed him at significant risk of harm.
On 7/25/16, a nurse again evaluated the patient for chest pain, this time using the chest
pain protocol. The nurse noted pressure-like chest pain and referred the patient to a
doctor. An EKG was done. This EKG did not include an automated reading but showed ST
elevation in lead III consistent with acute ischemia. Dr. Meeks, the Agency Medical
Director, was at DCC on the day we were reviewing this record. He is an emergency
medicine physician. He reviewed the record and agreed that this was an ST elevation
consistent with ischemia. This should have resulted in immediate transfer to a hospital.
Instead, the physician ordered Prilosec, a medication for acid reflux, and a follow up on
8/10/16. This was grossly and flagrantly unacceptable practice that placed the patient at
risk of death.
On 7/28/16, a doctor saw the patient for the five-day follow up from the 7/6/17
cardiologist visit. The doctor noted that the cardiologist recommended increasing the
Imdur, but the doctor took no history and failed to note the evaluation by the nurse four
days earlier for what appeared to be typical angina, and more importantly failed to note
the evaluation three days earlier with the EKG showing acute ischemia with typical
symptoms of angina. The doctor documented referral to cardiology and ophthalmology
but took no other action and did not update the status of the patient’s therapeutic care.
Since referrals to cardiology at UIC take on average 100 days, the patient should
probably have been sent to a local cardiologist.
On 8/1/16, a doctor saw the patient because Zantac was not working for his presumed
gastric reflux disease. The doctor took no history of the patient’s pain and advised the
patient to elevate the head of his bed without realizing that the patient’s symptoms
might be from his angina. The doctor failed to recognize the prior abnormal EKG. The

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therapeutic plan was not evaluated or refreshed. This lack of knowledge about how to
manage angina was significant.
On 9/16/16, the patient had an episode of chest pain walking up stairs which was
relieved by nitroglycerin. The doctor recommended a “medical movement” pass and
increased Prilosec, but did not increase anti-anginal drugs or order cardiac testing (EKG,
stress testing, or cardiac catheterization). The doctor failed to properly treat angina and
may have failed to recognize that the patient’s symptoms were angina. The episode of
care failed to follow generally accepted guidelines or usual practice.
On 10/27/16, a doctor saw the patient and noted that the patient had chest pain, but
the doctor was not sure if the pain was related to “gas” or to angina. The doctor thought
that the patient had lactose intolerance and prescribed a gas relieving medication and
documented that he would “consider” increasing Imdur (the anti-anginal medication) if
there was no improvement. This was a judgment error, in our opinion. Gastroesophageal reflux disease (GERD) is not life-threatening. His angina was life threatening.
The doctor was placing greater significance on a condition that was much less likely to
cause harm. This was incomprehensible practice.
On 11/30/16, a practitioner noted that his chest pain “resolved” since eliminating dairy
and assessed likely lactose intolerance and discussed elimination of lactose from his
diet.
On 3/22/17, an NP saw the patient in chronic care clinic but took no history and noted
that the patient offered no complaints. The NP did not address the chest pain, evaluate
the prior EKG, and did not address the angina. Notably, the patient had peripheral
vascular disease that was not being monitored.
On 3/24/17, a doctor noted that the patient complained of chest pain lying flat that was
relieved by nitroglycerin. The patient also described chest pain when walking
accompanied by calf pain when he walked. This description is consistent with angina
and claudication, a condition of atherosclerosis of leg arteries. Although the patient’s
description of pain was consistent with angina and peripheral artery disease, the doctor
prescribed Tums antacid and increased the dose of reflux medication. There was no
examination of the pulses to assess the peripheral artery disease. The doctor noted that
a cardiology appointment was pending and ordered a three-week follow up. The doctor
did not increase anti-anginal medication. This was not generally accepted practice for
treating angina.
On 4/17/17, an NP saw the patient and documented that the patient was waking up in
the middle of the night with chest pain and difficulty breathing. The NP did not order an
EKG and made an assessment of “chest pain/? GERD,” and advised the patient to take
Tums first when he got this pain, and if the pain was not resolved to take his
nitroglycerin. The NP did not adjust the anti-anginal medication. This patient needed to
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be diagnostically evaluated for ongoing unstable angina, but providers appeared
ignorant of what should be done.
On 4/20/17, a nurse evaluated the patient for chest pain at 1:05 a.m. The patient had
steady pressure in his chest with dyspnea. The nurse called a doctor and the patient was
referred to a hospital where NSTEMI [myocardial infarction] was diagnosed. The patient
had two stents placed.
The care for this patient was grossly and flagrantly unacceptable. The patient had
multiple risk factors for heart disease and had established severe heart disease. A
cardiologist recommended titrating up the anti-anginal medication for angina. Despite
this, the providers at DCC treated his symptoms of angina with antacids on multiple
occasions and never increased anti-anginal medication. On one occasion, the patient
had evidence on EKG of acute coronary syndrome that was not addressed and
unrecognized by a physician reviewing the EKG. The patient should have been referred
much earlier for cardiac diagnostic assessment, including nuclear stress testing and/or
cardiac catheterization, but this was not done until the patient had a heart attack. The
hospitalization and heart attack may have been prevented if earlier diagnostic
evaluation (cardiac catheterization) occurred. This is another case of underutilization,
which will be discussed in the specialty care section.
•

Another patient had HIV infection, high blood cholesterol, and prostate cancer.67 He was
66 years old. On 8/25/16, the patient was evaluated in chronic clinic for high blood
lipids. Although the doctor mentioned the patient’s HIV infection and prostate cancer,
the doctor did not address these conditions. A prior abnormal laboratory result
(abnormal renal function) was not addressed. On 11/22/16, a doctor saw the patient
again for chronic disease clinic. The patient asked the doctor about radiation treatment
for his prostate cancer, but the doctor did not document a response. The kidney
function was still abnormal (creatinine 1.78), but not addressed.
On 5/21/17, a doctor saw the patient for chronic disease clinic, but except for high
blood lipids, none of the patient’s other problems were addressed. The patient reported
right flank pain, but the doctor took no further history of this and ordered no laboratory
tests. We believe that all problems should be address at each chronic disease clinic visit.
Under the current system, many chronic illnesses are never monitored.
On 6/7/17, a doctor saw the patient for abdominal pain with episodes of vomiting since
the night before. The patient had anemia, but this was not addressed. The doctor
admitted the patient to the infirmary for intravenous fluid but ordered no laboratory
testing. Abdominal pain with vomiting warranted laboratory testing and possibly
radiologic testing (CT scan or ultrasound), yet these were not done.

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The patient was evaluated on 6/8/17 by a doctor and still had abdominal pain, but the
physician still ordered no diagnostic work up, instead diagnosing abdominal pain of
unknown etiology, and prescribed Toradol. Prescribing pain medication for abdominal
pain of unknown etiology was a failure to follow accepted standards of care, as the
doctor did not know what the source of the pain was. The doctor should have initiated a
work up of the abdominal pain.
On 6/9/17, a doctor ordered that the patient be given a regular diet the following day
and then be discharged to general population. The following day, the patient
complained to a nurse that he was weak and in a lot of pain. The nurse described the
patient as “looks like he is in pain, squinting, and not moving, breathing slowly.” The
nurse documented that she would talk to the doctor about not discharging the patient.
The patient was nevertheless discharged.
On 6/14/17, a doctor saw the patient, who had constant abdominal pain, weakness, and
diarrhea. The patient had lost 11 pounds over approximately three months. The
abdomen was tender, and the doctor noted an enlarged liver. The doctor admitted the
patient to the infirmary and ordered laboratory tests but no diagnostic radiologic
studies (ultrasound or CT scan). The patient exhibited dehydration (BUN 26), abnormal
kidney function (creatinine 1.75), possible malnutrition (albumin 2.5), and altered liver
function (AST 385 and ALT 368). Despite these significantly abnormal blood tests, no
diagnostic radiologic testing was ordered. The patient should have had a CT scan or
ultrasound of the abdomen on an immediate basis.
There was no infirmary note on 6/15/17, but the patient was sent offsite for an
ultrasound. The patient should have been sent to an emergency room for this study.
Instead, it was ordered as a consultation. The patient returned to the prison after the
ultrasound, and on 6/16/17, the ultrasound report was unavailable. The doctor noted
abdominal pain of unknown etiology and made no other effort to diagnose the patient’s
condition. This placed the patient at significant risk of harm. There were no physician
notes on the infirmary from 6/16/17 through 6/21/17, even though the patient had an
acute illness.
The ultrasound report, dated 6/15/17, appeared to have been faxed to the facility on
6/19/17. The report documented a perforated viscus with fluid around the dome of the
liver. Cirrhosis was also present. These are life threatening findings, yet no one reviewed
the report for two more days, when an NP noted the findings and described the patient
as having severe abdominal pain with nausea. The patient was sent to a hospital, where
he remained after surgery for a perforated viscus. Care for this patient was grossly and
flagrantly unacceptable and placed him at risk of death. Earlier diagnostic intervention
was indicated. Serious, potentially life-threatening symptoms were treated as a routine.
There was a lack of physician follow up. Notably this was during a time when there was
no physician on staff at the facility.

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•

Another patient had an annual physical examination on 2/15/16 and weighed 345 lbs.68
The patient had anemia for over four years without a work up, which fails to follow
generally accepted guidelines. This patient had high blood lipids, COPD/asthma, prior
hip replacements, and GERD. In February of 2016, the patient was found to have
carcinoma in situ of a rectal condyloma, a wart like condition. The patient had seven
colorectal follow-up visits and one dermatology visit for his rectal lesion. Only two of the
seven visits included a report, so the therapeutic plan was unclear. At a dermatology
visit on 1/11/17, biopsies were done and follow up was requested pending biopsy
results, but the biopsy results were never obtained or followed up by DCC physicians. It
was not clear what the patient’s clinical status was, as the doctors at DCC failed to
review reports. On 1/18/17, a liver biopsy, EGD, and colonoscopy were approved in
collegial review. It was not clear why these tests were recommended, as there was no
progress note documenting the rationale. The consultation reports were almost all
missing and the status of the patient was unclear. The patient refused a 4/5/17
colorectal appointment, but it was not clear why. The patient was not seen after this for
over five months. The biopsies taken by dermatology on 1/11/17 were never checked
on. The liver biopsy, EGD, and colonoscopy were never approved or completed. A
physician never followed up with the patient about his rectal squamous cell cancer or on
the failed appointment back to colorectal service.
On 7/11/17, blood tests done for unclear reasons showed persistent anemia and
elevated alkaline phosphatase, a liver enzyme, but these were never followed up by a
physician at the facility.
On 9/8/17, the patient developed difficulty breathing and was unable to get up off a
chair. An NP admitted the patient to the infirmary and ordered tapering prednisone,
antibiotics, a chest x-ray, CBC, and CMP.
A doctor covering at the facility discharged the patient from the infirmary on 9/11/17.
The doctor documented reviewing the x-ray, which he perceived as normal. The x-ray
report actually showed an elevated left diaphragm and left pleural effusion with left
lower lobe atelectasis abnormalities that should have resulted in immediate physician
examination and further radiological diagnostic studies (CT scan). The elevated
diaphragm suggested something was pushing up on the diaphragm and this needed to
be diagnostically resolved, but was not.
The radiologist x-ray report was not reviewed until 9/13/17. The doctor reviewing the
report did not examine the patient, but documented that the patient was doing well
and planned to repeat the x-ray in three weeks. This was unacceptable. The patient
should have been examined and a CT scan should have been done promptly.

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The chest x-ray was repeated on 9/20/17 and showed a density in the left base, a
possible combination of pleural effusion and infiltrate. A doctor again did not examine
the patient, but wrote a note that he would schedule the patient and would consider
repeating the x-ray. This was grossly and flagrantly unacceptable. The patient had an
abnormal x-ray indicating a serious infection or other serious disease and to not
examine the patient is unacceptable practice.
By 10/5/17, the patient told a nurse that he had not been able to walk for six weeks. The
patient had come to the infirmary in a wheelchair from general population to take a
shower. The patient was dizzy and was not able to independently transfer. The nurse
noticed that he was wheezing. The nurse referred to a doctor for possible infirmary
placement. The patient should have been evaluated promptly, yet was not seen for
three days. This patient’s serious medical condition was being neglected.
On 10/10/17, a doctor noted the prior abnormal chest x-ray and expiratory wheezing,
and assessed COPD; a chest x-ray, prednisone, nebulizer treatment, and oxygen were
ordered. No laboratory tests were ordered. The patient was ordered to the infirmary
but was not admitted to the infirmary until 10/14/17, four days later. On admission to
the infirmary the patient weighed 300 lbs. The patient had a 45-pound weight loss over
20 months, which was unrecognized. This is either a serious systemic deficiency or
indifferent medical care or both. The infirmary admission note failed to acknowledge
the abnormal chest x-ray or develop a plan for that. The doctor noted that the patient
had COPD and a self-care problem. No other history was taken. The prior history of
squamous cell carcinoma of the rectum was not recognized. The doctor ordered no
diagnostic studies; a CT scan was indicated. No laboratory tests were ordered but should
have been done. The patient should have been admitted to a hospital, but no diagnostic
studies were done. Care was grossly and flagrantly unacceptable.
Even though the patient was admitted to the infirmary for COPD, the patient was not
seen regularly. After the 10/14/17 infirmary admission note, a doctor did not see the
patient until 10/27/17, almost two weeks later. The patient was not eating or drinking,
and the doctor documented abdominal pain, decreased appetite, and that the patient
appeared dehydrated. The patient should have been admitted to a hospital. Instead, the
doctor documented that he would consider permanent placement and ordered a CBC
and CMP. The failure to recognize acute and serious problems was grossly and flagrantly
unacceptable medical practice.
The blood work reported 10/27/17 showed significant dehydration (BUN 69), renal
failure (creatinine 2.46), a life-threatening serum calcium (16), and anemia (hemoglobin
11.9). These life-threatening laboratory results were not reviewed for three days, when
the doctor next saw the patient. This was grossly and flagrantly unacceptable practice.
The patient was sent to a hospital.

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The patient was discharged from the hospital almost a month later, on 11/19/17. He
had been diagnosed with hypercalcemia, pleural effusion requiring a chest tube,
pneumonia, anemia, renal failure, bilateral deep vein thromboses, and an undiagnosed
retroperitoneal mass thought to be lymphoma. His last two weeks at DCC are described
above in the Urgent Care patient #1 record review. The patient died after a second
hospitalization about a month later.
A coroner’s report listed multi-organ failure and sepsis as the causes of death, but noted
that the patient had lymphoma which had not been previously diagnosed. Remarkably,
the autopsy documented that the retroperitoneum was “unremarkable” and the
regional lymph nodes were “unremarkable,” yet during hospitalization at UIC, a CT scan
showed a large retroperitoneal mass and multiple lymph nodes. The coroner did
document that the patient had lymphoma, and it was not clear if the coroner had the
lymph node biopsy result, which the facility never obtained.
This patient’s death was possibly preventable. Follow up of the patient’s rectal cancer
was poor and the patient was lost to follow up. A biopsy in January of 2017 was never
followed up. Liver biopsy, EGD, and colonoscopy approved in collegial review in January
of 2017 were never done. The patient had anemia that was not worked up for four
years. Once the patient developed a pleural effusion in September, he was
incompetently managed for almost two months, at which time his disease was so
advanced that he could not be treated. Earlier diagnosis and treatment may have
prevented his death.

Specialty Consultations
Methodology: Review specialty tracking logs. Interview the scheduling clerk. Perform record
reviews of persons who have had specialty consultation.
First Court Expert Findings
The First Court Expert found lengthy delays in obtaining an appointment at UIC. The date of the
order for consultation and the date of the appointment are not included on the DCC offsite
tracking log. This made it very inefficient to track the timeliness of the appointment based on
the order. On occasion, appointments are delayed so long that new referrals have to be made.
The First Court Expert’s opinion was that if a system wants to efficiently track whether offsite
specialty consultations are timely, they must track the date of order, date of authorization, date
of appointment, and date of primary care follow up for discussion of the consultation with the
patient.
The First Court Expert recommended that delays in scheduled offsite appointments must be
eliminated. He recommended that DCC obtain authorization from the UIC scheduling
coordinator within seven days after approval of the consultation. When UIC cannot provide the
service within 30 days, a local service needs to be used. He also recommended that
immediately after the patient returns from the offsite service, a nurse review the paperwork
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reports related to the consultation and, if unavailable, take steps to obtain these reports. After
paperwork is obtained, a primary care appointment needs to be scheduled so the primary care
clinician can review the report and discuss findings and recommendations with the patient. This
discussion needs to be documented in the medical record.
Current Findings
The findings of the First Court Expert were confirmed by our review as still in existence. We
agree with the First Court Expert’s recommendations. We confirmed the First Court Expert’s
findings and identified additional problems as listed below.
• The scheduling log is not standardized from facility to facility and does not appear to be
used to monitor timeliness of offsite consultations.
• At DCC, 22% of consultations on the scheduling log do not have a referral date. The
collegial review appears to be the milestone used to establish the onset of a referral for
care.
• Milestones, especially the referral and collegial review, are not consistently
memorialized in the medical record.
• The five-day “writ return” visit occurs without a consultation report. Providers do not
typically update the clinical status of the patient. The only information conveyed on the
five-day writ return provider note is to document the recommendations of the
consultant, if they are known. The diagnoses of the consultant are not included on the
problem list or followed as part of the chronic illness program, and are not consistently
documented as part of the five-day writ return review. In this respect, the provider is
merely acting as a second scheduling clerk and not as a medical provider following the
clinical status of the patient.
• Care before and after consultations was poor and resulted in preventable adverse
events.
• There remain significant delays in getting patients scheduled at UIC. Yet even though
delays are significant, alternate sources of consultation are not used. This results in
delays of care that can be harmful.
Studying scheduled offsite events has been difficult at all IDOC facilities.69 The referral process
at DCC requires the doctor to write a referral on a form that is received by the scheduling clerk
and discussed at the next collegial review.70 The scheduling clerk transmits this information to
the corporate UM doctors. After the collegial review, referrals that have been approved and are
for local services are promptly scheduled. Referrals that are to go to UIC are placed in folders
69 At NRC, we never received the scheduling tracking log we requested, even though the document we requested is apparently
used by the scheduling clerk. We were not able to talk to her until after the visit. At SCC, we did not receive the scheduling
tracking log we requested until after the visit. Before the visit, we received a tracking log nonresponsive to our request. At DCC,
we received a tracking log, but it did not contain information for a year as we had asked and was again nonresponsive to our
request. We asked again for this information after the visit. We were then told that prior to August 2017, a tracking log for
specialty care was not being used, which we verified as accurate.
70 A collegial review is a Wexford utilization management process. Doctors from each correctional facility have a conference call
with a Wexford corporate physician and every consultation referral is discussed. During this process, the Wexford corporate
utilization physician either approves or denies the consultation request. These conference call meetings ostensibly occur
weekly.

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for the corresponding specialty service. The scheduling clerk has 21 folders for UIC referrals.
The specialty services with the largest volume include cardiology, neurology, ophthalmology,
orthopedic surgery, urology, rheumatology, and radiology. On the day of our visit there were 75
requests for service that had not yet received an appointment.
The scheduling clerk faxes the requests to a UIC scheduler, who arranges for appointments. The
UIC scheduler permits 10 scheduled appointments a week. This amounts to 520 appointments a
year. The arrangement with UIC is that IDOC is allowed 2160 outpatient visits a year at no cost.
IDOC facilities allowed to participate in this arrangement include Stateville, Pontiac, Sheridan,
and DCC. The 520 permitted visits a year at DCC approximates the average number of allowable
visits for each of these four facilities (2160 divided by four). It appears therefore that
consultation timeliness is predicated on the availability of free care and not on the need of the
patient. By contract, Wexford is responsible for the cost of offsite medical care and should they
choose to have the patient seen elsewhere, they would be responsible for the cost.71 We were
told that approximately 90% of offsite medical care goes to UIC, which is 100 miles away, as
opposed to the 3-15 miles for local hospital providers. By design, IDOC has placed the geriatric
unit with many of the sickest patients at DCC. Yet, it has dramatically reduced access of this
population to specialty services. This has caused predictable morbidity and mortality.72
A quality improvement study in April 2017 showed that appointments were delayed for many
services. The average time to see a consultant was as follows:
• 239 days for gastroenterology
• 225 days for rheumatology
• 187 days for urology
• 179 days for neurology
• 175 days for orthopedic surgery
• 172 days for radiology
• 147 days for oncology
• 137 days for pain clinic
• 134 days for endocrinology
• 133 days for infectious disease
• 100 days for cardiology
The criteria used by IDOC in this study was that urgent consults were to occur in a week and
non-urgent consults were to occur within eight weeks based on the Wexford-IDOC contract.
None of these averages meet contract requirements and probably most patients require an
earlier appointment. These data show that the specialty care to UIC is significantly delayed and
thereby fails to protect patients from harm.
71 Exhibit 1, Schedule E, page 1 Non-Hospital Services states that Wexford is responsible for all professional services that are
NOT in a hospital setting. Contract between State of Illinois, Department of Healthcare and Family Services and Wexford Health
Services dated 5/6/11.
72
We note in the mortality review section that there were six death records from DCC reviewed and all six were preventable.
Many were related to lack of access to timely specialty care or other higher level services.

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We were told by the Wexford attorney that prior to August 2017 there was no scheduling log at
DCC. It appears that the scheduling log is a convenience log for the scheduler to coordinate
scheduling with offsite consultants. It is not used as a log to determine if patients receive timely
care. The only consistent item tracked on the offsite log is the collegial review date. It is present
on all entries. Referral dates appear to be less important events. 172 of 785 (22%)
appointments in the specialty tracking log do not have a referral date. It therefore appears that
the key variable in a referral is when the referral is approved, not when it is referred.
The First Court Expert found that appointments to UIC are not consistently timely and that
these appointments are not tracked. We found that 142 (18%) of referrals on the log (excluding
refusals and denied referrals) do not have an appointment date and are therefore pending. Of
142 pending referrals, 32 (23%) have been waiting longer than three months. Of the 32
appointments pending longer than three months, seven (22%) do not have a referral date, so
the length of time from referral to appointment cannot be tracked.
According to the HCUA, for a period of time when there was no physician at the site, collegial
reviews were not done. The HCUA discovered piles of requests for offsite referrals, apparently
from mid-level providers, that were not being evaluated in collegial review. The HCUA started
demanding that selected referrals be immediately scheduled based on her clinical sense of the
need and the scheduling clerk began scheduling patients at the direction of the HCUA.
With respect to documentation of specialty care which is required by IDOC Administrative
Directives, we could not find evidence in progress notes of consistent documentation of
referrals or collegial reviews. We could also not find evidence that doctors seeing the patients
after consultation understood what had occurred at the consultation. This resulted in
fragmented care, lack of continuity of care, and in some instances, preventable adverse events.
Due to lack of funds, the number of transportation vans has been reduced over the years. In the
past, the facility had as many as 42 cars for transportation and this has been reduced to 13.
There is one functioning wheelchair van for use for the disabled. This van is borrowed by other
facilities regularly, including from Illinois River, Stateville, Hill, and Sheridan. It was not possible
to verify whether the lack of adequate transportation vehicles is a barrier to timely attendance
for offsite consultation care, but it should be studied. Many patients, including those with
significant disabilities, complained as documented in medical records about a black box. One
inmate was injured when being transported while in a black box. The inmate did not appear to
be secured with a seat belt. We were unable to review this during our visit and noticed this
episode of injury on a chart review. But transportation for appointments should be evaluated
by IDOC to ensure patient safety.
We confirmed the First Court Expert’s finding that consultant reports were frequently
unavailable. This had an adverse effect on patient care.
We reviewed four records that verified our findings and demonstrated poor clinical care. A
summary of these is provided below.

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•

One patient had acute myeloid leukemia and was receiving chemotherapy and oncology
care at UIC.73 The patient went to chemotherapy five times from 2/27/17 to 3/28/17.
There were no reports from UIC. For the five oncology visits there was only one five-day
post writ follow up by a provider. That note did not document the problems of the
patient or include a therapeutic plan update. The patient was apparently losing weight,
but it was not being documented. On 3/9/17, the patient had a potassium of 6, which is
a critical value, yet it was unnoticed at the facility. This level of potassium requires
immediate attention, especially in someone with kidney disease, which this patient had.
About a week after this critical value, UIC called about a treatment for elevated
potassium noticed on one of their labs, but the nurse appeared to transcribe their
directions inaccurately. The nurse documented that UIC recommended lactulose for an
elevated potassium, which is not recommended therapy.
Doctors at DCC failed to document all of the patient’s problems in their notes and failed
to document a therapeutic plan for the patient throughout the course of care we
reviewed. The therapeutic plan of the oncologist was only known in its general terms
and the only communication with the oncologist was by way of very brief
recommendations on the referral form. The DCC physicians were not following
laboratory values during chemotherapy, even though chemotherapy can cause
significant deterioration of blood counts. About a week after a series of chemotherapy
sessions, a DCC doctor saw the patient, but did not monitor laboratory values, did not
document knowledge of the therapeutic plan, and did not document all problems. The
patient was documented as having no complaints. The following day, the patient was
emergently hospitalized for multi-lobe pneumonia with a critically low neutropenia
(0.5), low platelets (9), and hypotension. The low white blood count was likely due to
chemotherapy, and this was unrecognized and unmonitored by providers at DCC. This
patient was basically unmonitored throughout this series of specialty consults, which
placed him at risk of significant harm and may have resulted in a preventable
hospitalization.

•

Another example was a 48-year-old man who was transferred to DCC in February of
2015 with a diagnosis of metastatic colon cancer.74 The thinned chart volume we
reviewed was labeled volume three of three volumes, but we actually discovered that
there were six volumes of medical records for this individual.75 When the patient
transferred to DCC, he was being followed by oncology and was on chemotherapy. The
patient was to be scheduled for chemotherapy at the infusion center and also with the
oncologist for clinic follow-up visits. We started review of this patient for a 1/3/17
chemotherapy visit. The patient was scheduled for nine chemotherapy visits, which
appeared to occur timely. Only three of the nine visits included a report. There were
recommendations for oncology clinic follow up on two occasions, but we could not

Hospitalization and Specialty Care Patient #3.
Hospitalization and Specialty Care Patient #1.
75
This is yet another example of why an electronic medical record is necessary.
73
74

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verify that these occurred. A recommended CT scan was done a month late and there
was no report of the CT scan in the record. A recommended Doppler test was done two
months late and there was no report of this test in the medical record. The five-day
post-consultation physician visits seldom occurred. Moreover, it was not possible
reviewing the progress notes of the DCC medical staff to understand the progress,
status, or problems of the patient. The chemotherapeutic agents being used were not
identified. A complication of chemotherapy (hand foot syndrome and response or nonresponse to chemotherapy) was not documented as known to DCC physicians and was
not being monitored. It appeared that the scheduling clerk was managing this patient’s
care. This care was indifferent.

76
77

•

Another patient had Crohn’s disease, an inflammatory bowel disease.76 The patient
transferred to DCC from SCC. He was being followed at UIC for infusions of vedolizumab,
a monoclonal antibody medication that is used as an alternative to tissue necrosis factor
medication for moderate to severe Crohn’s disease. On 1/31/17, while at SCC, the
patient weighed 235 lbs. Crohn’s disease is an intestinal disorder characterized by
inflammation of the colon or small intestines causing pain, diarrhea, bloody stool, and
weight loss. Between 2/8/17 and 4/24/17, the patient was treated with vedolizumab
three times in the infusion clinic at UIC. Reports were not available for these visits.
Doctors saw the patient after each of these visits, but we could not verify that a report
was returned or was reviewed. The doctors did not take a history after these visits or
note the status of the patient. The doctors would merely reschedule infusion therapy
without monitoring the progress of the patient. At a five-day post-consultation visit on
3/28/17, a doctor documented that the patient complained of weight loss, but the
doctor took no history, failed to verify the amount of weight loss, and merely stated,
“doing well per GI and pt.” This was despite the patient complaining of weight loss. On a
nurse visit on 4/24/17, a nurse documented that the patient had abdominal discomfort.
The patient weighed 190 lbs., which was a 45-pound weight loss since transferring from
SCC on 2/2/17. This weight loss was unrecognized. The patient’s disease was not being
monitored. Reports from UIC were unavailable. UIC and DCC were not coordinating
care. The patient may have been deteriorating and was apparently losing weight
without being monitored. The DCC providers were indifferent to this patient’s serious
medical condition.

•

Another patient had severe mental illness and hypertension.77 He had persistent
hyponatremia (low serum sodium) for more than three years, probably due to his
psychotropic medication or mental illness, yet this was not documented as a problem
and not documented as being monitored by medical staff. The patient had an inguinal
hernia that progressively enlarged and was not treated for two and a half years, when it
had enlarged into the scrotum. This patient also developed a pressure ulcer on his left
hip on 6/14/17, which continues to affect the patient as of 4/4/18. The only staging of

Hospitalization and Specialty Care Patient #5.
Hospitalization and Specialty Care Patient #6.

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the wound was on 7/26/17, when an NP diagnosed a stage II ulcer. An NP documented
ordering DuoDERM on 7/26/17. When we asked the current physician at the site about
this wound, he replied that the patient picks at the wound and is mentally ill. Neither of
these explanations is documented in the medical record as an etiology of the
persistence of the wound. The patient has had this wound for over eight months and
should have evaluation for a chronic non-healing ulcer, which includes evaluation for
osteomyelitis. Wound care was not well documented. This type of wound can result in
systemic infection and should be managed more carefully. On 7/31/17, without
explanation, the patient became disoriented, drinking shampoo, and vomiting. He was
initially placed on mental health crisis watch but subsequently became disoriented and
was talking to himself. He was referred to mental health and was then sent to a hospital.
There were no medical notes prior to his transfer to the hospital.
Upon return to DCC, there were only limited notes from the hospital and no hospital
discharge summary. The patient had four of four blood cultures in the hospital growing
gram positive bacteria and the patient had rhabdomyolysis (breakdown of muscle) and
bilateral hydronephrosis (enlarged kidneys typically from inability to drain urine). How
this patient developed such a serious systemic infection at DCC is unknown because of
the paucity of medical evaluations prior to hospitalization. It may very well have been
due to his pressure ulcer. His care appeared neglectful. The patient was discharged from
the hospital on 8/8/17. The DCC doctor noted that the patient had bilateral
hydronephrosis and needed an ultrasound. The DCC doctor also noted that an infectious
disease doctor requested weekly CBC and CMP with an infectious disease follow up in
four weeks. The patient had a Foley catheter. The doctor at DCC did not document the
diagnosis or the reason for the blood infection or the reason for the Foley catheter.
Blood cultures were ordered for 10/1/17 and 10/2/17, after completion of antibiotics.
An ultrasound was completed on 8/25/17, but the report was not obtained. The patient
saw the infectious disease doctor on 9/8/17, but there was no report. The patient still
had the Foley catheter and the infectious disease doctor recommended consulting the
urologist about discontinuing the catheter. A doctor discontinued the Foley catheter
without consultation with an urologist. An urologist saw the patient on 10/2/17. There
was no report. The referral form had brief comments by the urologist recommending
urine culture, ultrasound of the kidneys, continuing Flomax, and return in two to four
weeks. When the intravenous antibiotics were completed the patient was sent to
general population. An ultrasound was completed on 10/18/17, and showed bilateral
hydronephrosis with distended urinary bladder, and large post void residual. This
condition can cause permanent kidney damage if untreated. On 10/19/17, the patient
was referred to urology. This referral was approved on 12/12/17 and approved again on
2/1/18. As of 4/4/18, the patient had still not seen a urologist. Uncorrected
hydronephrosis can result in end-stage renal disease. This patient has been waiting over
six months for a follow-up urology visit. We note that the average wait to see urology is
187 days. This person needed a more timely consultation, as he may sustain permanent
kidney damage. The lack of reports was significant and made it impossible to

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understand the status of the patient. It appeared that the lack of reports also made it
difficult for DCC providers to understand how to manage this patient.

Infirmary Care
Methodology: The clinic space and equipment in the infirmary was inspected, nursing staff
were questioned, clinical charts audited, nurse logs reviewed, porters questioned, and patientinmates interviewed. There was only limited contact with the infirmary physician.
First Court Expert Findings
The First Court Expert noted that infirmary LPNs were working outside the scope of practice,
patients were not seen by the provider at the minimum required intervals, an RN was not
assigned to the infirmary on all shifts, the provider charting was limited in format and content,
call buttons were not available in all rooms, there was insufficient equipment in the infirmary,
and there were defective and/or insufficient sheets and pillows.
Current Findings
With the exception of the finding that LPNs were working outside of their scope of practice, we
agree with the findings of the First Court Expert’s findings and we identified the following
additional findings:
• Fifty percent of the patient-inmates housed in the infirmary were classified as requiring
total or partial care with their activities of daily living.
• One long-term patient had developed contractures of all his limbs and stage 4 decubitus
ulcers while housed in the infirmary.
• At least half of the infirmary patient population requires skilled nursing care; however,
the infirmary is neither staffed nor equipped to provide this level of care.
• Physical therapy services are not provided in the infirmary.
• Provider admission and progress notes were brief and contained limited clinical
information or rationale for treatment plans.
• Provider admission and progress notes did not meet the frequency and timeliness
standards established by the IDOC.
• Admission RN notes are written in accord with the established timelines. Nurse notes
are written daily and provide useful information on the clinical status of a patient.
• The quality of provider notes was inconsistent and failed to reflect key components of
the patients’ histories, physical findings, and the treatment plan.
• In spite of the high level of physical and mental impairment of the patients housed on
the infirmary, there were no electric beds in the infirmary. This is a barrier to the
delivery of needed care and put the staff at risk for injuries.
The infirmary is located on the second floor of the medical building across from the ADA
housing unit. The infirmary has 28 beds; the census was 18 on the day of the inspection. The
physical plant and layout is unchanged since the First Court Expert’s report. Nurses reported
that the provider is expected to write progress notes within 48 hours of admission and three

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times a week for “acute” admissions, twice a week for “chronic” patients, and once a week for
“permanent” patients. The provider concurred that acute admissions are to have thrice weekly
notes, but chronic and permanent patients were only required to have weekly progress notes.
IDOC Policy 04.03.120 Offender Infirmary Services78 directed providers to write admission notes
with 48 hours and progress notes no less than three times a week for acute patients and once a
week for chronic patients. Review of five infirmary records verified that four of five provider
admission notes were written within 48 hours or on the next working day. One record of an
“acute” did not yet have a provider admission note or a progress note as of the sixth day of
admission. The frequency of the provider progress notes for these five patients were: no note
to date as of day six of stay,79 one progress note five days after admission and then none for the
next two weeks,80 six progress notes in 21 days,81 one note in 20 days,82 and one note in nine
days.83 The timeliness of the progress notes was not found to be fully in compliance with this
policy; four of the five infirmary records did not comply with this established policy. Nursing
notes were consistently entered no less than daily and commonly on every shift.
It was reported that an RN is assigned to the infirmary on all shifts seven days a week. LPNs and
CNAs provide added staffing in the infirmary. A number of inmate hospice workers supervised
by the nursing staff assist with a variety of tasks.
Nine of the individuals in the infirmary were designated as requiring assistance with activities of
daily living (seven partial assistance, two with total care); thus 50% of the infirmary patient
population were unable to fully care for themselves. Included in this non-independent group
were individuals with metastatic cancer, dementia with contracted limbs, post CVA, advanced
multiple sclerosis, and dementia. The RN on duty stated that all nine would be permanently
housed in a skilled nursing facility if they were not incarcerated.
We note that the IDOC acknowledges a lack of appropriate housing for the infirm and disabled
elderly prisoners. In her deposition, the IDOC Agency Medical Coordinator84 answered
questions on this issue.
“Q. What were you proposing in this e-mail of August 2nd, 2016?
A. For them to consider an assisted living environment at Kewanee or in another facility
or changes to a current facility.
Q. And in this you say that you’re writing to bring attention to the effect our aging
population has on the facility infirmaries, right?
A. Correct.

Reference Offender Infirmary Services.
Infirmary Patient #1.
80 Infirmary Patient #2.
81 Infirmary Patient #4.
82 Infirmary Patient #3.
83 Infirmary Patient #5.
84 This nursing position reports to the Agency Medical Director and supervises the Regional Nurse Coordinators.
78
79

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Q. And we are having problems placing offenders due to our infirmaries being full and
this is only going to continue to get worse as the baby boomer population ages,
right?
A. That’s what I wrote, yes.
Q. Do you know if anything has come of this suggestion?
A. I do not know.
Q. Getting tired of having to figure out where to put aging and elderly prisoners?
A. I want to appropriately place them for care, for appropriate care, and meet the
operational needs of our department.”85
Although approximately half of the infirmary rooms had nurse call buttons, many of the
patients were unable to utilize them due to their advanced mental and physical conditions.
Only the restraint/negative pressure room has direct line of sight from the glass window in the
nurse station.
We identified a number of concerns and deficiencies in the care provided to infirmary patients
as noted below.
• This patient was admitted to the DCC infirmary on 3/30/18 upon transfer from Schwab
Rehabilitation Center in Chicago.86 The nurse admission note written on Thursday
morning/early afternoon of 3/30/18 listed the diagnoses as neurogenic bladder, seizure
disorder, and low back pain, and noted that the patient used a seizure helmet, wore a
diaper due to urinary incontinence, was confused and disoriented, and walked with a
cane. The admission nursing note failed to note that the patient had advanced multiple
sclerosis. The patient was assigned to the “Acute” status. Nursing notes were written on
every shift. As of 4/3/18, five days after admission, there was not a provider admission
note or a progress note in the infirmary record. Five days after infirmary admission, this
patient had not been seen by a provider. This is not in accord with IDOC policy.87 One of
the other DCC providers should have been scheduled to cover infirmary admissions
during the vacation of the assigned provider.
•

The next patient is a 35-year-old patient who was admitted to the infirmary on 11/22/17
with abdominal pain and weight loss.88 Prior to admission to the infirmary he had been
in nurse sick call on 10/25/17 for abdominal pain and constipation, and his weight was
165 lbs. He was seen again in five nurse sick calls in October and November 2017 for
similar symptoms. His abdominal pain worsened with meals, he had nausea and
vomiting, and was provided a variety of over the counter medications. On 11/8/17, his
weight had dropped to 154 lbs.
On 11/22/17, nursing referred him to the NP because of knife-like abdominal pain for
two weeks and a pulse of 120. The NP noted that the patient’s weight was 144, a drop

Deposition of Kim Hugo, April 11, 2018 pp. 69-70.
Infirmary Patient #1.
87 Reference #IDOC Policy 04.03.120 Offender Infirmary Services.
88 Infirmary Patient #2.
85
86

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of 21 pounds within one month. The NP admitted him to the infirmary for observation
and a battery of stat tests (CBC, CMP, amylase, lipase, thyroid studies). The lab results
showed urine ketones, mildly elevated total bilirubin (1.5), and mild electrolyte
abnormalities. The infirmary nurse spoke with the physician, who advised continuation
of the current management. On the same day, the patient voiced having pain
near/behind his umbilicus. For the next few days he continued to have abdominal pain
with poor appetite, and the hard marble sized spot above his umbilicus continued to
cause pain. On 11/27 and 11/28/17, the physician examined the patient and felt that he
had a non-reducible umbilical hernia. The physician sent the patient to the KSB
Emergency Room on 11/28/17. An abdominal CT Scan at KSB showed no evidence of a
hernia but showed terminal ileum inflammation. KSB recommended follow-up with a
surgeon for a possible inflamed umbilical stump due to inflammatory bowel disease. At
the patient’s request he was discharged on 11/29/17 from the infirmary, and referrals
for gastroenterology and general surgery consultations were submitted. Only an
admission weight had been recorded during his eight day stay in the infirmary. No order
was placed to repeat the abnormal comprehensive metabolic panel (total bilirubin) or to
schedule an EGD and a colonoscopy.
The patient was seen by the NP 12/24/17 and had a weight of 141 lbs. Nurses saw the
patient in nurse sick call on 12/24/17, 1/4/18, 1/8/18, 1/9/18 (141 lbs.) for abdominal
pain. An NP saw the patient again on 1/12/18 for abdominal pain and a mass of
unknown origin near the umbilicus. Nurses saw the patient again at nurse sick call on
1/14/18, 1/16/18 (130 lbs.), and 1/18/18 (130 lbs.) for abdomen pain and tenderness,
left testes pain, and abdominal bloating. On 1/23/18 (123.7 lbs.), a nurse noted that the
patient was jaundiced/icteric, and his abdomen was tender to the touch. On 1/25/18,
the patient was sent to Town Square General Surgery for the consultation requested on
11/29/17. The patient returned with a diagnosis of significant jaundice. Stat labs drawn
at the surgeon’s office showed elevated total bilirubin of 14.9, alkaline phosphatase
509, ALT 327, and AST 136 with normal amylase and lipase levels.
On 1/26/18, the patient as transported to the UIC ED and admitted to the hospital. His
3/7/18 UIC discharge summary noted the diagnosis of mucinous producing
adenocarcinoma/cholangiocarcinoma, biliary stents insertion, and s/p excision of an
umbilical nodule. The patient was readmitted from the infirmary to UIC on 3/13/18 for
weight loss and malnutrition. He was started on Gemcitabine chemotherapy and
returned to DCC on 3/16/18 with the diagnosis of Metastatic Cholangiocarcinoma.
The patient was readmitted to the DCC infirmary on 3/16/18. The patient was
transported to receive chemotherapy infusion at UIC on 3/20/18 and 3/27/18, and went
to an oncology appointment on 3/24/18. Nursing notes were written on nearly every
shift from 3/19/18 to 4/2/18. The patient’s condition is determined to be terminal and
chemotherapy is palliative. The patient’s weight has decreased from 111 lbs. on 3/21/18
to 104 lbs. on 3/28/18.

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Although the patient had multiple encounters with the DCC health care team between
10/25/17 and 1/25/18, including one admission to the infirmary and a referral to KSB
emergency, they missed opportunities to more expeditiously and thoroughly evaluate
this patient’s symptoms and condition.
Following a month of unexplained abdominal pain, when the patient was noted on
11/22/17 to have lost 21 pounds and laboratory tests and a CT scan at KSB failed to
identify a cause, he should have been admitted for additional diagnostic workup. EGD,
colonoscopy and contrast CT were indicated. The general surgery consultation
requested on 11/29/17 was not scheduled until 1/25/18, at which time the patient was
already overtly jaundiced. This two-month delay for a surgical consultation in a
continuously symptomatic patient was unacceptable. Although the total bilirubin
performed on 11/22/17 was only mildly elevated, the comprehensive metabolic panel
should have been repeated after his infirmary discharge on 11/29/17, especially since
the patient continued to have abdominal pain and lost another 20 pounds over the next
two months. All of these missed administrative and clinical opportunities to intervene
and appropriately manage this patient’s care resulted in avoidable delays that have
negatively impacted on his care and his health.
•

The next patient is an elderly patient with long standing dementia, history of pica,89
hypertension, upper and lower extremity contractures, and deep decubiti ulcers.90 He
was thought to have Picks Disease (frontotemporal dementia). He has been housed in
the infirmary for a number of years. The infirmary record reveals daily vital signs and
nursing notes. He requires total care (feeding via gastric tube, bathing, diapers). His
limbs are fully contracted, he remains in a fixed fetal position. He was observed being
transferred to a tub by the CNA and a hospice worker. He has chronic decubitus ulcers
(pressure sores) over his coccyx and left gluteus. These ulcers have required antibiotic
treatment on at least two occasions in the past year (September 2017 and October
2017). The wounds are now emitting a foul-smelling discharge and one was noted as
deeply tunneling toward bone. The nurses write no less than daily progress notes. On
3/15/18, the nurses noted that the coccyx ulcer was foul smelling and on 3/20/18 the
nurse wrote that one of the ulcers had a putrid smell and was tunneling. She requested
a consult from the infirmary provider. On 3/21/18, the provider saw the patient, advised
continued local wound care, and submitted a referral request to the wound care clinic at
CGH Hospital in Sterling, IL. This was the only note written by the provider between
3/15/18 through 4/3/18. A single provider note in nearly three weeks for this
permanent resident of the infirmary with an infective decubitus ulcer is not in
compliance with the IDOC Offender Infirmary Services guidelines.91 The extreme
contractures and the recurrent pressure sores in this patient are strong indications that
the past and current level of care in the DCC infirmary does not meet the community

Pica is an eating disorder typically defined as persistent eating of nonnutritive substances.
Infirmary Patient #3.
91 Reference IDOC Policy 04.03.120 Offender Infirmary Services.
89
90

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standard of care. Contractures are preventable with ongoing physical therapy; decubitus
ulcers are preventable with frequent repositioning of the patient in beds or wheel chair.
The manifestation of these findings in this long-term patient indicates that the DCC
infirmary is not able to provide a level of care that is expected to be provided in skilled
nursing facilities. Once the patient started to develop contractures, he should have been
transferred to a facility in the IDOC or in the community that could have provided the
needed preventive care.
•

The next patient is a 46-year-old who was admitted on 3/14/18 to the infirmary.92 Nurse
and provider admission notes were completed on the day of admission. His admitting
diagnosis was right foot ulcer/cellulitis with a purulent discharge. Intravenous fluids and
antibiotics were started. The patient also has a history of depression, schizophrenia, and
cardiac murmur. There were nursing notes written at least once on every shift; dressing
changes were performed multiple times a day. There were six provider notes from
3/14/18 through 4/2/18 (19 days). On 3/19/18, wound cultures grew MRSA, which is
sensitive to the antibiotics being administered. The patient was placed in contact
isolation, where he remained until isolation was discontinued on 4/1/18. Progress notes
on 3/19/18 (improved), 3/20/18 (no drainage), 3/21/18 (granulating), 3/22/18 (healing),
3/27/18 (slow healing), and 4/1/18 (sanguineous discharge) documented the status of
the infection. The care provided to this patient was deficient and did not meet the
community standard of care. The failure of the provider to initiate investigations to
identify an underlying, potentially correctable, etiology of this chronic foot ulcer of sixmonth duration was unacceptable.
During this infirmary admission there was no reference to the previous treatment in
September to December 2017 for an infection at the same site. This important clinical
information would have raised the possibility that there was some underlying cause for
this recurrent infection. A recurrent infection would have warranted further lab studies
including blood glucose, HbA1C, CBCs and a careful examination for the adequacy of
arterial circulation (pulse, arterial blood flow) and sensation in the involved foot. None
of these indicated tests and examinations were performed. There was also no
documentation that the patient’s history of a cardiac murmur resulted in an
examination of his heart. The cause of this recurrent infection was never evaluated nor
explained, minimizing the opportunity to implement prevention measures and putting
the patient at risk for another reoccurrence of this serious infection.

•

92
93

The next patient is a 61-year-old with a history of hypertension, hyperlipidemia, BPH,
psychiatric disorder, and atrial fibrillation. 93 He was admitted to the infirmary on
3/27/18 with dizziness. His medications on admission included Atorvastatin, aspirin,
Flomax (Tamsulosin), Zoloft (sertraline), Cogentin, Haldol, and possibly Norvasc
(amlodipine). A nurse admission note was recorded on 3/27/18. The nursing note on

Infirmary Patient #4.
Infirmary Patient #5.

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3/28/18 documented orthostatic drops in blood pressure and the patient was placed on
fall precautions. On 3/29/18, the first and only provider note stated that the patient was
now off Norvasc (a medication for blood pressure) and that Midodrine was being
administered TID. The provider note made no mention of the recent past history of
atrial fibrillation, the recent history of admission to Karen Shaw Berea (KSB) hospital for
similar symptoms and did not include a cardiac examination. Nursing notes were written
almost on every shift with orthostatic blood pressure measurements performed twice
daily. The patient was asymptomatic but had orthostatic drops in blood pressure of
20mmHg.
The patient had been admitted to KSB approximately 10 days prior with orthostatic
hypotension with syncope. He was also found to have paroxysmal (intermittent) atrial
fibrillation with a low-moderate CHADS-VASc94 score for which anti-platelet treatment
(aspirin) was initiated at this time. His hematocrit was 40 and hemoglobin 13.5; his
echocardiogram revealed an ejection fraction of 60-65% with a moderately dilated left
atrium and trace mitral valve regurgitation. None of this pertinent information was
recorded on any of the progress notes during this infirmary admission.
There was only a single very limited provider note recorded from 3/27/18 to 4/3/18
(eight days) for this acute admission. This is not in accord with IDOC Policy,95 which
directed that acute admissions have three provider notes per week. The failure to even
succinctly summarize the recent KSB admission and testing put the patient at risk for
being inappropriately managed in the infirmary. The patient should have had a basic
metabolic panel (glucose, BUN, electrolytes), CBC, and an ECG performed. The provider
note did not indicate the cause of this patient’s dizziness and persistent orthostatic
hypotension nor document possible alternative etiologies. Consideration should have
been given to a cardiac arrhythmia or side effects of some of the patient’s other
medications (Tamsulosin, sertraline) and to seeking specialty consultation for this
patient’s unexplained orthostatic hypotension.
In summary, a number of the patients admitted to the DCC infirmary require a higher level of
care than can be delivered in the DCC infirmary. These high-risk patients need to be transferred
to a skilled nursing facility in the community until this higher level of care can be provided in an
IDOC facility. The provider notes in the infirmary failed to meet the IDOC standard for
timeliness and do not adequately address the acute and chronic needs and illnesses of the each
infirmary patient.
With the exception that since RN’s are assigned to all shifts in the infirmary, we did not find
that LPNs are working outside their scope of services, we agree with the recommendations of
the First Court Expert and have additional recommendations that are found at the end of this
report.
94
95

The CHAD score determines whether a patient requires anticoagulation for atrial fibrillation.
Reference #IDOC 02.04,120 Offender Infirmary Services.

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Pharmacy and Medication Administration
Methodology: We reviewed medication services by touring the medication room with the
Nursing Supervisor (Wexford) who is also the vendor’s Site Manager. We observed nurses as
they prepared, administered, and documented medication administration. We reviewed
medication administration records and corresponding medical records of 12 patients selected
from lists of patients on medications that cannot be missed. We also reviewed medication
room inspection reports, pharmacy reports, the Wexford–IDOC contract, Administrative
Directives, and DCC operational policies and procedures.
First Court Expert Findings
The system used and policies and practices described in the First Court Expert’s report are
unchanged today. Medications are provided by BosWell, a subcontractor to Wexford, using a
“fax and fill” system. Pharmacy assistants are responsible for sending orders and requisitions
for stock medication to be dispensed by BosWell. These same personnel receive shipments and
verify medications received against those ordered. Once this is completed, the medications are
moved to the medication room where they are prepared by nurses for administration.
Medications were either administered by nursing staff to a line of patients waiting in line at the
health care unit or were taken to the living units and administered through the food port at the
cell door. A security officer escorted the nurse while administering medication cell side.
Documentation of medication administered, refused, or not available is done on a paper
Medication Administration Record (MAR) that is kept in a binder in the medication room for the
current month and filed in the medical record the month after.96 The First Court Expert had no
adverse findings with respect to medication administration.
Current Findings
Medication administration has apparently deteriorated since the First Court Expert report.
Medication administration at DCC is problematic and relies on outdated practices that are no
longer considered safe from patient harm. These problem areas include:
• Handwritten and incomplete orders
• Inconsistent documentation by providers in the progress notes about the decision to
order medication and clinical rationale
• Handwritten transcription of orders to the MAR
• Late transcription of orders
• Pre-pouring medication
• Use of unsanitary envelopes to administer medications in the Special Treatment
Center97 (STC)
• Not having the MAR available during medication administration in STC
• Not documenting administration of medication at the time it is given.

96
97

Lippert Report DCC p. 21.
This is a mental health unit at the DCC.

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Chronic disease patients are not monitored to ensure continuity in treatment. Their compliance
with prescribed treatment is not assessed. Prescription end dates do not coincide with chronic
clinic appointments and require patients to request renewals via sick call.
In addition, we found that medication errors are documented and reported, but not analyzed
to determine root causes or trended to identify problems and improve patient safety.
Persistent problems with medication practices are not subject to corrective action or systematic
quality improvement.
Orders and Delivery of Medication
Medications are obtained from BosWell Pharmacy Services, via subcontract with Wexford.
Prescriptions are faxed to BosWell and filled in 30-day “blister packs” and then delivered to
DCC. A pharmacy assistant at DCC receives and inventories the medications and then puts them
into the medication room nurses use to prepare medication to give to patients. The lead
pharmacy assistant reported that prescriptions faxed to BosWell by mid-afternoon are received
the next day. Prescriptions faxed after that take another day to arrive. If medications are
urgently needed, they can be obtained from a local pharmacy.
We toured the room used to administer medications to inmates housed in general population,
the medication storage room where nurses work, and the area where the pharmacy assistants
send and receive medication supply. These rooms were clean, uncluttered, well-lighted, and
kept secure. There is a refrigerator with a thermometer and temperature log that was up to
date. All other refrigerators used to store medications had thermometers and documentation
of daily temperature checks. Of the logs inspected, temperatures were within the correct
range. There was an opened bottle of lemon juice in the refrigerator that was undated. Multiple
dose containers should always be dated when opened and not used for more than 30 days after
opening. We also found four undated insulin vials of the 10 being used by nurses in the
dispensary on Monday April 2, 2018 to give insulin to diabetic patients. Multidose vials should
also be dated when opened. No outdated medication was found in the pharmacy/medication
administration areas. We did find expired HIV rapid test material in the refrigerator in the
dispensary, occult blood testing material, and eye wash solution in the nurses’ room in XHouse.
Issues with accountability of controlled substances were identified by facility audits of
Institutional Directive (ID) #04.03.110 in the spring of 2016.98 Accountability of controlled
medications was also found in pharmacy inspections during that same time.99 Corrective action
was implemented and substantial compliance with ID #04.03.110 was found in performance by
the fourth quarter of the year and was sustained in 2017.100 On Monday April 2, 2018, we
observed the count between day and evening shift, and verified that it was accurate. Other
issues identified in the pharmacy inspection reports were pre-signing for medication
Facility Review Report, April-June 2016, July-September 2016.
Dixon Correctional Center Annual Governing Body Report, September 21, 2016 pp. 142-143.
100 Facility Review Report, October 2016-December 2016, January-March 2017.
98
99

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administered, outdated medications still being administered, patient specific blister cards used
for stock, medication not stored correctly, and failure to document medication administered.
The only corrective actions taken were education and counseling. There is no systemic analysis
to determine root cause and develop solutions that support performance improvement or
prevent human error.
Orders for prescription medication were often barely legible. The lead pharmacy assistant
reported that BosWell seldom returns orders because they are unreadable. However, a nurse
could not decipher a provider’s handwriting when asked by the Expert during chart review.
Only 73% of the orders reviewed were complete (signed, dated, and timed). Only 64% of the
orders had a corresponding progress note. Sometimes there was a comment written on a lab or
diagnostic study report indicating intent to order medication; however, there was no progress
note. The providers need to document their decisions and rationale about treatment in the
progress note, but at DCC this is not done consistently.
Nurses transcribe provider medication orders onto the patient’s MAR. We did not find any
transcription errors among the 12 charts reviewed. We did find that sometimes nurses
handwrite the new order over an old order.101 This is an alteration of the record and should be
prohibited. We also found a consistent pattern of transcribing orders more than a day after the
order was written.102 This causes a delay in the initiation of treatment. In fact, only 70% of the
medications ordered had the first dose administered within 24 hours of the start date.
Transcription errors are by far the most common type of medication error reported to the DCC
CQI committee.103 These errors are evaluated to document whether there was harm to the
patient. There is no other documentation or other report that medication errors are trended or
analyzed to identify systemic sources of error, nor has it been identified as a problem for
possible improvement by the CQI committee.104
Medication errors have long been recognized as a substantial area of focus in improving the
safety of patient care.105 Handwritten orders and transcription have been eliminated in many
correctional health care programs. An obvious solution is to install computerized provider order
entry (CPOE). This eliminates transcription by hand. Labels generated from the computerized
order after it has been reviewed by a pharmacist are affixed to the MAR.106 Automated
dispensing cabinets are also being used more often now to record the withdrawal of controlled
substances and eliminate manual inventory control systems like that implemented at DCC
because of non-compliance on the audit at DCC. Upgrading pharmacy services in this way
Pharmacy/Medication Administration Patients #3 & 7.
In four of 11 charts (36%), the order was transcribed more than eight hours later.
103 DCC Annual Governing Body Report, September 21, 2016 p. 144.
104 HCU Policies and Procedures P-129 p. 68 only requires analysis of individual events but does not analyze error trends. See
also the DCC Annual Governing Body Report, September 21, 2016 p. 144. The report of medication errors made to the CQI
committee does not include root cause analysis nor is there any discussion of change.
105 Institute of Medicine (2000), To Err is Human: Building a Safer Health System. Washington DC: The Academies Press.
106Patient Safety Network. (2017) Medication Errors, Agency for Healthcare Research and Quality available at
https://psnet.ahrq.gov/primers/primer/23/medication-errors.
101
102

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requires capital expenditure and would only likely happen as a statewide decision made by
IDOC. But if these pervasive problems are not identified, discussed, studied, or reported at the
facility level, IDOC is without notice that there is a systemic issue that must be addressed
statewide.
When the medication arrives from BosWell, a pharmacy assistant verifies the medication
received against the order, which serves to identify dispensing errors. Once verified, the
medication is put in the nurses’ medication work room into boxes designated by the housing
location of the inmate.
Medication Administration
There are two ways medications are administered at DCC. Inmates in general population come
to the HCU and stand in line to receive their medication. In the STC, a mental health treatment
program, medications are brought to the inmate by a nurse and administered cell-side.
Practices of staff are problematic with both methods.
Nurses pre-pour all medication administered to inmates in general population. The only
exception is “as needed” (PRN) medications. Pre-pouring entails multiple steps: looking at the
MAR; selecting the right medication for the patient; and popping the pill out of the blister pack
into a soufflé cup. The soufflé cups are placed in a tray with a card with the patient’s name on
it. If it is a medication that must be crushed, the nurse will crush it in advance as part of the prepour. If the patient had a pattern of not taking the medication, the nurse waits until the inmate
appears at the window and indicates he will take it. Then the nurse obtains it from the blister
pack, crushes it and administers it to the patient. We were told by the Nursing Supervisor
(Wexford) that all controlled medications are crushed; any others are only crushed as a result of
an order to do so. Blanket crushing policies such as this are not recommended. Any medication
to be crushed should only be as a result of a provider order. We did not observe medication
being floated. Documentation that medication was given takes place after all medications have
been administered to the general population. The only exception to this practice is “as needed”
medications, which are documented as given at the time administered.
Correctional officers supervise inmates waiting in line for medication. Inmates are called over
by housing unit, so the line does not become too long. There is also an officer near the
medication window who monitors the inmate’s behavior during and immediately after
medication is administered. Nurses use the name and photo on the inmate’s identification card
to verify that it is the right patient. When asked if they had ever had an inmate exchange
identification cards, the nurses said no and were surprised to hear that it occurs with some
regularity at other correctional facilities. Because of the window between the nurse and the
patient, there is very little interaction that takes place. This barrier diminishes the opportunity
for inmates to ask questions or voice concerns about the medication, side effects, or other
symptoms they may experience. Nurses are also unable to observe more than the inmate’s face
and so cannot identify changes in the inmate’s condition at these encounters.
Problems with this method of medication administration are:
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•

•
•

Pre-pouring defeats the purpose of patient specific packaging. As soon as the
medication is taken out of the blister pack, verification that it is the correct medication,
for the right patient, at the right time, and the right dose is not possible. This is a patient
safety risk and unnecessarily exposes the patient to errors in administration (receiving
the wrong drug). It is also a wasteful use of the cost of blister packaging.
Nurses do not have a way to verify medication that is not taken. Visual identification of
remaining medication is not accurate.
Medication is not documented at the time it is given. This practice is a source of errors
and omissions in documentation of patient care.

Medications administered to inmates in the STC are also pre-poured. Adjustments have been
made in times when medication is administered to accommodate expectations for inmate
treatment programming and the time available for any one medication pass is limited.
We accompanied a nurse escorted by a correctional officer during the midday medication pass
in STC. The medications to be administered were in small envelopes with each inmates’ name.
The officer approached the cell door and the nurse called out the inmate’s name as it was
opened. Each cell had one or two inmates. The inmate stood in the doorway. The nurse asked
to see the inmate’s identification card but did not use a second identifier. The nurse poured the
medication into the inmate’s hand or, if the medication was “floated,” into a glass of water that
the inmate had. The nurse and the officer observed the inmate swallow the medication and
checked his mouth afterward. If the inmate did not want to take a particular medication the
nurse put it back in the envelope. One inmate questioned the identity of one of the
medications he was to receive. Because the medication was not in its original container the
nurse could not identify it. Instead, the inmate returned the medication to the nurse. She said
that she would check and tell him what the medication was at the next medication pass. The
interaction between the nurse, officer, and inmates was professional.
The MAR is not taken when the nurse administers medication in the STC and so the nurse did
not document administration at the time the medication was given. The nurse is instead
expected to document after returning to the nurses’ medication work room.
Problems with medication administration in the STC are the same as those listed for the
method used in general population and in addition include:
• Repeated use of the same envelopes is a source of transmission for infectious disease
because they are handled multiple times.
• Crushed medications in the envelope contaminate other medication in the envelope
and may cause an adverse interaction.
• The MAR is not available to the nurse at the time medication is administered and
therefore is not used as a reference when there is a concern or question at the point of
patient care.

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Only 37% of the MARs selected for review were complete.107 Documentation of doses given,
refused, or not available was missing from five of eight charts reviewed. This is extremely poor
performance and calls into question the accuracy of the MARs. Contemporaneous charting on
the MAR at the time of administration is considered the nursing standard of practice. DCC does
not meet this standard of professional performance.
KOP medications are delivered to inmates in general population once a day at a line designated
for this purpose. There are no KOP medications in the STC.
When we shared feedback about our findings with the HCUA, we were told that the
programming requirements of STC are such that the only way medications can be delivered is
the method being used now. Similarly, she explained that they tried to administer directly from
the patient specific blister packs in general population but that it took too much time, so they
reverted to pre-pour. It is true that pre-pour reduces the amount of time the nurse is with the
patient, but it significantly increases the risk of medication error and patient harm. Both
arguments are another way of saying that facility operations are impeding nurse’s ability to
provide patient care safely and in accordance with contemporary standards of practice. This is
dangerous and needs to be fixed.
Renewal of Chronic Disease Medications
Chronic disease medications are provided to patients monthly either as KOP or each dose is
administered by a nurse. The scheduled appointments for chronic disease clinic do not coincide
with the end date on medications ordered for chronic disease. Providers are to be notified of
impending expiration dates.108
DCC HCU Policies and Procedures for Chronic Disease require providers to review current
medications and ensure continuity of prescription medicines.109 During our record review we
identified several patients prescribed medication that required continuity who had lapses on
their care.110 Chronic disease patients are not monitored to ensure continuity in treatment nor
is their compliance with prescribed treatment assessed.
In summary, DCC medication services do not meet the standard of practice, they employ
outdated methods that compromise patient safety, and they are not reviewed and analyzed to
make improvements that prevent human error.

Infection Control
Methodology: We interviewed the medical lab technician assigned to track and report on
infection control. We also interviewed inmate-porters, reviewed the Infection Control Manual,
Pharmacy/Medication Administration Patients #6, 7, 8, 9 & 12.
HCU Policies and Procedures P-128 Medication Services p. 61.
109 HCU Policies and Procedures P-107 p. 11.
110 Intrasystem Transfer Patient #1, Pharmacy/Medication Administration Patients #1, 2 & 4, Infection Control Patient #1.
107
108

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CQI minutes, and other documents related to communicable diseases and infection control. We
also reviewed the charts of two patients who completed a course of TB prophylaxis.
First Court Expert Findings
The First Court Expert Report noted that there was no named infection control nurse at DCC.
Two nursing supervisors shared responsibility for compliance with IDOC policy concerning
communicable diseases, blood borne pathogens, and compliance with Illinois Department of
Public Health reporting requirements. Inspection of the health care areas and inquiry about
infection control practices revealed that personal protective equipment was available, and that
infectious waste was properly disposed. He was unable to confirm that inmate porters assigned
to work in the infirmary had received any training in cleaning and sanitation; the Nursing
Supervisors had not addressed the issue with the porters.111
Current Findings
We agree with the findings of the First Court Expert’s report. In addition, we identified
additional findings and confirmed some of the findings of the First Court Expert’s findings as
follows:
• Paper barriers were noted to be used on most but not all examination tables.
• The floors and surfaces in the health care building, particularly the second and third
floor, are dirty or have deteriorated to the extent that they are a medium for
transmission of infectious disease.
• Inmate porters are allowed to work in the infirmary without being trained in proper
cleaning procedures and personal protection.
When we asked the Nursing Supervisor (IDOC) to speak with the person responsible for
infection control, we were directed to the medical lab technician (Wexford). The lab technician
did not see herself as having responsibility for infection control. She does submit reports of
infectious conditions as required to the state Health Department. She also tabulates the
monthly infection control report that is presented at the CQI meeting. This report lists the
number of patients placed in isolation, compliance with testing the room for negative pressure,
cases reportable to Public Health, MRSA cases, and patients screened for, monitored, and
treated for HIV, and HCV. She was knowledgeable of the facility’s infection control manual,
including control of infectious disease outbreak, and has assisted in several investigations
including norovirus, chicken pox, and MRSA. She also has experience with the facility’s
approach to controlling influenza transmission. The chronic care nurse manages the HIV and
HCV clinics. The HCUA stated that she has overall responsibility for infection control only
because of the number of vacancies in her supervisory staff. There is no single person with
leadership and responsibility for infection control. The lab technician has insufficient training to
be responsible for the infection control program.
CQI Minutes and the 2016 Annual Report show that communicable disease data is collected
and reported monthly. There is minimal to no discussion of the meaningfulness of the data
111

Lippert Report DCC p. 33.

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reported. CQI Minutes also report statistics regarding skin infections due to MRSA. Data does
not include tracking of skin infections due to other pathogens. Equipment and instructions for
prevention, response, and reporting of occupational exposures were readily available at the
facility.
The IDOC Infection Control Manual was reviewed. It was last updated in 2012. While the
material in the manual is thoughtful and many resources are provided, some of them are out of
date. The manual should be updated at least every two years. An up to date and accurate
infection control manual is critically important in guiding the work of staff assigned these duties
in the absence of dedicated positions for trained infection control staff, as is the case at DCC.
The IDOC Nursing Treatment Protocols, revised March 2017, were reviewed, and provide
guidance to nurses in the care of common infectious diseases and infections such as scabies,
urinary infection, rash, pediculosis, chicken pox, and skin infections.
We note in the Clinic Space and Sanitation sections of this report many infection control
challenges and hazards that were observed during our site visit at the facility that need to be
remedied to prevent spread of infection or safety hazards to patients, including elderly inmates
at risk of falls.
The CQI minutes report four occupational exposures to blood borne pathogens in 2017.112 The
HCUA reported that three of these were needlestick injuries. She requested Wexford provide a
different type of re-sheathing needle to help prevent additional injury. To date, Wexford has
not responded to her request. At a minimum, Wexford should conduct an evaluation of the
effectiveness of existing hypodermic needles and review of feasibility of instituting more
advanced engineering controls as required by Occupational Safety and Health Administration
(OSHA).113 Further, the CQI committee should conduct a focused review of these injuries and
determine what measures to implement in order to increase employee safety.
One porter had documentation in his medical record that he had received formal training on
blood borne pathogens and had been vaccinated against hepatitis B. The other porter had not
yet been trained concerning his duties in sanitizing patient rooms, showers, tub rooms, and
showers, and had received only the first of the three required hepatitis B vaccination shots. He
is reportedly scheduled to receive the required training. Neither porter had been offered
hepatitis A vaccination, even though there is a higher risk of exposure to pathogens, and a more
frequent and higher degree of sanitation is needed in the infirmary.
Tuberculosis screening is completed annually. We did not evaluate actual practices for TB
screening. We reviewed the charts of two patients who completed prophylaxis. In one case, the
112
113

DCC Infection Control Minutes August, September, and October 2017.

osha3161
preventing needlestic

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inmate gave a history of a positive skin test and there was a record of a normal chest x-ray in
2006. In April 2017, a physician ordered the skin test and x-ray repeated. The x-ray was normal
but no results for the skin test were recorded. Six months later at a chronic care clinic, the
inmate requested TB prophylaxis. The NP documented that he was asymptomatic and had a
normal chest x-ray and initiated treatment. Once initiated, the inmate was seen in TB clinic
monthly for review of medication compliance and symptom review. Labs were drawn as
ordered.114
The other patient received three TB skin tests in July and August 2017, all recorded as 20mm,
which is considered positive. A chest x-ray was normal, and he was asymptomatic. TB
prophylaxis was initiated shortly thereafter. He was seen by the nurse monthly in TB clinic for
review of medication compliance and symptom review. Labs were drawn as ordered.
In both cases, initial tuberculosis skin testing and follow up was haphazard. Once treatment
was initiated and the patient seen by the TB control nurse, monthly care was timely and
appropriate.115
If tuberculosis prevention were managed by specifically designated nurses according to
standardized protocol with provider consultation, the initiation of preventive treatment would
be more timely and precise. We note as described in the Clinic Space section of this report that
the negative pressure unit in Room 35 of the infirmary is tested, with results documented in a
nursing log on a weekly basis.
Inmates may request HIV testing at any time and it is also offered to inmates just before release
from incarceration. Inmates who are infected with HIV are managed as part of the chronic clinic
program with oversight from UIC. Hepatitis C (HCV) disease is also managed via the chronic care
clinic, with their work up and treatment directed by UIC.

Radiology Service
First Court Expert Findings
The First Court Expert’s report did not include any findings about the radiology equipment or
services.
Current Findings
• The Illinois Emergency Management Agency (IEMA) radiation safety inspections and
reports for the radiology units at DCC are current. The active x-ray equipment at DCC
was found to be in compliance with the Radiation Protection Act of 1990.
• The access to plain film x-rays at DCC is acceptable.
• The turnaround time for radiologist readings and return of the reports is good.

114
115

Infection Control Patient #1.
Infection Control Patient #2.

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•

The system decision not to have the x-ray technician wear radiation exposure
dosimeters may not be in accord with State of Illinois regulations and is definitely not in
accord with community practice.

Plain film and fluoroscopy x-ray services are provided Monday-Friday during the daytime hours.
A single radiology technician staffs and manages the unit. This technician also assists the
management of the optometry clinic, which is located 20 feet from the radiology suite. Studies
not provided at DCC are referred to UIC or two local hospitals. Patients requiring emergency xrays are generally referred to the nearby Katherine Shaw Bethea Hospital (KSB) emergency
room.
It was reported that there is not a waiting list for non-urgent onsite x-rays. Most x-rays are
reported to be taken within one to two days after receiving the order. Weekend and holiday
requests are completed on the next working day. The requests and the radiology log for four
patients were reviewed. All four had films taken within one to three days of the request. All of
the films were read within 24 hours, with a report faxed to DCC on the day after the reading.
The films are read by a local contracted radiologist.
During the Expert’s visit the existing and aging plain film radiology unit was removed, and a
used but updated non-digital unit was being installed. The radiology technician has a work
space inside the entrance to the radiology suite that has a locked door.
Although the Illinois Emergency Management Agency (IEMA) Division of Nuclear Safety,
Certificate of X-ray Registration was not posted in the radiology suite, the x-ray technician
produced the certificate, the IEMA list of active equipment, and a April 25, 2017 letter from
IEMA stating that during the April 18, 2017 radiation safety inspection, that the DCC “radiation
producing equipment and operative procedures reviewed by the inspector were in compliance
with applicable Illinois radiation protection regulations.”116 The x-ray technician produced her
current license that is valid through July 31, 2018.
The x-ray technician was noted not to be wearing a radiation exposure dosimeter badge. She
stated she had been told by Wexford that the State of Illinois does not require the use of
dosimeters. She communicated that she is required to wear separate dosimeters at two
different medical facilities in the Rockford area where she works in her off hours.
In summary, the radiology services at DCC have reasonable access and turnaround time of
reading and reports. The decision of the system to not provided radiation exposure dosimeter
badges is not in accord with community standards and needs to be further reviewed by the
IEMA.
The First Court Expert’s report did not have any recommendations about the radiology services.
We have noted recommendations that are noted at the end of the report.
116

Reference IEMA Division of Nuclear Safety Certificate and Letter.

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Dental Program
Dental: Staffing and Credentialing

Methodology: Reviewed staffing documents, interviewed dental and other staff, reviewed the
Dental Sick Call Log and other documents.
First Court Expert Findings
• DCC has one full-time dentist, one 14-hour part-time dentist, two full-time assistants,
and no dental hygienist, a serious omission. To expect the dentists to provide hygiene
and periodontal care to 2300 inmates in addition to their expected dental workload is
unrealistic and, in our opinion, cannot be done. It is also a poor use of a dentist’s time
and resources.
• CPR training is current on all staff, all necessary licensing is on file, and DEA numbers are
on file for the dentists.
Current Findings
Dental staffing has not changed materially since the First Court Expert’s Report. We agree with
the First Court Expert that dental staffing is inadequate and the lack of a dental hygienist is a
serious omission.117 Moreover, we identified current and additional findings as follows.
Most dental personnel work 10-hour days (from 6 a.m. to 4 p.m.); however, patients are not
treated until count ends, typically after 8 a.m.118 Dentists are paid for two hours (6 a.m. to 8
a.m.) when patients are not available. The clinic has been closed Mondays for about a year,
since Dr. O’Brien reduced his time by 10 hours, and Wexford has been unable or unwilling to
find a dentist to work Mondays. The dental assistant is present on Mondays, the day there are
no dentists present. This is a foolish waste of patient treatment time resources and should be
corrected immediately.119
We were told that an IDOC dental assistant position vacated by a retirement two years ago has
finally been advertised.120 In addition, there is one dental assistant vacancy. The current
(Wexford) dental assistant has not had formal dental assisting training and does not take x-rays,

Makrides, N. S., Costa, J. N., Hickey, D. J., Woods, P. D., & Bajuscak, R. (2006). Correctional dental services. In M. Puisis (Ed.),
Clinical Practice in Correctional Medicine (2nd ed., pp. 556-564). Philadelphia, PA: Mosby Elsevier, p. 557 (“In prisons where
routine dental care will be provided, the basic dental team should consist of a dentist, dental assistant, and dental hygienist”).
118 Dr. Crisham: Wednesday 6 a.m. to 4 p.m. & Friday 6 a.m. to 10:30 a.m.; Dr. O’Brien: Tuesday, Wednesday & Friday 6 a.m. to
4 p.m.; and Dr. Schmidt: Friday: 6 a.m. to 4 p.m. There are 54.5 hours of dentist coverage Tuesday through Friday, or 1.36 fulltime dentist equivalents (FTE). Of the 54.5 dentist hours, 12 (21%) are between 6 a.m. and 8 a.m., a period when patients are
not available. This ‘dead time’ comprises 0.3 FTE, reducing the dentist FTEs available for treatment to 1.06 FTEs
119 While a case can be made for one dental assistant arriving shortly before patient treatment begins to prepare the clinic for
patients’ arrival, two hours is too much time. Moreover, since the dental assistant leaves at 3:30 p.m., it is unlikely the dentists
(whose day ends at 4 p.m.) are treating patients.
120 “In need of a dental assistant. It has been vacant since 2016 and it is starting to effect productivity. Backlog numbers are
starting to go up again.” Dixon Correctional Center Quality Improvement Committee, August QI Meeting Minutes, September
2017, p. 1 (emphasis in original). That the position had not been filled at the time of our visit (April 2018) illustrates the
indifference IDOC has shown to the Dixon dental program.
117

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a critical deficiency. CPR is current on all dental staff. Licensure and DEA registration is current
for all dentists.

Dental: Facility and Equipment

Methodology: Toured the dental clinic and radiology area to assess cleanliness, infection
control procedures, and equipment functionality. Reviewed the quality of x-rays taken at DCC
and the reception centers. Reviewed compliance with radiologic health regulations. Observed
clinical care.
First Court Expert Findings
• The clinic consists of three chairs and units with adequate free movement around them.
Two dental units are two years old and in good repair. The third chair is old, worn, and
does not work. There are no plans to repair this chair.
• There is a panoramic unit in the health services x-ray department in a dedicated room. It
is old but functions adequately. The x-ray unit in the clinic works well. The autoclave is
old but functions well. The compressor is in the basement and works well. The
instrumentation is adequate in quantity and quality. The handpieces are old but wellmaintained and repaired when necessary.
• The cabinetry is old and showing wear and corrosion and staining on work surfaces, but
is functional, although this makes disinfection of surfaces more difficult. The ultrasonic
works well.
• There was a separate sterilization area of adequate size and surface workspace. The
staff office is large with a single desk. The dental records are maintained in this room. It
also houses the dental laboratory with its equipment and workspace. There is adequate
room for all. The clinic is adequate in size and function to meet the needs of the inmate
population.
Current Findings
Dental facilities and equipment have not changed materially since the First Court Expert’s
Report and are adequate. While we concur with the First Court Expert, we identified current
and additional findings as follows.
The clinic comprises three chairs and units, with adequate free movement around them.
Dentists and assistants have adequate room to work unimpeded. Two dental units are in good
repair. The third chair is old and has not worked for at least four years.121 There are no plans to
repair this chair. There is no ultrasonic scaler.
The foot pedal controls on three sinks are non-functional and are secured with clear packing
tape. According to the dental assistant, a work order was placed approximately one year ago,
and she was told that the parts are not available.

121

The chair will have to be repaired or replaced to accommodate a dental hygienist, who should be hired immediately.

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There is an old but functioning panoramic x-ray unit in the health services x-ray department. Xrays are taken by the x-ray technician. The intraoral x-ray unit, autoclave, compressor, and
ultrasonic cleaner work well. The instrumentation is adequate in quantity and quality. The
handpieces (drills) are old but well-maintained and repaired when necessary. The x-ray units
have recently passed inspection by a health physicist.
The dental assistant said that they have not taken bitewing x-rays in months and dentists order
panoramic x-rays for biennial exams if they feel the panoramic x-ray taken at the reception
center is dated or clinically inadequate.122

Dental: Sanitation, Safety, and Sterilization

Methodology: Reviewed Administrative Directive 04.03.102. Toured the dental clinic and
observed dental treatment room disinfection. Interviewed dental staff and observed patient
treatment.
First Court Expert Findings
• Adequate surface disinfection using proper disinfectants was performed between
patients. Protective covers were used on some surfaces.
• Instruments were properly bagged and sterilized, with handpieces sterilized and in bags.
• The sterilization procedure was flawed because instrument flow was improper, since it
did not go from dirty to sterile in a linear fashion.
• The ultrasonic was on the opposite side of the autoclave from the sink. It should flow
from ultrasonic to sink to work area to autoclave without crossing its path.
• A biohazard label was not posted in the sterilization area and there was no warning sign
where x-rays were being taken to warn of radiation hazards.
• Safety glasses were not always worn by patients.
• The clinic was neat and orderly.
Current Findings
Dental sterilization, safety, and disinfection has not changed materially since the First Court
Expert’s Report and are adequate. While we concur with the First Court Expert’s findings, we
identified current and additional findings as follows.
The clinic was neat and clean. Surface disinfection between patients was adequate and
instruments were bagged and stored properly. The sterilization procedure was flawed because
instrument flow did not go from dirty to sterile in a linear fashion. The ultrasonic cleaner was
on the opposite side of the autoclave from the sink. Instruments should flow from ultrasonic to
sink to work area to autoclave without crossing the ultrasonic cleaner’s path.
A biohazard label was not posted in the sterilization area123 and there was no warning sign
where x-rays were being taken to warn of radiation hazards.124
122

This is highly problematic and will be addressed in the section on comprehensive care.

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Neither a stethoscope nor a sphygmomanometer was present. According to the dental
assistant, dentists borrow them from nursing when they feel that patients have a problem, and
often nurses will come to the clinic to take the blood pressure.
According to the dental assistant, patient eye protection is not used routinely;125,126 however,
we noted that the dentist suggested a patient wear his own glasses for protection.

Dental: Review Autoclave Log

Methodology: Reviewed the last two years of entries in autoclave log, interviewed dental staff,
and toured the sterilization area.
First Court Expert Findings
• Spore testing was performed weekly and was documented, and no negative results
were recorded.
• The past three years were reviewed and showed that autoclaving was accomplished
weekly and documented.
• They utilize the Maxitest system through Henry Schein. A single negative result was
documented, but corrected immediately with a retest, which was negative.
Current Findings
Autoclave log maintenance is unchanged since the First Court Expert’s Report and is adequate.
We agree with the First Court Expert’s findings and note that the sterilization log for the past
two years was in order. Testing was performed weekly and documented. No negative results
were recorded.

Dental: Comprehensive Care

29 CFR 1901.145(e)(4). “The biological hazard warning shall be used to signify the actual or potential presence of a biohazard
and to identify equipment, containers, rooms, materials, experimental animals, or combinations thereof, which contain, or are
contaminated with, viable hazardous agents.”)
124 Occupational Safety and Health Standards – Toxic and Hazardous substances. 29 CFR 1910.1096(e)(3)(i). Each radiation area
shall be conspicuously posted with a sign or signs bearing the radiation caution symbol and the words, “CAUTION RADIATION
AREA.” Emphasis in original.
125 Guidelines for Infection Control in Dental Health-Care Settings ---2003. MMWR, December 19, 2003/ 52(RR17):1:16; pp. 1718. (“PPE [personal protective equipment] is designed to protect the skin and the mucous membranes of the eyes, nose, and
mouth of DHCP [dental health care provider] from exposure to blood or OPIM [other potentially infectious materials]. Use of
rotary dental and surgical instruments (e.g., handpieces or ultrasonic scalers) and air-water syringes creates a visible spray that
contains primarily large-particle droplets of water, saliva, blood, microorganisms, and other debris. This spatter travels only a
short distance and settles out quickly, landing on the floor, nearby operatory surfaces, DHCP, or the patient. The spray also
might contain certain aerosols (i.e., particles of respirable size, <10 µm). Aerosols can remain airborne for extended periods and
can be inhaled” and “Primary PPE used in oral health-care settings includes gloves, surgical masks, protective eyewear, face
shields, and protective clothing (e.g., gowns and jackets). All PPE should be removed before DHCP leave patient-care areas (13).
Reusable PPE (e.g., clinician or patient protective eyewear and face shields) […]”). Emphasis added. Moreover, protective
eyewear prevents injury from objects or liquids accidentally dropped by providers.
126 Why We Take Infection Control Seriously. UIC College of Dentistry. Viewed at https://dentistry.uic.edu/patients/dentalinfection-control, viewed February 2, 2018 (“We use personal protective equipment […] as well as provide eye protection to
patients for all dental procedures.”} Emphasis added.
123

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Comprehensive, or routine care127 is non-urgent treatment that should be based on a health
history, a thorough intraoral and extraoral examination, a periodontal examination, and a visual
and radiographic examination.128 A sequenced plan (treatment plan) should be generated that
maps out the patient’s treatment.
Methodology: Interviewed dental staff, reviewed randomly selected dental charts of an
inmates who received non-urgent care based on Dental Reports.
First Court Expert Findings
• A review of 10 records revealed that no comprehensive examination was ever
performed, and no treatment plans were developed.
• A periodontal assessment was not done in any of the records and no examination of soft
tissues or periodontal assessment was part of the treatment process.
• Hygiene care and prophylaxis were never provided, and oral hygiene instructions were
never documented.
• Bitewing or periapical x-rays were never taken to diagnose caries. Restorations were
provided from the information from the panoramic radiograph. This radiograph is not
diagnostic for caries.
• None of the record entries were time documented.
Current Findings
Comprehensive care has not improved materially since the First Court Expert’s Report and
remains inadequate. We concur with the First Court Expert’s findings; however, we identified
current and additional findings as follows.
Of 12 records reviewed, none had a periodontal assessment documented. All but one129 had
the treatment plan that consisted only of charting dental problems (primarily decay) with no
mention of periodontal disease. In fact, the standard instrument pack for an examination
contains a mirror and an explorer but lacks a periodontal probe.130 Moreover, none of the
treatment plans were informed by bitewing x-rays. Of 10 records of patients who received
biennial exams, none was informed by a periodontal assessment or bitewing x-rays.131,132 None
had signed and updated health histories.

Category III as defined in Administrative Directive 04.03.102.
Stefanac SJ. Information Gathering and Diagnosis Development. pp. 11-15, passim.
129 Comprehensive Care patient #9.
130 This is consistent with the dental program’s indifference to periodontal disease.
131 While all had panoramic x-rays, it is below accepted professional standards to diagnose caries and periodontal disease with a
panoramic x-ray alone. Furthermore, many of the x-rays were inadequate (Biennial Exam Patients #2, 5, 6, 8, 9, and 10).
132 Dentate or partially dentate adults who are new patients receive an “[i]ndividualized radiographic exam consisting of
posterior bitewings with panoramic exam or posterior bitewings and selected periapical images.” Furthermore, recall patients
should receive posterior bitewing x-rays every 12 to 36 months based on individualized risk for dental caries. With respect to
periodontal disease, “[i]maging may consist of, but is not limited to, selected bitewing and/or periapical images of areas where
periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically.” Dental Radiographic Examinations:
Recommendations for Patient Selection and Limiting Radiation Exposure. American Dental Association and U.S. Food and Drug
Administration, 2012. Table 1, pp. 5-6.
127
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Per the dental assistant, the dentists review charts of newly arrived prisoners using the
panoramic x-ray taken at the reception center and decide whether to place the prisoner on a
treatment list.133 It takes approximately 90 days to be seen for routine care; however, once
treatment commences, subsequent appointments are said to occur within a few weeks. Co-pay
is not charged when the appointment is generated by the clinic (as opposed to a patient
request).
Diagnosis and treatment of periodontal disease is nonexistent. Not only are comprehensive and
biennial examinations not informed by periodontal probing and appropriate intraoral x-rays,
but oral prophylaxis is not included in the exiguous treatment plans when present. 134,135 To
illustrate the dental program’s turning a blind eye to periodontal disease, the daily and monthly
treatment logs do not have a category for oral prophylaxis and scaling and root planning,
procedures that are essential to prevention and early non-surgical treatment of periodontal
disease.136
Wait times for extractions, fillings, and dentures were four, eight, and 12 weeks, respectively.137
However, since the dental program neither diagnoses nor treats periodontal disease and
provides inadequate examinations for caries that are not informed by intraoral x-rays, the
amount of dental disease that should be treated is understated substantially, and the wait
times and backlogs are artificially deflated.138

Dental: Intake (Initial) Examination139

Methodology: Reviewed 11 dental records of inmates that have received recent intake (initial)
dental examinations and Administrative Directive 04.03.102 (Dental Care for Offenders).
First Court Expert Findings
• Reviewed 10 inmate dental records that were received from the reception centers
within the past 60 days to determine if: 1) screening was performed at the reception
center and 2) a panoramic x-ray was taken, to insure the reception and classification
However, most of the panoramic x-rays taken at the NRC are clinically inadequate and even an adequate x-ray is insufficient
to diagnose caries and periodontal disease.
134 Stefanac SJ. Information Gathering and Diagnosis Development. A panoramic radiograph has insufficient resolution for
diagnosing caries and periodontal disease. Intraoral radiographs (e.g., bitewings) and periodontal probing are necessary (p. 17).
Also, Periodontal Screening and Recording (PSR), an early detection system for periodontal disease, advocated by the American
Dental Association and the American Academy of Periodontology since 1992, is an accepted professional standard. Id., pp. 1214. See American Dental Hygiene Association. Standards for Clinical Dental Hygiene Practice Revised 2016. Periodontal probing
is also a standard of practice for dental hygiene.
135 Makrides et al., p. 560 (Early diagnosis of periodontal disease is important since the disease is often painless and the
prevalence of moderate to severe periodontal disease in correctional populations is high and often not associated with pain).
136 These procedures can be performed by a dentist or dental hygienist, and a dental practice that does not provide these
treatments is operating substantially below accepted professional standards.
137 Dixon Correctional Center Quality Improvement Committee Minutes, October 12, 2017, p. 1.
138 Providing x-rays for caries, and periodontal diagnosis and treatment consistent with accepted professional standards would
require more treatment capacity or the waiting times would increase markedly.
139 The First Expert Report describes the examination performed at intake screening as a “Screening Examination;” however,
Administrative Directive 04.03.102 describes it as a “complete dental examination.” We use the terminology of the
Administrative Directive and refer to the intake or Initial Dental Examination as a complete dental examination.
133

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policies as stated in Administrative Directive 04.03.102, section F. 2, are being met for
the IDOC.
Current Findings
Dental intake examinations have not changed materially since the First Court Expert’s Report
and remain inadequate. The First Court Expert focused on the initial examination process (i.e.,
whether the clinic complied with the Directive 04.03.102), while we focused on the clinical
domain (e.g., quality of the panoramic radiographs). We believe since the Directive 04.03.102 is
inadequate, measuring DCC’s compliance with it would be unproductive.
Of 11 charts recently received from reception centers, only one panoramic x-ray140 was of
diagnostic quality. Most were washed out, some contained artifacts, and others were
improperly aligned. Two were classified IIa for oral surgery.141

Dental: Extractions142

Methodology: Interviewed dental personnel and reviewed 11 dental and medical records
randomly selected from Daily Dental Reports. In none of the 11 records reviewed was the
medical history updated. While some medical history forms had markings (e.g., a vertical line
suggesting no medical issues), none had the date last reviewed and the dentist’s signature.
All the extractions relied on panoramic x-rays; several143 were more than three years old.144
Consequently, only five x-rays were clinically adequate.145 Signed consent forms were present
in all charts; however, they did not list the reason the tooth was to be extracted. Furthermore,
the clinical progress note in one record did not document the reason for the extraction.146
First Court Expert Findings
• All dental treatment should proceed from a well-documented diagnosis. In none of the
10 records examined was a diagnosis or reason for extraction included as part of the
dental record entry.
• In none of the records was a consent form available. When asked, I was told that it was
just not a part of the treatment process for surgery at DCC. This is a serious omission
and a major violation of a well-established standard of care.
Current Findings

Dental: Intake (Initial) Examination Patient #2.
Dental: Intake (Initial) Examination Patient #7: Teeth #3, 13, and 18 were charted IIa for oral surgery but the referral
disposition box not marked. Patient #9: Tooth #17 was charted IIa for oral surgery, but referral disposition box not marked.
Patient 10: Tooth #19 was charted IIa for oral surgery, but referral disposition box not marked.
142 The dental assistant said that she requests the medical charts for all scheduled extraction patients.
143 Extraction Patients #3, 4, 6, and 7.
144 The only x-ray that shows the roots of #14 is a panoramic x-ray that has no date or other patient information on the label.
145 Extraction Patients #1, 2, 9, and 11.
146 Extraction Patient #5.
140
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We concur with the First Court Expert’s findings Expert and note that documentation
associated with extractions has improved; however, it remains inadequate. Moreover, we
identified current and additional findings as follows.
While the First Court Expert found that the diagnosis of the tooth that was extracted was not
documented, and consent forms were not present, we found that all 11 records had signed
consent forms and all but one chart147 documented the reason for the extraction.
In none of the 11 records reviewed was the medical history updated. While some medical
history forms had markings (e.g., a vertical line suggesting no medical issues), none had the
date of last review and the dentist’s signature.
All the extractions relied on panoramic x-rays; several148 were more than three years old.149
Consequently, only five x-rays were clinically adequate.150

Dental: Removable Prosthetics

Methodology: Reviewed eight charts of patients who received partial dentures in the past year
selected randomly from the Prosthetics List and interviewed dental staff.
First Court Expert Findings
• In only two of the five records reviewed on patients receiving removable partial
dentures were oral hygiene instructions provided.
• Periodontal assessment was not documented in any of the records. In two of the five
records a prophylaxis and/or a scaling debridement was provided.
• Because comprehensive examinations and treatment plans were not documented in any
of the records, it is almost impossible to ascertain if all necessary care, including
operative and/or oral surgery treatment, is completed prior to fabrication of removable
partial dentures.
Current Findings
We concur with the First Court Expert and note that removable prosthetics care has not
changed materially and remains inadequate. Moreover, we identified current and additional
findings as follows.
Of eight patients who received partial dentures, none had a sequenced treatment plan. While
the Treatment Needed portion of the chart was marked, there was no date or signature, nor
was a treatment sequence indicated. Moreover, none of the treatment was informed by
bitewing or periapical x-rays, or periodontal probing. This is not an adequate treatment plan.
None had documented oral prophylaxis or oral hygiene instruction.
Extraction Patient #5.
Extraction Patients #3, 4, 6, and 7.
149 The only x-ray that shows the roots of #14 is a panoramic x-ray that has no date or other patient information on the label.
150 Extraction Patients #1, 2, 9, and 11.
147
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Dental: Sick Call/Treatment Provision

Methodology: Interviewed dental staff; reviewed Dental Sick Call Logs, Daily Dental Reports,
and reviewed records of 10 inmates who were seen on sick call for dental problems randomly
selected from Daily Dental Reports and Sick Call Logs.
First Court Expert Findings
• Inmates access dental sick call through either a sick call sign-up process or via the
inmate request form. The sick call sign-up takes place in the health services unit every
morning. They sign up one day and are seen and evaluated the next day by an RN. The
RN then refers the complaint to the dental program and the inmate is scheduled within
four to five days.
• Request forms are received from the institution mail, evaluated by the dentist, and
scheduled for an examination and evaluation within four to five days.
• No system was in place to attempt to see inmates with urgent care complaints within 24
to 48 hours from the date of the request form. Emergency call-ins from staff are seen
the same day.
• In none of the records was the SOAP format used.
• Minimal diagnosis was available for any delivered care. Routine care was not being
provided at sick call appointments. The chief complaint, as well as could be determined,
was being addressed at sick call.
Current Findings
The dental clinic is now closed on Monday, reducing access to care markedly. We concur with
the First Court Expert; however, we note that sick call treatment documentation has improved
since the SOAP format is now used consistently. Moreover, we identified current and additional
findings as follows.
Inmates seeking dental care place a request in a box in the housing unit, send it through prison
mail, or communicate directly with staff. Written requests are screened by nursing and referred
to the dental clinic for scheduling, and typically staff communicate directly with dental
personnel. Since the clinic is closed on Mondays, patients with urgent care issues may have to
wait four or five days to be seen by a dentist.
The SOAP format was used for all sick call entries; however, in none of the 10 charts reviewed
was the health history updated. There were several instances where treatment was performed
without adequate x-rays or a treatment plan.151
According to the dental assistant, the dentist reviews charts of newly arrived prisoners and,
using the panoramic x-ray that is typically taken at the reception and classification center,
Sick Call Patient #4: fillings (teeth #18, 19) done without intraoral x-rays or treatment plan. Patient #5 complained of pain in
the right side. The dentist concluded there was no decay and treatment was not indicated. However, intraoral x-rays were not
taken, and the most recent x-rays were almost three years old. This is insufficient data to base a diagnosis. Patient #7 had a
fractured tooth that was scheduled to be filled without recent intraoral x-rays. The most recent x-rays were dated 4/30/10.
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decides whether to place the prisoner on a treatment list. It takes approximately 90 days to be
seen; however, once treatment commences, subsequent appointments are within a few weeks.
Co-pay is not charged when the appointment is generated by the clinic (as opposed to a patient
request).

Dental: Orientation Handbook

Methodology: Reviewed Orientation Manual and related documents.
First Court Expert Findings
The Orientation Manual only mentions dental care in relation to co-pays. It describes medical
sick call procedures, but no mention is made of dental sick call.
Current Findings
Inmate orientation to dental care has improved since the First Court Expert’s Report. The First
Court Expert found that the orientation manual did not describe how to access dental care.
While there are now two orientation manuals for DCC, one for the General Population and for
the Special Treatment Center, neither manual addresses access to dental care. There is,
however, an adequate description of how to access health care via sick call.

Dental: Policies and Procedures

Methodology: Reviewed Administrative Directives that deal with the dental program.
Interviewed dental staff. Reviewed dental charts. Toured dental clinical areas. Reviewed DCC
organizational chart.
First Court Expert Findings
The Policy and Procedures Manual and statements for DCC only paraphrase the Administrative
Directives. It includes nothing specific for DCC and the running of the dental program. When
asked, the dental director knew little of its existence and had never reviewed it.
Current Findings
Dixon policies and procedures have not changed materially since the First Court Expert’s
Report. We concur with the findings in the First Court Expert’s Report that the Policy and
Procedures Manual is inadequate and should be revised. We were provided with institutional
directives covering several domains; however, none addressed dental care. There is a binder in
the clinic that contains (inter alia) Administrative Directive 04.03.102 (Dental Care for
Offenders), blank forms used by the dental program, and an outdated version of the Illinois
Dental Practice Act. There was an untitled, undated, unsigned policy relating to dentures of
uncertain provenance.

Dental: Failed Appointments

Methodology: Reviewed Dental Sick Call log. Interviewed dental staff. Reviewed Daily Dental
Reports.

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First Court Expert Findings
A review of monthly reports and daily work sheets revealed a failed appointment rate of about
10.4%. All failed appointment inmates are required to sign a refusal form. They are all located
and brought to the dental clinic to do so.
Current Findings
Failed appointments have remained unchanged since the First Court Expert’s report. We concur
with the findings in the First Court Expert’s Report and note that failed appointments are not an
area of concern at Dixon. Moreover, we identified current and additional findings as follows.
As noted in the First Expert report, inmates who fail to appear for a dental appointment are
located and made to sign a refusal form. This is an excellent practice and should be employed
by all IDOC dental programs.
Since the failed appointments are not reported to the CQI Committee or noted in the Daily and
Monthly Dental Logs, it is difficult to determine retrospectively; however, it appears not to be a
substantial problem.

Dental: Medically Compromised Patients

Methodology: Reviewed health history form and records from recent intake exams. Compared
the health history in the dental chart to the medical problem list.
First Court Expert Findings
• Because the dental record is maintained in the dental clinic separate from the medical
record, identification of medically compromised patients relies on assessment by the
clinician and on the history section on the cover of the dental record.
• Of the 10 records reviewed of inmates on anticoagulant therapy, only one was
adequately red-flagged to catch the immediate attention of the provider. Four of the
records did not indicate that the inmate was on anticoagulant therapy. Five of the
records indicated anticoagulant therapy, but they were not sufficiently red-flagged. On
one record, treatment was provided and was managed properly.
• When asked, the clinicians indicated that they do not routinely take blood pressures on
patients with a history of hypertension.
Current Findings
Health history documentation for medically compromised patients is unchanged from the First
Court Expert’s Report and we concur that it is inadequate. Moreover, we identified current and
additional findings as follows.
Of the 12 records randomly selected of prisoners who were taking insulin or anticoagulant
medication who appeared on the Chronic Care Program Report, the relevant medical condition
was not noted in the health history in the dental charts of two patients.152 There was no
152

Medically Compromised Patients #1 and 11.

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documented periodontal assessment and request for follow-up for the diabetics, which is
particularly problematic given the relationship between periodontal disease and diabetes.153,154
Of the patients on anticoagulant therapy,155 all but one on anticoagulant therapy had it noted
on the health history.156 Health histories were not filled out or updated at last visit in most
charts.157

Dental: Specialists

Methodology: Interviewed dental staff, reviewed CQI documents, and reviewed dental charts
of inmates who were seen by an oral surgeon.
First Court Expert Findings
The dental program utilizes the Joliet Oral and Maxillo-facial Surgery group. This case was the
only one sent out in the past nine months. It was a large cyst of the body and ramus of the
mandible, a very extensive surgery. All other surgeries, including impactions that require
removal, surgical extractions, and lesion removals, are done by the dentists at DCC.
Current Findings
Oral surgery consultations have not changed materially since the First Court Expert’s Report.
We agree that oral surgery consultations appear to be adequate. We reviewed the charts of
two inmates who were referred to the Joliet Oral and Maxillo-facial Surgery group within the
past year. Both cases were extensive, and the referral and treatment provided appeared to be
appropriate.

Dental: CQI

Methodology: Reviewed CQI minutes and reports. Interviewed dental staff.
First Court Expert Findings
• The dental program contributes monthly statistics to the CQI committee.
• The waiting list for extractions and fillings is eight weeks and for dentures is 12 weeks.
These are very reasonable lengths of time. No concern was expressed.
• The dental program recently completed a CQI study that evaluated percentage of
required denture adjustments at the time of insertion. The study is under evaluation to
see if any changes can be made in the construction or delivery process.
• No other studies are ongoing at the time of this report.

Patients #1, 2, 3, 4, 5, 10, and 12. None of the records documented that an oral prophylaxis (prophy) was performed.
See, for example, Herring ME and Shah SK. Periodontal Disease and Control of Diabetes Mellitus. J Am Osteopath Assoc.
2006; 106:416–421; Patel MH, Kumar JV, Moss ME. Diabetes and Tooth Loss. JADA 2013;144(5);478-485 (adults with diabetes
are at higher risk of experiencing tooth loss and edentulism than are adults without diabetes); and Teeuw WJ, Gerdes VE, and
Loos BG. Effect of Periodontal Treatment on Glycemic Control of Diabetic Patients. Diabetes Care 3 3 :421-427, 2010
(periodontal treatment leads to an improvement of glycemic control in type 2 diabetic patients).
155 Patient #6, 7, 8, 9, and 11.
156 Medically Compromised Patient #11.
157 Medically Compromised Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.
153
154

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Current Findings
The Dental CQI program has not improved since the First Court Expert’s Report. Since dental
peer review records and facility reviews were not available to the First Court Expert, it is
difficult to compare our findings except with respect to the number of CQI reports.
Peer Review
We asked to see all peer reviews of dentists working at the eight facilities on our site visit
schedule and were informed that dentists (unlike other practitioners) are not routinely peer
reviewed. According to Attorney Ramage, speaking for Wexford,158 neither the IDOC contract159
nor Wexford policy requires that dentists be peer reviewed.160 He further stated that “[r]outine
peer reviews of dentists are not a mandatory standard of NCCHC;”161 however, he is confuted
by the NCCHC, which specifically includes dentist peer reviews in its Clinical Performance
Enhancement Standard P-C-02.162
Moreover, “Wexford Health has never found a true dentist ‘peer review’ to be a productive
means to determine clinical quality.”163 Finally, it is Wexford’s position that the dentist peer
reviews are not a part of the community standard.164 While clinical peer review is not the
community standard for dental care in a private practice environment, it is the community
standard for institutional care; that is in the military and Department of Veterans Affairs, and
Departments of Corrections that have recently emerged from federal monitoring, for example,
California and Ohio.165

Email from Andrew Ramage to Michael Puisis 3/29/2018.
The contract addresses “physician peer review,” which applies to the on-site medical director, staff physicians, nurse
practitioners, physician assistants, and psychiatrists; however, dentists and psychologists are excluded. Wexford Contract,
¶2.2.2.19 and ¶7.1.5.
160 However, Wexford Clinical Performance Enhancement Policy P-403 states, “[a] minimum of one annual “peer review” [will
be performed] whereby a practitioner’s clinical performance is evaluated by a senior or supervising practitioner, and, when
necessary, senior practitioners are evaluated by regional/corporate staff. […]” ¶III A3; and “[t]he senior dentist will complete a
peer review for each dentist and ensure the completion of the biennial external review for those qualified. The Regional
Medical Director will assign a peer reviewer for small contract locations having single or part-time dentists.” Wexford Resp.
RTP#5, Question 2, p. 0405.
161 Ramage email, id.
162 “In contrast [to an annual performance review], a clinical performance enhancement review focuses only on the quality of
the clinical care that is provided. This type of review should be conducted only by another professional of at least equal training
in the same general discipline. For example, an RN should evaluate other RNs and LPNs, a physician should review the work of a
physician, and a dentist should review the work of a dentist; and “[Clinical Performance the standard requires that the facility’s
direct patient care clinicians and RNs and LPNs are reviewed annually. Direct patient care clinicians are all licensed practitioners
who provide medical, dental, and mental health care in the facility. This includes physicians, dentists, midlevel practitioners,
and qualified mental health professionals (psychiatrists, psychologists, psychiatric social workers, psychiatric nurses, and others
who by virtue of their education, credentials, and experience are permitted by law to evaluate and care for mental health
needs of patients). NCCHC recognizes that there are many other professions that have licensed practitioners (e.g., dental
hygienists) who may be considered direct patient care clinicians. While it is good practice to include these professionals in the
clinical performance enhancement process, technically it is not required by the standard. National Commission on Correctional
Health Care, Clinical Performance Enhancement (https://www.ncchc.org/clinical-performance-enhancement-1) viewed 3/30/18
(emphasis added).
163 Ramage e-mail, id.
164 Id.
165 California Department of Corrections Inmate Dental Services Program. September 2014, ¶ 4.3; Ohio Department of
Corrections Policy 68-MED-12, ¶ VI B 3.
158
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We were provided with peer reviews of Drs. Crisham (performed 12/30/15) and O’Brien
(performed 1/16/17) and were able to locate five of the 20 charts on which the peer review
was based. Our findings were consistent with those of the reviewer; however, several critical
elements were absent from the checklist, and were not evaluated. Consequently, many of the
fundamental flaws we found in the dental care provided at DCC, such as inadequate treatment
plans, failure to use bitewing x-rays to inform caries diagnosis, and failure to diagnose and treat
periodontal disease, were undiscovered. Dental peer review as implemented by Wexford and
countenanced by IDOC is poorly designed and is not therefore determinative of clinical quality.
Facility Reviews
We were provided with several facility in which the dental program was deemed to be
compliant with the Administrative Directive 04.03.102.166 However, the Administrative
Directive does not address clinical adequacy; so while the findings of the reviews may be useful,
they omit the most important domain and provide a false sense of security considering the
myriad clinical deficiencies reported by the First Court Expert and confirmed by our inspection.

Internal Monitoring and Quality Improvement
Methodology: Interview facility leadership and staff involved in quality improvement activities.
Review CQI Committee meeting minutes, including the Annual Meeting minutes.
First Court Expert Findings
The First Court Expert found that the only data used for purposes of quality improvement were
statistics that served no purpose with respect to quality improvement. There was no
documented effort to investigate processes of care or professional performance with an
intention of improving the program. The Acting CQI Coordinator had no experience in CQI. The
First Court Expert described the CQI program as inactive. He also commented that there was a
lack of data (specifically tracking logs) that could be used to determine the timeliness of
scheduled services.
The First Court Expert recommended that the program needs CQI leadership that has training in
quality improvement philosophy and methodology. He recommended that operational
processes and professional performance must be studied. Studying grievances in a meaningful
way was recommended. The First Court Expert recommended that this program be used to
improve every operational process in the medical program. He recommended use of logbooks
to track information for use in studying these processes. He recommended retraining the CQI
leadership regarding quality improvement philosophy and methodology as well as study design
and data collection. He recommended studying outliers in order to develop targeted
improvement strategies.
Current Findings
166 December 2015 to May 2016, and June 2016 to November 2016. While these purport to be semi-annual reviews, we were
not provided with reviews for 2017 and do not know whether the dental program was reviewed since November 2016.

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While the First Court Expert described the quality improvement program as inactive, we would
describe it as nascent. There has been an effort to initiate quality studies and the HCUA has a
desire to improve the program. However, because she acts as the HCUA, CQI Coordinator,
supervisory nurse, and director of medical records, she is spread thin and has less than
necessary time to devote to this task. While there have been some small improvements, the
quality improvement program has a considerable way to go.
There is no CQI coordinator. The HCUA has not had any training in CQI. No one at the site had
experience in CQI methodology or implementation. The HCUA did have the IDOC CQI manual.
This is the first facility to have this document, which is required in the AD on quality
improvement.167 This document was produced in 1992 and has not been modified since then.
Despite its age, this document has some valuable information and gives reasonable instruction
on how to set up and maintain a quality improvement program. Because this manual is already
available it should be used in the CQI effort, but it is not. This manual should be updated. The
apparent effort to train staff on CQI methodology appears nonexistent.
The CQI program is not performing all required studies as stipulated in the ADs. Primary source
verification is not done except to verify an existing state license. Offsite services are not
reviewed with respect to quality or appropriateness as required by the AD. There is no evidence
of 100% review of denials of specialty care in CQI minutes.
Monthly CQI meeting minutes contain very little information. Most of the statistical data
provided has no bearing on quality improvement. For example, while listing the number of
persons seen in NP, physician, and nursing sick call is useful administratively, it gives no
measure of the quality of those visits and gives no information as to whether there is a problem
with these processes. The same could be said of most of the statistical information provided in
this report. We noted in the Infection Control section of this report that needle sticks and blood
borne pathogen data is provided but not analyzed. This misses an opportunity to protect
employees and reduce unnecessary needle stick injuries.
As with the prior two IDOC facilities we have reviewed, the CQI plan is a generic plan that gives
no specific information on the work that the CQI committee will be engaged in for the
upcoming year. The short-range goals for the year were to fill vacancies and to develop an
orientation program. Long-term goals were generic goals that did not include identification of
problem prone areas of service. The CQI plan needs to be a site-specific plan on what the
quality improvement program will be engaged in during the upcoming year with respect to
improving care.
The 2016 annual CQI report provided to us contained nine medical studies. One study on
diabetes care in mental health patients had no methodology and it was not clear what the
AD 04.03.125 Quality Improvement Program page 2 of 10: II.F.1. “The Agency Medical Director shall develop, maintain, and
distribute to the facility Health Care Unit Administrators a Quality Improvement Manual. The Health Care Unit Administrators
shall maintain the Quality Improvement Manual locally.”
167

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study was measuring. Another study that studied 100 patients referred urgently for specialty
care was intended to study how many had consultations completed within two weeks. The data
was not included, and the results were therefore not provided.
Of the remaining seven studies, five were outcome studies and two were process studies. Four
of the five outcome studies were:
• Two studies of whether x-rays were received back timely from the radiologist.
• A study of whether inmates who received education after evaluation for injury then reinjured themselves.
• A study of whether nurse referrals to providers were seen timely.
• A study of whether inmates with poorly controlled hypertension were improved after a
year of routine management.
Two of these were true outcome studies; the other two were not outcome studies. Clinical
outcomes are end point measures of health status; for example mortality, hospitalization, an
HbA1C level of 7 or less, or normal blood pressure. An outcome study measures the
effectiveness of interventions based on the ultimate outcome measure. An example would be
to study the effect of colorectal cancer screening on colon cancer mortality or the effect of
increasing the interval of chronic clinic visits on obtaining a normal blood pressure.
One of the studies at DCC that was an outcome study assessed whether education had an effect
on the outcome of re-injury. This study showed that two of 13 individuals re-injured themselves
after education. However, the study did not make any analysis of whether the education had an
effect or not. The study drew no conclusions, so it was not clear what the purpose of the study
was. Also, we question why this topic was chosen when there are so many other important
problems at this facility. The second outcome study looked at 10 individuals who were in poor
hypertension control. The study looked at their status after a year of typical management to
assess whether their degree of control had improved with typical management. Four patients
were improved. Four patients were discharged and two patients refused. There was no
comment on this study. The sample was so small that its value is questionable. The remaining
“outcome” studies were not outcome studies but were performance measures.
DCC studies were mostly measurements of performance. Performance measurement of typical
processes are reasonable ways to study job performance, but these are not CQI outcome or
process studies. More important, almost none of these studies looked at clinical outcomes or
clinical performance, which remains unstudied.
The CQI program appears to make no effort to evaluate the clinical quality of care. We heard
complaints from IDOC custody and IDOC health care leadership about the poor quality of
physician care. We agree that physician quality is poor, based on mortality reviews and chart
reviews. Yet there was no evidence of the CQI program monitoring for this.
The Wexford peer review program is supposed to be a method of evaluating for clinical quality
of care. This program is an episode-of-care based system using a single episode of care to
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answer up to 10 or 11 discrete questions to determine whether care was adequately provided.
These episodes of care are randomly selected. There was one prior peer review of the former
Medical Director and two peer reviews of NPs. Virtually all episodes of care were 100%
adequate, which given our chart reviews does not accurately reflect what we would consider
the status of quality of provider care at this facility.
The medical record documents that are used for these peer reviews are typically not provided.
Also, it is not possible to know the context of care when evaluating a single episode of care. In
death records that we have reviewed, we noted multiple patients who had considerable weight
loss that was not identified, laboratory tests that were recently done that were not reviewed,
medical conditions that were not identified or followed up, etc. These problems will not be
identified by looking at a single episode of care because the prior orders and problems will not
be available for review. We find that using single episodes of care does not work well for this
system. Also, because so many physicians have inadequate primary care training, they will not
be able to review primary care with a level of expertise that is equivalent to a typical
community standard of care. Doctors not trained in primary care are often reviewing other
doctors also not trained in primary care. It is not unexpected that few problems are identified.
There is no mortality review at DCC. Monthly and annual CQI minutes list the deaths. A
Wexford physician, typically the doctor who cared for the patient, writes a death summary. This
is a non-critical summary of events from the perspective of the Medical Director. There is no
evidence that anyone is examining deaths to understand if there were quality issues or
identified problems that should be addressed to prevent further deaths. Although no one is
reviewing deaths in an attempt to prevent further death, we found that of six deaths we
reviewed, four were preventable and two were possibly preventable. Details of these deaths
are found in the mortality review section of the summary report. The high number of
preventable deaths at DCC justifies a robust mortality review process performed by persons not
associated with care of the patient.
We found serious problems with clinical medical care at DCC in these reviews, including:
• Multiple episodes of care that failed to follow generally accepted guidelines and
multiple episodes of grossly and flagrantly unacceptable care.
• In multiple deaths, each patient lost significant amounts of weight without anyone
recognizing that the patient was losing weight. In one of these cases the patient had lost
60 pounds.
• In several patients, significant life-threatening laboratory values were not timely
addressed.
• Care for patients with mental health issues was not well coordinated with the mental
health staff.
• On multiple occasions, patients who should have been hospitalized or sent to a
specialist were not. This underutilization contributed to or resulted in death.
In most cases, these deficiencies related to physician quality; some might have been systemic
deficiencies. Untimely specialty care and delayed hospitalization may be a result of inadequate
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physician training or barriers to use of these services by the vendor. The doctors who cared for
the patient should not be documenting a death summary. Because they cared for the patient,
they have a conflict in reviewing their own care and may be unlikely to find problems when
problems exist. For that reason and under these circumstances, mortality review should be
conducted by either the Office of Health Services or an external reviewer. The vendor should
not be permitted to perform the only mortality review on their own services.

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Recommendations
Leadership, Staffing, and Custody Functions
First Court Expert Recommendations
1. The First Court Expert recommended to make a priority of filling the vacant Medical
Director, Health Care Unit Administrator, Director of Nursing, Nurse Practitioner, and
seven Correctional Nurse I (RN) positions. We agree with this. The Medical Director and
Health Care Unit Administrator, Director of Nursing, and Nurse Practitioner positions
have been filled. However, two nurse supervisor positions, the Director of Medical
Records, staff physician, and multiple nursing positions are now vacant. All positions
need to be filled. It is critical to fill supervisory positions, but that does not mean that
staff positions can remain vacant. A vacancy rate of 23% is unacceptable.
2. The First Court Expert’s recommendation was as follows. Due to concerns regarding
non-registered nurses conducting sick call and working outside of their educational
preparation and licensed scope of practice, and when all the Correctional Nurse I
positions are filled, total registered nursing positions should be evaluated as to the need
for additional positions or a reconfiguring of current positions in order to provide an “all
RN” conducted sick call process. We agree with this recommendation, but believe that
the nurse staffing, particularly on the infirmary and geriatric units, and the physician
budgeted staffing are deficient. For this reason, it is our recommendation to perform a
staffing analysis based on the existing service requirements of the program. Staffing
should be augmented based on that analysis. The analysis should be based on policy
requirements and clinical care requirements of the program.
Additional Recommendations
3. Physicians receiving privileges to practice primary care at this facility must have
completed residency in a primary care program. This needs to be inserted in the
contract obligations of the vendor.
4. The IDOC contract needs to require that vendor health care managers have training in a
health discipline appropriate for their management responsibilities.
5. The current vendor is unable to provide physicians of sufficient training and in sufficient
numbers. The IDOC needs to explore alternate avenues to fill physician spots with
qualified physicians.
6. This facility needs infection control and quality improvement positions.

Clinic Space
First Court Expert Recommendations
1. Develop and implement a plan to replace the style of beds being used for geriatric
patients on the third floor of the medical building.
2. Properly equip designated sick call rooms in the health care unit and X-house.
We agree with these recommendations.
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Additional Recommendations
3. All medical equipment must be inspected, calibrated, and tagged no less than annually
by a qualified bioengineering team.
4. Each room used for nurse sick call should be on the first floor of the medical building.
5. Each room must have its own exam table and be properly equipped. The use of two
exam tables in the same open room is to be discontinued.
6. Both elevators must be operational at all times.
7. All the beds in the infirmary must be hospital beds with adjustable heights and sections.
8. At least one electrically adjustable hospital bed should be available in the infirmary.
9. The metal beds in the geriatric unit need to be replaced with beds that are safe, can be
readily sanitized, and meet the needs of the geriatric population.
10. Additional shower chairs need to be provided in the patient housing areas of the
medical building. Existing shower chairs with torn upholstery need to be repaired or
replaced.
11. The cracked and missing floor tiles noted throughout the entire medical building are
safety hazards for both patient-inmates and medical and correctional staff, and should
be expeditiously repaired, replaced, and maintained.
12. The environmental rounds and the deficiencies noted in the monthly Medical Safety and
Sanitation Report should be expanded to include the condition of the patient beds, the
functionality of the negative pressure infirmary room, the compliance with annual
inspection of medical devices, and other clinical space and equipment findings.

Sanitation
First Court Expert Recommendations
The First Court Expert had no recommendations
Additional Recommendations
1. Safety and sanitation inspections need to include all areas of clinical space including
infirmary beds, ADA units, the geriatric floor, annual inspection of clinical equipment
and devices, and all other clinical areas.
2. Maintenance needs to be done to replace missing tiles, rusted vents, cracked walls, and
peeling paint.

Medical Records
First Court Expert Recommendations
1. Medical records staff should track receipt of all outside reports and ensure that they are
filed timely in the health record. We agree with this recommendation. This presumes
that outside reports are all obtained. We strongly recommend that all outside reports be
obtained timely and filed within timeframes required by the IDOC Administrative
Directive.

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2. Charts should be thinned regularly, and MARs filed timely. We agree with this
recommendation if a paper record continues to be used.
3. Problem lists should be kept up to date. We agree with this recommendation.
Additional Recommendations
4. An electronic medical record needs to be implemented in the IDOC. The difficulty in
maintaining and finding paper documents in this system is a systemic barrier to care.
5. If a paper record continues to be used, thinning charts should include carrying forward
key diagnostic studies and consultant reports that are important to track the status of
the patient’s conditions.

Reception Processing and Intrasystem Transfer
The previous Court Expert’s recommendation has been achieved. All newly transferred inmates
are brought to the dispensary and screened upon arrival to identify immediate medical needs
and reconcile prescribed medications so that treatment can be continued. The next day, these
inmates are seen again by nurses who complete an in-depth interview, review the medical
record, and initiate the plan of care.168
Current Recommendations
1. We recommend that health care leadership establish a process to monitor and provide
feedback as part of the CQI program. Errors and omissions should be subject to focused
study to improve the accuracy of transfer information and continuity of patient care.
2. Written directives of IDOC and Wexford be revised to add responsibility for the sending
IDOC facility to accurately complete the Health Status Summary in advance of inmate
transfer.169
3. When facilities send inaccurate or incomplete information on the intrasystem transfer
form they should hear about the mistake from the receiving facility.

Nursing Sick Call
First Court Expert Recommendations
1. Develop and implement a procedure for one style of sick call. This recommendation has
been implemented at DCC.
2. Develop and implement a plan for an “all RN” sick call process. We agree with this
recommendation.
3. Develop and implement a plan to assure non-medical personnel do not have access to
inmate sick call requests. This recommendation has been implemented at DCC.
4. Develop and implement a plan to maintain inmate sick call requests on file. We agree
with this recommendation.
Lippert Report DCC p. 42.
Documents to be revised include the IDOC-Wexford contract, Wexford Policy and Procedure P-118 Transfer Screening, and
DCC HCU Policies and Procedure P-118 Transfer Screening.

168
169

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5. Develop and implement a plan to initiate and maintain a sick call log. This
recommendation has been implemented at DCC.
6. In the X-House, develop and implement a plan to conduct a legitimate sick call
encounter, including listening to the patient complaint, collecting a history and objective
data, performing a physical examination when required, making an assessment, and
formulating a plan of treatment, rather than the current practice of talking to the
patient through a solid steel door and basing treatment on the conversation only. This
recommendation has been implemented at DCC, but the medical record is still not
available to the nurse to refer to during the sick call encounter. This must be corrected.
7. Per Office of Health Service policy, assure sick call encounters are documented in the
medical record in the Subjective-Objective-Assessment-Plan (SOAP) style. We agree with
this recommendation and found practices more consistent with this recommendation.
8. Develop and implement a plan to assure the Office of Health Services’ approved,
preprinted treatment protocol forms are used at each sick call encounter. We agree
with this recommendation and found practices more consistent with this
recommendation.
9. Develop and implement a plan to ensure each of a patient’s complaints are addressed
during a sick call encounter, or a prioritization of needs to address future encounters is
developed, rather than the current practice of allowing only one complaint per visit. We
agree with this recommendation and did not find any instances of patients being limited
to only one complaint per encounter.
10. Develop and implement a plan of education for all nursing staff which will be conducted
by the Medical Director and addresses the following issues:
a. Assure the patient’s complaint is addressed at the time of the sick call
encounter.
b. Assure documentation is complete and, at a minimum, addresses the complaint,
duration, history, pain level if applicable, location of pain, location of injury, etc.,
and collection of complete vital signs including weight, an examination if
applicable, and an assessment and plan.
c. Use of the Office of Health Services approved treatment protocols at each sick
call encounter.
d. When using the protocol, staff must comply with the OTC dosages, as increasing
the strength or frequency may take the OTC dosage to an unauthorized
prescription dosage.
We found that there is still significant room for improvement in the quality of nursing
sick call. We agree that sick call encounters should include elements a–d above. We do
not agree that training conducted by the Medical Director is necessary to accomplish this
level of performance. We recommend instead a trended analysis of specific areas that
are problematic and a system review of process to identify structural or other barriers to
desired performance.170

For example, are nurses distracted or rushed during sick call encounters? Do they have all of the equipment and supplies
necessary to perform the work? Are the Treatment Protocols clear in guiding the nursing assessment and treatment plan?
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11. The nursing department must implement a sick call logbook with fields including date,
patient name, patient number, reason for visit, date of clinician appointment, and if
cancelled, reason for cancellation and date for the rescheduled appointment. A sick call
log has been implemented. However, the problem of providers seeing patients timely
when referred from nursing sick call still exits. Providers also failed to follow up at
intended intervals and treatment orders were not carried out. We recommend filling
vacant provider positions with qualified practitioners and adding physician positions as
described in the recommendations under the heading Leadership, Staffing and Custody
Functions.
Additional Recommendations
12. The quality of nursing assessments and the plan of care should be monitored by
nursing service as part of the peer review or quality improvement. This should replace
Medical Director review.
13. Rooms used for nursing sick call should each have an exam table, equipment, and
supplies to conduct a thorough physical assessment without having to move the
patient or share equipment.
14. Medical records must be available when the nurse sees patients housed in X-House.
This is one example of the benefit of having an electronic health record.
15. The sick call documentation forms should be revised to indicate if the referral is
emergent, urgent, or routine. The indicated urgency should be used to schedule
provider appointments.
16. Providers should see patients timely according to the urgency of the referral.171
17. Revise HCU Policy and Procedure P-103 so that patients in segregation are seen by
providers according to the urgency of the referral rather than holding clinic on a single
day of the week.
18. Require nurses to assess patients who request sick call for dental pain according to an
IDOC Nursing Treatment Protocol.
19. Revise the IDOC Nursing Treatment Protocol for Toothache/Dental Complaints to
clarify expectations regarding dental pain, particularly the assessment, factors in
determining the urgency of referral, the timeframe to see the dentist, and options to
treat pain until seen by a dentist. We suggest accomplishing this by developing
separate protocols for dental infection, dental trauma, and dental pain.

Chronic Care
First Court Expert Recommendations
1. There should be a single nurse assigned to the chronic care program to identify, enroll,
monitor, and track patients in an organized and comprehensive way.

Emergent referrals should be seen immediately, urgent referrals should be seen the same day, and routine referrals seen
within 72 hours.

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2. Patients with HIV should be enrolled and monitored in the chronic disease program.
There should be a system in place to identify medication noncompliance (or other
missed doses) and refer those patients to a provider timely.
We agree with these recommendations.
Additional Recommendations
3. Problem lists in the medical record must be complete and accurate.
4. The care of chronic illnesses must be in accord with national standards of care and the
Office of Health Services Chronic Illness Treatment Guidelines.
5. Age-based routine health maintenance, including cancer screening and immunizations
for patients with and without medical conditions, must be provided in accord with the
United States Preventive Services Task Force (USPSTF) guidelines and other national
standards of care.
6. Chronic care visits must address at every visit all interrelated medical conditions that
impact on the treatment, control, and outcomes of that clinic’s specific disease. Strictly
focusing on a single specific disease and not addressing other associated clinical
problems is not in the best interest of the patient and delays needed interventions.
7. The chronic care providers must regularly document the review of the MAR, the CBGs,
nursing and provider sick call notes, and blood pressure readings when they see patients
in the disease-specific chronic care clinics.
8. Nursing or quality improvement staff should do monthly medication compliance audits
on all patient with HIV, diabetes, chronic anticoagulation, seizure disorders, and other
chronic illnesses as needed. The results should be communicated to the providers and
to the QIC.
9. The IDOC should develop a plan to shift anticoagulation treatments from Vitamin K
antagonists (warfarin) to newer types of anticoagulants that do not require frequent
ongoing lab testing to determine the adequacy of anticoagulation. The frequent lab
testing and medication adjustments are logistically complicated and put patient-inmates
at risk for poor outcomes. Utilizing newer anticoagulation medications that do not
require frequent ongoing measurement of the level of anticoagulation should be
strongly considered by the IDOC.
10. Patients with selected chronic illnesses including diabetes, hypertension, and
hyperlipidemia should have the 10-year cardiovascular risk calculated to determine if
they require a HMG CoA-reductase inhibitor (statin drug) at a proper dosage to
minimize the risk of myocardial infarction, stroke, and other cardiovascular diseases.
11. Providers should be provided with access to electronic medical references and/or cell
phones with internet capability that would allow clinical staff to readily access updated
clinical information in their offices and in all clinical service areas. This is the standard of
care in the community.
12. DCC and IDOC must establish a process to monitor the status of high-risk patients who
refuse chronic clinic appointments during the interval between chronic care clinics. The
current practice of not rescheduling chronic care patients who refuse to attend their
scheduled appointment until the next chronic care clinic, which may be as long as six

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months later, is not in the best interests of the patient or the institution. These patients
should be promptly rescheduled based on the urgency of their medical condition.
13. Providers must document any modification of warfarin dosage and the INR result in the
patient’s progress notes, chronic care notes, or a warfarin log. The current practice of
documenting changes in warfarin doses on the INR lab form is a barrier to continuity of
care and the communication of this vital clinical decision.
14. Providers must consistently document key clinical information, the performance of
indicated examinations, the rationale for clinical decisions and therapy modifications,
and any modifications of the treatment plan in the chronic care progress notes.
15. DCC must develop a process to ensure that all patients 50 years of age or older are
screened for colon cancer and men 65 years of age or older with a history of tobacco
use are screened for abdominal aortic aneurysm (AAA).
16. Uncontrolled Chronic illnesses with problems that appear to be beyond the expertise of
the DCC providers are to be referred for specialty consultation.

Urgent/Emergent Care
First Court Expert Recommendations
1. A log book be maintained that contains fields for date, time, patient name, patient
number, presenting symptom, where the assessment was performed, and the
disposition, including if the patient was returned to the cellhouse or sent offsite. We
agreee with the previous Court Expert and found that such a log is maintained when
inmates are sent to the Emergency Department. All onsite emergency response incident
reports and critiques are maintained in a binder kept on site and reviewed in the monthly
CQI meetings.
2. When patients are sent offsite, a staff person be assigned responsibility to obtain either
the emergency room report or, if the patient was admitted to the hospital, the
discharge summary. We agree with this recommendation.
3. All patients sent offsite should be brought to the clinic for a nurse to review the relevant
documents and ensure the required documents, if not available, are obtained (see
recommendation #2) and the patient is scheduled for a follow-up visit with a primary
care clinician. We agree with this recommendation and recommend, in addition, that the
follow-up visit be scheduled the next working day.
4. At the primary care clinician visit, the clinician must document a discussion of the
findings and plan. We agree with this recommendation.
Additional Recommendations
5. Determine if the Health Care Unit is to maintain a trauma bag for mass casualty disaster
as specified in DCC ID #04.03.108.
6. Add the expiration dates of medications and solutions kept in the emergency response
bags to the equipment checklist to identify products nearing expiration so that they can
be replaced.
7. Revise DCC ID #04.03.108 to reduce the number of mass casualty drills required. It
should conform to the HCU Policy and Procedure P-112.
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8. A corrective action or improvement plan should be developed based upon the critique
of the annual mass casualty drill. Implementation of the plan should be monitored by
the CQI Program.
9. The process or persons assigned to critique emergency responses should be revised to
provide meaningful feedback on strengths and weaknesses. This feedback should be
reviewed by CQI for trends and areas identified for correction or improvement.
10. All emergency room visits should be reviewed with regard to timeliness,
appropriateness of preceding care, accuracy of information in the health record, and
continuity of care upon release back to the facility. This should be done by clinical
leadership and the QI program.
11. Sentinel events resulting in hospitalization should be monitored by the Office of Health
Services to ensure that quality of care is practiced and that the sentinel event was not
preventable.172
12. Potentially preventable hospitalizations should be monitored by the Office of Health
Services to ensure that quality of care is practiced.

Specialty Consultations
First Court Expert Recommendations
1. The delays in obtaining scheduled offsite services must be eliminated. Wexford must be
required, within seven days after verbal approval, to have provided authorization to the
UIC coordinator. If the UIC is assigning an appointment date greater than 30 days in the
future, an effort must be made to obtain the service locally. After the service has been
provided, the patient should be returned through the medical clinic and a nurse should
review the paperwork or take steps to obtain it. After the paperwork is obtained, the
patient must be scheduled for a follow-up visit with the primary care clinician, who must
document the discussion of findings and plan. We agree with this recommendation.
However, certain adjustments should be made for those follow-up appointments that
are requested for periods longer than 30 days (for example, when a consultant
recommends a six month follow up).
Additional Recommendations
2. Given the existing problems with the Wexford system of obtaining offsite care, it should
be abandoned. Patients are being harmed. Until a system is put in place that protects
patients, all referrals by providers should be scheduled without utilization review.
3. Senior management from Wexford or IDOC needs to obtain medical records from
consultants and hospitals on a timely basis.

Infirmary Care
First Court Expert Recommendations
172 A sentinel event is any unanticipated event in a health care setting resulting in death or serious physical injury to a patient
not related to the natural course of the patient’s disease.

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1. Staff the infirmary with a registered nurse 24 hours a day, seven days a week.
2. Educate nursing staff on the need for complete charting, which includes providing a
thorough description of a patient’s medical condition.
3. Develop and implement a plan to provide an accessible nurse call system for patients
who are physically unable to access the current call system and provide for a credible
system for those patient rooms with no nurse call system.
4. Establish minimum inventory levels for bedding, linens, and pillows and provide
acceptable items which are not torn, threadbare, or frayed.
5. Provide a permanent manned security post within the infirmary.
6. Develop and implement a plan to obtain needed additional equipment as determined by
the Medical Director, Health Care Unit Administrator, Director of Nursing, and a nursing
staff representative who is routinely assigned to the infirmary.
7. Develop and implement a plan to provide additional institutional radios to the infirmary
nursing staff.
We agree with these recommendations.
Additional Recommendations
8. Provider infirmary admission notes and progress notes should be performed in accord
with the timeframes detailed in IDOC policy 04.03.120, Offender Infirmary Services.
9. Provider notes must communicate the rationale for modifications in treatment; list
reasonable differential diagnoses; document pertinent histories, physical findings, and
symptoms; record clear treatment plans; and write regular comprehensive progress
notes that update the status of each and every acute and chronic illness.
10. All Infirmary beds must be functional hospital beds with the capability to adjust the
height, head, and foot of the bed, and have operational safety railings. Non-functional
infirmary beds put the safety of patient-inmates and staff at risk. At least one electrical
bed should be available for use in the infirmary.
11. Physical therapy services must be provided in the infirmary for those patients who
cannot be readily moved to the physical therapy treatment room on the first floor of the
medical building.
12. Patients whose clinical needs and support of their activities of daily living exceed the
capability of the DCC infirmary must be transferred to a licensed skilled nursing facility
either in the IDOC or in the community.
13. Given the numbers of elderly patients and the skilled nursing needs that are not now
provided, the IDOC should perform a statewide analysis of its geriatric needs and
develop a plan that ensures safe housing in an appropriate level of care for this
population. Based on a review of this facility it appears that IDOC needs a new skilled
nursing unit. But this effort should not be undertaken before an analysis of the need is
completed.

Pharmacy and Medication Administration
The First Court Appointed Expert made no recommendations concerning pharmacy and
medication administration.
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Current Recommendations
1. Adopt a computerized provider order entry (CPOE) program to eliminate handwritten
orders. Replace handwritten transcription of orders to the MAR with printed labels after
the pharmacy has reviewed and verified the order. Medications which must be started
urgently may be transcribed in handwriting onto the MAR. When the label arrives, it
should be affixed to a new line on the MAR and documentation continued on the new
line.
2. Evaluate continuity of care with respect to prescription medication for chronic illness.173
Included in this review should be whether there is a progress note written to
correspond with the order describing rationale and plan of care regarding prescription
medication. The results of these reviews should be reported and analyzed in CQI. The
Regional Medical Directors need to review these CQI efforts and provide coaching and
feedback to the providers.
3. Order implementation should take place within 24 hours. Adopting CPOE eliminates
delays in treatment resulting from not transcribing orders timely.
4. Medication should be administered in patient specific, unit dose packaging. The practice
of pre-pouring should be eliminated in GP and STC, as well as the multiuse envelopes in
STC.
5. The MAR should be used by the nurse to verify that the medication, dose, and route of
administration is correct immediately before giving the medication to the patient. The
nurse should have the MAR available to answer any questions or concerns the patient
has about the medication.
6. Medication should be documented on the MAR at the time it is administered.
7. Printed labels should be provided to place on the MAR when a new order is dispensed.
Orders should not be handwritten on the MAR unless it is a medication to be given
immediately.
8. A system for timely renewal of chronic disease and other essential medications should
be developed.
9. Nurses should refer any patient who does not receive three consecutive doses of
medication critical in managing a chronic disease (insulin, Plavix, factor H, HIV
medication, antirejection medications, etc.) to the treating provider. The treating
provider should meet with the patient and determine if treatment can be modified to
improve adherence.
10. Patient adherence with KOP medications prescribed to treat chronic disease should be
monitored at regular intervals (monthly by nursing and by the provider at each chronic
disease visit).
11. Revise the policy and procedure for medication administration to provide sufficient
operational guidance to administer medications in accordance with accepted standards
of nursing practice.
12. The CQI program should develop, implement, and monitor quality indicators related to
pharmacy services and medication administration.
National Commission on Correctional Health Care (2014) Standards for Health Services in Prisons. E-12 Continuity and
Coordination of Care During Incarceration. p. 93.

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13. Root cause analysis and corrective action plans should be used to target the causes of
performance that is below expectations. Corrective action should consider system
improvements such as computerized provider order entry, use of bar coding, patient
specific unit dose packaging, EMAR, etc., to support desired performance.

Infection Control
First Court Expert Recommendations
1. Develop a position description and name an Infection Control Registered Nurse (IC-RN).
We agree with this recommendation.
2. Develop and implement a plan for the IC-RN to conduct monthly documented safety
and sanitation inspections focusing at a minimum on the health care unit, infirmary, and
dietary department, with monthly reporting to the Quality Improvement Committee
(QIC). We agree with this recommendation.
3. Develop and implement a plan for the IC-RN to monitor food handler examinations and
clearance for staff and inmates. We do not agree with this recommendation. A medical
examination of persons to work as a food handler is not necessary because it only
represents that individual’s condition on the day of the exam and is not predictive of
future illness or disease that would contradict working as a food handler. Instead, we
recommend that staff and inmates working in food service be trained and pass an
examination on proper food handling techniques, sanitation procedures, and what
health conditions need to be reported to the food services supervisor.
4. Develop and implement a plan for the IC-RN to monitor compliance with initial and
annual tuberculosis screening, with monthly reporting to the QIC and facility
administration as needed. We agree with this recommendation.
5. Develop and implement a plan to aggressively monitor skin infections and boils, and
work jointly with security and maintenance staff regarding cellhouse cleaning practices,
with monthly reporting to the QIC and facility administration as needed. This
recommendation has been accomplished with regard to MRSA infection. Reporting and
surveillance should be expanded to include skin infections in addition to MRSA.
6. Develop and implement a plan to daily monitor and document negative air pressure
readings when the room(s) are occupied for respiratory isolation, and weekly when not
occupied. This recommendation has been accomplished. However, the room air
exchange monitor does not work, and parts are no longer available. Staff use the tissue
test to monitor air flow. An HVAC expert should evaluate negative airflow in the room
annually.
7. Develop and implement a training program for healthcare unit porters which includes
training on blood-borne pathogens; infectious and communicable diseases; bodily fluid
clean-up; and proper cleaning and sanitizing of infirmary rooms, beds, furniture, toilets,
and showers. This recommendation has been partially accomplished. Apparently,
training has been developed, but porters are assigned work before this training is
completed. We agree that porters should be trained and vaccinated before being
assigned work in the infirmary.

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8. Monitor all sick call areas to assure appropriate infection control measures are being
used between patients, i.e., use of paper on examination tables which is changed
between patients or a spray disinfectant is used between patients, examination gloves
are available to staff, and hand washing/sanitizing is occurring between patients. We
agree with this recommendation.
9. Develop and implement a plan to monthly monitor all patient care associated furniture,
including infirmary mattresses, to assure the integrity of the protective outer surface,
with the ability to take the furniture out of service and have repaired or replaced as
needed. We agree with this recommendation. Safety and sanitation inspections take
place monthly, but items that need to be repaired or replaced are not taken out of
service.
10. Interface with the County Department of Health and Illinois Department of Health and
provide reporting as required by each department. This recommendation has been
accomplished.
Additional Recommendations
11. Infections and communicable disease data should be analyzed and discussed as part of
the monthly and the annual CQI meetings. This should include discussion of trends,
updates from the CDC, and review of practices. For example, employee exposures to
blood borne pathogens, such as the needlestick injuries in 2017, should be analyzed by
CQI with consideration of alternate systems, products, and methods to reduce potential
injury.
12. Track and report skin infections due to all pathogens, not just MRSA, including
infestations with scabies or body lice.
13. Update the IDOC Infection Control Manual now and at least every two years.
14. Airborne Infection Isolation (AII) rooms need to be regularly serviced, inspected by
knowledgeable individuals, and monitored regularly. The maintenance of adequate air
changes and pressure should be documented on a log specifically as part of the infection
control program.
15. The cracked and missing floor tiles noted throughout the entire medical building
interfere with the proper cleaning and sanitation and create infection control hazards
for both patient-inmates and medical and correctional staff and should be expeditiously
repaired, replaced, and maintained.

Radiology Service
No recommendations.

Dental Program
Dental: Staffing and Credentialing
First Court Expert Recommendations

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1. Hire a dental hygienist immediately. We agree with this and specify that the dental
hygienist should be full-time. We agree with this recommendation.
Additional Recommendations
2. Dentist staffing should be increased to 2.0 FTEs.
3. Dental assistant staffing should be increased to 2.5 FTEs.
4. All dental assistants should be qualified to take intraoral x-rays.
5. The clinic should be open for patient treatment five days per week.
6. Dentists’ hours should coincide with patient availability.
7. Dentist and dental assistant schedules should be coordinated so that dentists are not
treating patients when an assistant is not available.

Dental: Facility and Equipment

First Court Expert Recommendations
1. Repair or replace the chair and unit that is not working. We agree with this
recommendation.
Additional Recommendations
2. Purchase an ultrasonic scaler.
3. Repair the faulty foot pedal controls on all sinks. If repair is not feasible, the sinks should
be replaced.

Dental: Sanitation, Safety, and Sterilization

First Court Expert Recommendations
1. Sterilization flow to the autoclave should be from dirty to sterile in a linear fashion; from
ultrasonic to sink to work area to autoclave.
2. Safety glasses should be provided to patients while they are being treated.
3. That a biohazard warning sign be posted in the sterilization area.
4. A warning sign should be posted in the x-ray area to warn pregnant females of radiation
hazards.
We agree with these recommendations.
Additional Recommendations
5. The clinic should obtain a stethoscope and a sphygmomanometer.

Dental: Review Autoclave Log

First Court Expert Recommendations: None.
Additional Recommendations: None.

Dental: Comprehensive Care

First Court Expert Recommendations

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1. Comprehensive “routine” care should be provided only from a well-developed and
documented treatment plan.
2. The treatment plan should be developed from a thorough, well documented intra and
extra-oral examination, to include a periodontal assessment and detailed examination
of all soft tissues.
3. In all cases, that appropriate bitewing or periapical x-rays be taken to diagnose caries.
4. Hygiene care should be provided and documented as part of the treatment process.
5. Care should be provided sequentially, beginning with hygiene services and dental
prophylaxis.
6. All record entries should include date and time.
We agree with these recommendations.
Additional Recommendations
7. The health history should be updated and signed at all biennial exams.
8. A periodontal probe should be added to a mirror and explorer in all examination packs.
9. All prisoners who arrive from a reception center should receive a comprehensive exam
within 30 days.
10. The daily and monthly log forms should be amended to include oral prophylaxis and
scaling and root planing.

Dental: Intake (Initial) Examination

First Court Expert Recommendations
Although no recommendations were made, the First Court Experts did not review the quality of
the panoramic x-rays or the disposition of potential urgent care issues noted at intake.
Additional Recommendations: None.174

Dental: Extractions

First Court Expert Recommendations
1. A diagnosis or a reason for the extraction be included as part of the record entry. This
is best accomplished through the use of the SOAP note format, especially for sick call
entries. It would provide much detail that is lacking in most dental entries observed.
2. A consent form be developed and signed by the patient and the dentist. That
the procedure and any potential complications be well explained to the patient. While
all records contained signed consent forms, we recommend that the consent forms
specify the reason for the extraction.
We agree with these recommendations.
Additional Recommendations:
3. The heath history should be updated before a tooth is extracted.
4. Teeth should not be extracted without clinically adequate x-rays.
174

We address the inadequacy of the panoramic x-rays in the NRC report.

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Dental: Removable Prosthetics

First Court Expert Recommendations
1. A comprehensive examination and well-developed and documented treatment plan,
including bitewing and/or periapical radiographs and periodontal assessment, precede
all comprehensive dental care, including removable prosthodontics.
2. Periodontal assessment and treatment should be part of the treatment process and that
the periodontium should be stable before proceeding with impressions.
3. That all operative dentistry and oral surgery as documented in the treatment plan be
completed before proceeding with impressions.
We agree with these recommendations.
Additional Recommendations: None.

Dental: Sick Call/Treatment Provision

First Court Expert Recommendations.
1. Implement the use of the SOAP format for sick call entries. It will assure that the
inmate’s chief complaint is recorded and addressed, and a thorough focused
examination and diagnosis precedes all treatment. We note that all the sick call records
we reviewed used the SOAP format.
2. Daily dental sick call should be seen and evaluated by the dentist, rather than through
the medical program. We do not agree with this recommendation. Instead, we
recommend that nurses triage all requests for dental care. Non-urgent requests
(cleaning, routine exams, fillings, etc.) should be sent to the dental clinic for scheduling.
All other dental complaints should be assessed at nursing sick call, treated for pain as
needed, and referred to the dentist based upon clinician urgency.
3. Requests from inmates with urgent care complaints should be scheduled for the next
work day from receipt of the nursing referral from sick call. We agree with this
recommendation.
4. Efforts should be made to see urgent care complaints via the request form in a timelier
manner. They could easily be scheduled for the next day. Sick call sign-ups are seen the
following day by RNs who have pain medication protocols available. Dental sick call
signups should be scheduled directly by dental for the following day, rather than by the
RN who then refers them to dental. We do not agree that urgent complaints should be
scheduled directly by the dental service. Only requests for routine (non-urgent) care
should be scheduled by the dental service.
Additional Recommendations
5. RNs should perform face-to-face examinations on patients with complaints that suggest
pain or infection and refer or palliate per protocol. Nurses should refer patients to the
dentist according to criteria for urgency established in the treatment protocol.
6. The health history should be updated at each clinical encounter.

Dental: Orientation Handbook
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First Court Expert Recommendations
1. Amend the orientation manual to include dental sick call procedures and instructions on
how to access routine, urgent and emergency care. The recommendation is moot since
recent revisions adequately address sick call procedures and access to health care.
Additional Recommendations: None.

Dental: Policies and Procedures

First Court Expert Recommendations
1. The dental program should develop a current detailed, thorough, and accurate policy
and procedures manual that define show all aspects of the dental program are to be
run, to include access to care, care provision, clinic management, infection control, etc.
Once developed, it should be reviewed and updated on a regular basis and as needed
for new policies and procedures. We agree with this recommendation.
Additional Recommendations
2. The Dental Program Binder should be reviewed and updated.

Dental: Failed Appointments

First Court Expert Recommendations
1. Failed appointment percentages are slightly high and should be watched. We agree with
this recommendation.
Additional Recommendations
2. Failed appointment percentages should appear on the Monthly Dental Logs and be
reported to the Quality Improvement Committee.

Dental: Medically Compromised Patients

First Court Expert Recommendations
1. The medical history section of the dental record should be kept up to date and that
medical conditions that require special precautions be red flagged to catch the
immediate attention of the provider. These would include medication allergies,
anticoagulants, interferon therapy, pre-medicated cardiac conditions and any other
health condition that would require medical intervention prior to dental treatment.
2. That blood pressure readings be routinely taken of patients with a history of
hypertension, especially prior to any surgical procedure.
We agree with these recommendations.
Additional Recommendations
3. Diabetics diagnosed with periodontal disease should be offered an oral prophylaxis
every six months and non-surgical periodontal treatment (i.e., scaling and root planing)
if clinically indicated as part of the chronic care program.

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Dental: Specialists

First Court Expert Recommendations
None. Specialists are available and utilized.
Additional Recommendations: None.

Dental: CQI

First Court Expert Recommendations
1. The CQI process should be used extensively to address the program deficiencies
outlined in the body of this report. Policies and procedures should be developed from
this process to ensure that measures are in place to maintain program continuity and
improvement. We agree with this recommendation.
Additional Recommendations
2. Annual dentist peer reviews should be implemented immediately.
3. The dentist peer review form should be modified to focus on substantive aspects of
clinical care such as diagnosis, treatment planning, the appropriate use of periodontal
probing and x-rays, and the treatment of periodontal disease.
4. Facility reviews of the dental program should be performed semi-annually. They should
encompass clinical aspects of the dental program and be reviewed by a disinterested
dentist.

Internal Monitoring and Quality Improvement
First Court Expert Recommendations
1. This program must be recreated and provided the leadership that has had training in
quality improvement philosophy and methodology. The program should focus on both
process improvement and professional performance improvement as well as grievance
responses. The program must be used to improve intrasystem transfers, both nurse and
provider sick call, the chronic care program, infirmary care, unscheduled services care,
scheduled offsite services care, medication administration, grievances, infection control,
dental services, and mental health services. This program requires the use of logbooks
for tracking capabilities for both intrasystem transfers, sick call, infirmary care, chronic
care, unscheduled services care, scheduled offsite services, and grievances.
2. The leadership of the continuous quality improvement program must be retrained
regarding quality improvement philosophy and methodology, along with study design
and data collection.
3. This training should include how to study outliers in order to develop targeted
improvement strategies.
We agree with these recommendations.
Additional Recommendations

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4. We recommend that the current peer review program of Wexford be revised. The Office
of Health Services or outside reviewers should monitor physician performance for
sentinel event reviews and mortality reviews. Standardized professional performance
evaluations by Wexford should focus on whether the patient’s care over a span of time
was adequate and resulted in an expected outcome. The professional performance
evaluation should be related to privileges granted at re-credentialing.

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Appendix A
DCC Staffing as of 4/5/18
Position

Budgeted
positions

Vacancies

LOA longterm

Health Care
Administrator

1

0

0

0

State

Director of
Nursing

1

1

0

1

State

1

0

0

0

Wexford

1

1

0

1

State

Physician

1

1

0

1

Wexford

Nurse
Practitioner

2

0

0

0

Wexford

Nursing
Supervisor

2

1

0

1

State

Nursing
Supervisor

1

0

0

0

Wexford

RN
LPN
Certified Nurse
Assistant

48
10

10
2

1
1

11
3

State
Wexford

6

1

1

2

Wexford

Pharmacy Tech
Medication
Room
Assistants
Chief Dentist
Dentist
Dental Assistant
Dental Assistant
Office
Coordinator

1

0

0

0

State

3

0

0

0

Wexford

1
0.4
1
1

0
0
1
0

0
0
0
0

0
0
1
0

Wexford
Wexford
State
Wexford

1

0

0

0

State

1

1

0

1

State

7
1
0.2

0
0
0

0
0
0

0
0
0

Wexford
Wexford
Wexford

Medical
Director
Medical Record
Director

Health
Information
Assistant
Staff Assistants
Phlebotomist
Optometrist

April 2 - April 5, 2018

Effective State or
vacancies Wexford

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Physical
Therapist
Physical
Therapy
Assistant
Radiology
Technician

0.2

0

0

0

Wexford

1

0

0

0

Wexford

1

0

0

0

Wexford

93.8

19

3

22

*The Director of Nursing will be filled on 4/16/18.
**One of the filled nursing supervisor positions will be vacant beginning 4/16/18.

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Logan Correctional Center
2nd Court Appointed Expert Report
Lippert v. Godinez

Visit Date: April 23, 2018 – April 26, 2018

Prepared by the Medical Investigation Team
Mike Puisis, DO
Jack Raba, MD
Madie LaMarre MN, FNP-BC
Catherine Knox, RN, MN, CCHP-RN
Jay Shulman, DMD, MSPH

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Table of Contents
Overview............................................................................................................................... 2
Executive Summary ............................................................................................................... 2
Findings................................................................................................................................. 6
Leadership, Staffing, and Custody Functions.............................................................................. 6
Clinic Space, Sanitation, and Support Services ........................................................................... 8
Sanitation .................................................................................................................................. 15
Medical Reception .................................................................................................................... 16
Nursing Sick Call ........................................................................................................................ 18
Medical Records........................................................................................................................ 21
Urgent/Emergent Care.............................................................................................................. 23
Specialty Consultations ............................................................................................................. 29
Pharmacy and Medication Administration ............................................................................... 38
Infection Control ....................................................................................................................... 42
Radiology Services .................................................................................................................... 45
Infirmary Care ........................................................................................................................... 46
Chronic Care .............................................................................................................................. 53
Women’s Health ....................................................................................................................... 66
Dental Program ......................................................................................................................... 70
Internal Monitoring and Quality Improvement Activities ........................................................ 83
Recommendations .............................................................................................................. 87
Leadership, Staffing, and Custody Functions............................................................................ 87
Clinic Space, Sanitation, and Support Services ......................................................................... 87
Medical Reception .................................................................................................................... 88
Nursing Sick Call ........................................................................................................................ 88
Medical Records........................................................................................................................ 89
Urgent/Emergent Care.............................................................................................................. 90
Specialty Consultations ............................................................................................................. 90
Pharmacy and Medication Administration ............................................................................... 91
Infection Control ....................................................................................................................... 92
Radiology Services .................................................................................................................... 93
Infirmary Care ........................................................................................................................... 93
Chronic Care .............................................................................................................................. 94
Women’s Health ....................................................................................................................... 95
Dental Program ......................................................................................................................... 96
Internal Monitoring and Quality Improvement ...................................................................... 100
Appendix A........................................................................................................................ 102
Appendix B ........................................................................................................................ 103
Appendix C ........................................................................................................................ 104

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Overview
From April 23 through April 26, 2018, the Court Expert team visited the Logan Correctional
Center (LCC). This report describes our findings and recommendations. During this visit, we:
• Met with leadership of custody and medical
• Toured the medical services area
• Talked with health care staff
• Reviewed health records and other documents
• Interviewed inmates
We thank the Warden and staff for their assistance and cooperation in conducting the review.
LCC is the woman’s reception center for the State of Illinois. This facility was opened in 1978.
LCC was meant to hold 1,106 individuals but now holds 1806 females and is at 163% of rated
capacity. In 2013, Logan became a female-only facility.

Executive Summary
Based on a comparison of findings as identified in the First Court Expert’s report, we find that
dental care is improved and there were improvements in access to care, but all other areas
were either the same or worse than the First Court Expert’s findings. Clinical care in all areas of
record reviews appeared worse, and in some cases resulted in harm. Medication management
was much worse than described in the previous report. Although there is an electronic medical
record, it is incompletely implemented. We find that overall, the Logan Correctional Center
(LCC) is not providing adequate medical care to patients and there are systemic issues that
present ongoing risk of harm to patients and result in preventable morbidity. The deficiencies
that form the basis of this opinion are provided below.
The Wexford supervisory nurse is dedicated to business duties related to the Wexford contract
instead of being responsive to her role as supervisory nurse. This problem has been ongoing
since the First Court Expert’s report. The HCUA has too many responsibilities. Her
responsibilities include HCUA at LCC, acting Regional Coordinator for the central region,
infection control nurse, Continuous Quality Improvement coordinator, and nurse supervisor.
LCC has only one supervisory nurse, making nurse supervision ineffective. This is compounded
by lack of collaboration between IDOC leadership and Wexford leadership at this site. A
physician position has been vacant for so long that it is now filled with a nurse practitioner
position and the responsibilities of the Medical Director are such that she completes her notes
at home after normal work hours. There have been five doctors at LCC over the past four years.
Though there is only a 2% vacancy rate for the 53.15 positions, LCC had the lowest staffing rate
per thousand inmates of all the facilities we visited. LCC had 30% less staffing per thousand
inmates than NRC, the IDOC male intake facility, even though females require more testing
evaluations than males.

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Clinic space was inadequate. LCC used to be a medium security male facility and was not built
with the intention of serving as the main female intake center and main female facility. As a
result, there are inadequate numbers of examination rooms. There is insufficient equipment,
including a lack of microscopes for analyzing specimens for yeast and trichomonas infections, a
safe and functioning medical vehicle, a functioning colposcope, automated external
defibrillators (AED), and physical therapy equipment. The health units were generally clean and
well organized. Emergency response bags need to be inventoried and sealed. Negative pressure
rooms need to be monitored and logs for this purpose need to be maintained. Safety and
sanitation rounds need to include inspection of medical equipment, medical rooms including
negative pressure rooms, emergency response bags, and the training of porters. This is not
currently part of the sanitation rounds.
Intake evaluations do not include a thorough review of systems. The clinic where intake
evaluations occur does not have a microscope, which limits the ability to perform a thorough
examination related to vaginal infections. Because of the process of documenting medication
administration, it is not clear whether medication ordered in the intake area is actually
provided to the patient. Despite having identified these deficiencies, we found that the
physician assistant working in this area performed very well. He was thorough and
conscientious, and we were impressed with his work.
Access to care had some improvements, but some deficiencies identified by the First Court
Expert remained. Many, but not all, patients had timely access to care; there are a high
percentage of no shows and refusals to nurse sick call, without effort to determine the reason.
Providers do not consistently evaluate patients with medical conditions identified by nurses.
Instead, providers treat patients by remote orders without examining the patient. This is
inappropriate.
LCC uses an electronic medical record, but this record was only partly implemented and is
therefore ineffective in supporting the clinical program. Medication administration is not
electronically recorded. Obstetrical records are maintained on paper and not integrated into
the electronic record. Problem lists are improperly maintained. Problem lists include symptoms
or undiagnosed findings, which are not diagnosed problems. Because of this, there is no official
problem list we could identify used with this electronic medical record. There are insufficient
computer terminals to log onto the medical record, particularly on the infirmary, and providers
have to write their notes in an area where they are not examining the patient. This promotes
bad practice. We also noted that the electronic medical record has a feature that transfers
week-old vital sign information into a later note. This feature should be disabled, as all clinical
encounters need current vital signs. The data in the electronic record has not been able to be
used in obtaining data for quality improvement purposes. We also note that the electronic

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medical record appears to have encouraged cut and pasted notes,1 which is improper
documentation.
Unscheduled nursing evaluations are now tracked on a nursing sick call log. We found that
licensed practical nurses (LPN) and registered nurses (RN) were independently managing
patient medical conditions when they should have referred to a physician. This included
providing medications to patients and evaluating serious medical conditions that needed to be
evaluated by a licensed provider.
We found in four of six hospitalized patients that there were delays in diagnosis because of
untimely referral for higher level care. Two of these delays were extended (10.5 and 11
months). One likely resulted in dissemination of colon cancer. Four of six hospitalized patients
did not have hospital records, so it was not possible to determine what occurred at the
hospital.
We found that specialty care fails to protect patients and the current system of obtaining
specialty care should be abandoned, based on patient safety concerns. Tracking of specialty
consultations is not based on requirements of the IDOC. Referral dates are not tracked unless a
consultation is completed. We noted multiple denials of referral, even when physicians did not
appear to know how to manage the patient’s problem. We noted one patient who appeared to
not have rheumatoid arthritis, yet was being treated for several years with high dose steroid for
presumed rheumatoid arthritis, medication that was causing harm. When the patient finally
went to a rheumatologist, the rheumatologist noted no findings consistent with rheumatoid
arthritis and recommended decreasing the steroid medication. This was not done and follow up
with the rheumatologist stopped. We noted several other patients who sustained harm as a
result of lack of follow up or referral to appropriate specialty care.
We found systemic issues related to pharmacy and medication administration. The medication
room was dirty and there were opened yet undated vials of medications as well as expired
medication. Medication assistants working in the pharmacy are unlicensed and were only
provided on-the-job training, but deliver hundreds of keep-on-person (KOP) medications to
patients on a daily basis, often without documenting onto a medication administration record
(MAR). Observation of medication administration showed it was unhygienic. Similar to other
facilities, nurses pre-pour medications into improperly labeled envelopes and administer
medications without simultaneously recording administration. Patients are not positively
identified by the nurse prior to administration of the medication. Keep-on-person (KOP)
medications are delivered to patients without consistent documentation in the medical record.
Some medication administration records (MAR) were absent in 10 of 10 records reviewed and
several of these patients had MARs showing that they did not receive ordered medication.
MARs are not timely scanned into the EMR. We found other deficiencies, including orders not
Cut and pasted notes in an electronic medical record consist of copying a section or entire record of a prior note and pasting
that copied section into a more current evaluation document. Every episode of care should be documented with information
obtained during that episode of care.

1

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being transcribed to the MAR, nurses documenting continuation of medication after it had
been discontinued, and improper documentation on MARs.
LCC has no budgeted infection control staff. We noted that deficiencies identified on safety and
sanitation reports are sometimes not addressed, repeatedly. Inmate porters have not received
training and have no evidence of being vaccinated for hepatitis A or B. Negative pressure rooms
were not functional on the first day of our visit, suggesting that they are not being routinely
monitored. Paper barriers are not in evidence in all examination areas. The washer used to
launder infirmary linen still operates with water below acceptable temperature.
Radiology services are timely and there is no backlog. Access to this service is good. Equipment
appears to be in compliance with state regulations. We had concerns about the safety of the
radiology technician with respect to panorex films, as this unit does not have typical shielding,
and we question whether the technician is receiving unnecessary radiation exposure.
The infirmary was clean and organized. The infirmary lacked sufficient electronic devices for
entering information into the electronic medical record. This forced some staff to write their
notes at a later time or in other locations. The physician wrote some infirmary notes on a
routine basis well after hours and in one case over a week after the clinical event. This is
inappropriate and will lead to errors. Not all shifts on the infirmary were covered by an RN.
Weights are not tracked well at LCC, resulting in delays in initiating diagnostic testing. Patients
on the infirmary in need of specialty care often do not receive it. The use of antibiotics appears
excessive and not in line with typical standards of care, and appear guided by presumptive
diagnoses rather than an accurate diagnosis supported by diagnostic testing. We view this as a
lack of ordering appropriate diagnostic testing and referral. We could not consistently find
consultation reports for infirmary patients.
Chronic care patients are seen in a separate clinic encounter for each of their chronic illnesses.
For primary care this is inefficient, results in duplicative documentation, promotes lack of
attention to interactions between various diseases, and drug-drug interactions. Patients should
be evaluated for all of their conditions at one time and based on the degree of control of their
illness, not on an inflexible schedule. For hepatitis C, viral load testing is not performed in
accordance with IDOC hepatitis C guidelines. As with other facilities, LCC does not adhere to
contemporary standards of lipid management, immunization, or colorectal cancer screening.
Providers lack access, at the point of care, to electronic references. We noted problems in
record reviews related to chronic disease management.
There are insufficient providers to provide female specific care. Care of the pregnant females
was generally of good quality. Of 11 records of pregnant females, only one had not been timely
evaluated. However, we note that pregnancy has such high risk potential that all patients must
be timely evaluated. Referral to a high-risk OB center was in place and appeared to function
well. Screening Pap smears and mammograms were mostly done, but rates could be improved.
We note that Pap smears for HIV infected women do not occur at the recommended frequency.
We attribute lower than desired screening rates to insufficient staffing and monitoring.
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Microscopy is not used in diagnosis of vaginal infections (trichomonas, yeast, and bacterial
vaginosis). Presumably, this is done presumptively, which is not the standard of care.
The dental program has improved marginally since the First Expert Report due to the
introduction of the electronic health record. Routine treatment is timely but inadequate, since
it is not informed by a comprehensive oral examination (i.e., intraoral x-rays, a periodontal
assessment, and a treatment plan). Adequate soft tissue oral cancer examinations are not
performed at the reception screening and are not documented at biennial examinations. The
failures of the dental program documented in this report place patients at risk of tooth loss by
fostering widescale underdiagnosis and under-treatment of caries and periodontal dental
disease. The program remains below accepted professional standards and is not minimally
adequate.
The quality improvement program has no one who is trained in quality improvement
methodology and no one specifically assigned to perform quality improvement work. The
Quality Improvement Plan was inadequate. There was a lack of understanding of the difference
between outcome and process studies. There was no critical evaluation of data obtained for the
program. Mortality reviews did not include critical analysis and failed to identify correctable
problems with care.

Findings
Leadership, Staffing, and Custody Functions
Methodology: We interviewed medical and custody leadership, reviewed staffing documents,
and other pertinent documents.
First Court Expert Findings
The Director of Nursing (DON) position was vacant, significantly impacting the workload of the
Health Care Unit Administrator (HCUA). The HCUA and Medical Director positions were filled
with capable persons. The First Court Expert found that there was a strong leadership team in
place and the Warden was supportive. The Assistant Warden of Programs was a nurse. The
Medical Director was conscientious. There were 62.21 positions, with a 6% vacancy rate. The
HCUA was also acting DON and acted as the infection control nurse.
Current Findings
There was no significant change compared to the findings of the First Court Expert. LCC now has
a HCUA, Medical Director, and DON. The HCUA has been in her position since the time of the
First Court Expert’s visit. She is experienced, but similar to the First Court Expert findings, has
too many responsibilities. She is the HCUA at LCC, is filling in as the IDOC Central Regional
Coordinator, is the LCC Continuous Quality Improvement Coordinator, covers as the infection
control nurse at LCC, and also provides some nurse supervision. It is not possible to effectively
manage all those responsibilities.
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Nursing supervision is inadequate. The Schedule E has no DON position, but recently a DON
position was created and has been recently filled. Prior to this position being filled, the Wexford
supervisory nurse was the only nurse supervisor. However, the supervisory nurse, according to
the HCUA, spends much of her time performing business duties as the Wexford site manager
and is not supervising nurses. For this reason, a DON position was created. The Schedule E
nursing supervisor positions will apparently continue to perform business duties. The lack of
participation in nursing supervision by the Wexford supervisory nurse has increased the work of
the HCUA. This is made worse because the HCUA cannot schedule or discipline nurses, who are
all Wexford staff. The HCUA told me that whichever nurse is assigned to respond to
emergencies (referred to as the desk nurse) is the effective nurse supervisor. This is not
effective supervision. The new Wexford DON and nursing supervisor were both ill and not
present during our visit; therefore, we were unable to speak with them.
We were impressed by the enthusiasm and dedication to improvement of the HCUA and the
direction she has provided to the program. However, her work has not yet been complemented
by coordination with Wexford leadership staff. The reasons for this are unclear, but do appear
to affect the program. The absence of apparent collaboration between the HCUA at this facility
and Wexford management is a lost opportunity in making improvements.
There are two physician positions at LCC, the Medical Director, and a staff physician. The
Medical Director has been in her position since May of 2016. The staff physician position has
not been filled for some time. Because of the extended length of vacancy, the program has
filled the vacant physician position with another nurse practitioner. The failure to fill the
physician position with a qualified physician overburdens the Medical Director, who needs to
see all infirmary patients and all complicated patients. Nurse practitioners manage all patients
with chronic illness. The Medical Director cannot complete her work during daytime hours. In
particular, admission and discharge notes for the infirmary have been a problem significant
enough to study this issue as a CQI study. The Medical Director will see patients during the day
and often completes her notes at night while at home. We found some notes written as late as
midnight two days after the patient was apparently evaluated and one note written over a
week after the episode of care. This is not a good practice and can lead to errors. The
overwhelming clinical burden for the Medical Director also results in less available time to work
with the HCUA in improving systemic problems at the facility.
As we will describe in the section of Women’s Health later in this report, there are insufficient
providers to handle the volume of female specific health needs. This should be addressed.
There has been considerable physician turnover at the LCC. Since 2014, there have been five
doctors at LCC. The inability to consistently fill physician positions with qualified physicians has
been an ongoing problem at this facility. The failure of Wexford to fill physician positions
significantly impacts the program. We do not agree with the substitution of the staff physician
with a nurse practitioner. The inability to recruit and retain physicians has resulted in the
program reducing its physician coverage.

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This facility has all Wexford staff except for the HCUA, who is a state employee. The Schedule E
provided prior to our visit is not entirely accurate. The vacant staff physician position has been
changed to a nurse practitioner position, and a DON position has been created. Given these
changes, there are 53.15 positions in the medical program, of which only one is vacant.2 This is
a 2% vacancy rate, which is very good. Based on a population of 1806, there are 29.4 staff
positions per 1000 inmates, which is the lowest staffing rate of all facilities we visited. NRC, the
male intake facility, had 41 staff per 1000 inmates; LCC has 30% less staffing than NRC, even
though female intake requires more work because of the additional examinations and testing
needed. In our opinion, there are insufficient RN positions. LPNs perform independent
evaluations, which they should not be doing. Vital signs are not obtained consistently for all
clinical encounters and monitoring of infirmary patients could be more thorough. We do not
agree with having a single physician at this facility, and the lack of ability to recruit physicians
negatively affects clinical care of patients.
The LCC operational policies were last reviewed on September 15, 2016. However, the actual
policies appear dated and are not completely pertinent to the current facility. The receiving
screening policy gives no specific direction with respect to how reception screening at LCC is to
occur. This policy is a generic policy which does not even list the requirements of testing or
evaluations that are required by the Administrative Directives (AD). The medical records policy
is still similar to generic IDOC policy with respect to the paper record, even though LCC now has
a partial electronic medical record (EMR). The policy does not address down-time procedures
for the electronic record, does not address how medication administration records (MARs) are
placed into the electronic record or how offsite consultation reports are placed into the
electronic record. This is important because, as we learned, medical record documents can be
dated in the electronic record based on the date of scanning into the record or based on the
date of service. This process should be established by policy so that it is clear to clinical staff
when a clinical event occurred.

Clinic Space, Sanitation, and Support Services
Methodology: Accompanied by a Wexford staff assistant, the experts inspected the single-story
health care building, which housed the main medical care clinical unit, with medical exams
rooms, nurse sick call rooms, one exam room/treatment room, dental clinic, telehealth rooms,
x-ray suite, optometry clinic, medication storage room, nurse medication preparation rooms,
injectable medication (enoxaparin, insulin, etc.) administration windows, medical records
department, infirmary, supply storeroom, health care administrative and clinician offices, and a
conference room. Accompanied by the HCUA, we separately visited the housing unit #6,
commonly referred to as the Americans with Disability Act (ADA) unit, and inspected patient
rooms, showers and toilets, day room, and the physical therapy room. We also toured the
clinical space in building X Reception and intake screening unit. We reviewed the Safety and
Sanitation reports for the months of July, August, November, December 2017, and February
2018.
2

See Appendix A for a staffing table for this facility.

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First Court Expert Findings
The First Court Expert found the clinical areas at LCC reasonably clean and well maintained. The
First Court Expert raised concerns that the noise level in the medical reception building made it
difficult to properly interview and communicate with new admissions during the intake history
and evaluations.
Current Findings
• The infirmary beds were all hospital beds in good condition with adjustable heights,
heads, and legs. The three crisis room beds were elevated concrete slabs with
mattresses.
• The battery powered nurse call devices located in the infirmary patient rooms were
functional. The crisis rooms were located in direct line of sight from the infirmary
nursing stations and did not have call devices.
• Only one of the infirmary’s three negative pressure rooms was adequately functioning.
The engineering staff corrected this problem during the site visit. The nursing staff had
not noted nor reported this malfunction in their daily log.
• The five exam rooms in the medical building were not sufficient to accommodate the
number of anticipated users. There is a Medical Director, four nurse practitioner
positions, a part time obstetrician, and two sick call nurses. Each should have an open
and fully equipped examination room. Based on the budget there is need for 7.5
examination rooms. It is our opinion that an additional physician is needed. The planned
conversion of one nursing office in the outpatient clinic into an additional provider room
will still not provide sufficient space for the number of anticipated users.
• The telehealth room used for monthly UIC HIV and hepatitis C care and infrequently
scheduled renal specialty consultation, is also utilized by the OB-GYN specialist for
obstetrical Doppler ultrasound evaluation and by a contracted general US technician for
general ultrasonography exams. The room is clean and modestly, but adequately, sized.
The telehealth room schedule is arranged so that there is no competition for this space.
• Most but not all of the medical equipment and devices in the medical building had
documentation of annual inspection by biomedical engineering. However, the
obstetrical Doppler ultrasound, the capillary blood glucose testing units, one oxygen
concentrator, one Gomco suction machine, and one IVAC unit did not have current
inspection labels.
• The colposcope has exceeded its functional life span, has broken parts that are not able
to be repaired, and needs to be replaced.
• There was only one operational AED at LCC during the time of the site visit. A single AED
at a correctional facility with the population and geographic size of LCC is not adequate
to enable a timely and effective emergency response.
• The medical vehicle used to move emergency staff throughout the expansive campus
needs to be replaced. Its doors were difficult to open.
• The two emergency response bags on the campus (one in the medical vehicle, the other
in the outpatient clinic equipment room) were both unsealed.

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•

•

Monthly safety and sanitation inspections and reports are being done by the health care
team at LCC. The current inspections focus on physical plant issues (toilets, infestations,
mold/mildew, etc.) that must be addressed and corrected by the correctional
leadership.
The safety and sanitation reports do not include documentation of the condition,
functionality, and certification of clinical equipment or adequacy of clinical space.

The vast majority of the inmate population is housed in multiple residential buildings, each of
which are divided into small dormitories. There is a separate reception building (X-building)
where all new admissions are housed until intake screening is fully completed. All medical
health care for patient-inmates who have completed the intake screening and have been
assigned to a sentenced housing unit is provided in the single story medical building that is
located in the central area of the LCC campus. This medical unit is approximately 300 to 1000
feet from inmate housing. Inmates who cannot walk are pushed in wheelchairs by inmate
workers or transported in a correctional van to the medical building for all of their care needs.
The single floor linear medical building is the hub of the health care delivery services provided
at LCC; it is separated into two sections, with the patient-inmate entrance in the middle of the
two sections. Ambulatory care services are located in one wing and the other wing houses the
infirmary, biohazardous waste room, medication storage and preparation room, injectable and
KOP medication delivery area, medical records, health care administration, optometry room,
and dental services.
A correctional staff station is situated at the entrance in the medical building. At this security
station there is a video monitor that receives live feed from the infirmary rooms. Correctional
officers were at this station during the entire four-day visit of the Experts. Officers stated that
they also do visual checks of the infirmary rooms at 30-minute intervals, but the experts seldom
saw correctional staff in either wing of the medical building. Directly across from the security
station was a patient-inmate waiting area with bench seating that could accommodate
approximately 15 women.
The ambulatory care wing of the medical building has a centralized nurse station and five
private exam rooms, a telehealth room, an equipment storeroom, a phlebotomy room, and two
nurse offices. There is a centralized nursing station in the outpatient clinic area with an open
counter, two chairs, computer monitors, and supply cabinets. The station was clean and
organized.
Two of the exam rooms are used for nurse sick call; one of these rooms is shared with the OBGYN specialist, who is onsite two to three days per week. The other three exam rooms are used
by the physician and three nurse practitioners; one additional nurse practitioner position is
vacant. There is an insufficient number of exam rooms. There are 5.5 budgeted providers and
two sick call nurses. It is our opinion that an additional physician is needed. The five
examination rooms are insufficient to accommodate the 7.5 budgeted staff who have need of
an examination room.
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Each exam room has an exam table, computer monitor, desk, two chairs, wall mounted otoophthalmoscope unit, liquid soap or sanitizer solution, paper hand towels, mounted sharps
container, and a supply cabinet. Four of the five exam rooms had a sink with hot and cold
water; the chronic care nurse practitioner room had hand sanitizer in the room without a sink.
Three of the five exam tables had a paper barrier in place. The oto-ophthalmoscope was fully
operational in four of five rooms; the ophthalmoscope head was not functional in one room.
The exam tables were in good condition, but a few had unsealed minor tears that made the
tables difficult to fully sanitize. Only one sink had a small amount of mineral deposit. Oxygen
tanks were stored in the two exam rooms, but the tanks were only stored in safety racks in one
of the rooms. The OB-GYN room had a gooseneck lamp and a cryosurgery unit with three
cryosurgery/liquid nitrogen tanks; only one of the tanks were secured in a safety rack. Only one
of the provider rooms has a functional microscope with slides, cover slips, and normal saline,
but the microscope was dusty and appears to be infrequently used. A new nurse practitioner
stated that she had not yet been trained to perform vaginal wet mounts3. This same room has
disposable gynecology specula with a functional attachable light source and a supply of thin
prep solution containers. The physician’s exam room had a sealed medication cart that had
documented daily inspections noted on a log. The exam rooms were generally clean and
adequately organized.
The telehealth room has a chair, an exam table, and a telemonitor with a stethoscope
attachment. UIC infectious disease specialists schedule monthly half-day sessions for the
management of HIV and hepatitis C patients, and a Wexford contracted nephrologist provides
teleconsultation on an infrequent “as needed” basis. LCC’s contracted OB-GYN specialist uses
this room to perform obstetrical Doppler ultrasonography on a weekly basis. Once a month a
contracted ultrasound technician also does general ultrasonography studies in this room. The
schedule for the utilization of this room accommodates the part-time needs of these four
services. There is no sink or hand sanitizer in this room which should be present as clinical
evaluations are performed.
The phlebotomy room is staffed by two phlebotomists who split their time between the
reception center and the medical building. The lab room has a phlebotomy chair, a refrigerator,
a sink with hot and cold water, soap and paper towels, a sharps box, a centrifuge, and a
computer monitor. The refrigerator was empty and the freezer compartment needed to be
defrosted. Lab specimens are sent to the UIC laboratory and result turnaround time was
reported to be 24-48 hours. The room was clean and organized.
The radiology suite has chest x-ray and plain film units and a mammography machine in a
shielded room. A panorex unit is located in an internal corridor that leads into the radiology
technician work area. The suite is staffed by a radiology technician on Monday, Wednesday,
Typically, female examination rooms in female centers, particularly intake centers, have microscopes in the examination
rooms. These are used to examine vaginal specimens to identify yeast and trichomonas infections. A vaginal smear is applied to
a microscope slide and examined under the microscope. Alternatives to this are to perform yeast culture or nucleic acid
amplification tests (NAAT), which are expensive to perform. When microscopes are unavailable, there is greater propensity to
guess regarding diagnoses, which is not appropriate.
3

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and Friday. A contract mammography technician performs mammography studies on Tuesday
and Thursday. (Further findings about the radiology services are detailed in the Radiology
Services section.)
There were two nurse offices adjacent to the nursing stations. The chronic care nurse occupies
one these rooms to arrange chronic care schedules and statistics. The other room was used by
two nurses but will soon be converted into a sixth exam room.
An equipment room contained a back board, a tool control rack, and an emergency response
bag. There was a log that tracked the tool count on each shift. The emergency response bag
was unsealed and contained a very limited amount of medical supplies. It was communicated
that this emergency response bag was the backup bag for the medical team. Injectable
glucagon and EpiPen in the backup bag were current but will expire within the next few weeks.
It is unacceptable to have an unsealed emergency response bag in the medical building. This
bag would be of limited use in the case of an emergency at LCC. An automated external
defibrillator (AED) used to be stored in this room but the unit was reported to be out for
repairs. The only AED and fully stocked emergency response bag for the entire 1,700-bed
institution is kept in the medical vehicle that is parked at the back door of the medical building.
LCC does not have a crash cart. The institution performs basic CPR, applies the AED, and calls
911 for cardiac arrests. This is an acceptable option for responding to codes/cardiac arrests.
An ambulatory clinic nurse escorted the expert to inspect the medical vehicle, an aging four
door Jeep-like vehicle. This vehicle is only used to transport clinical staff to the injured or ill
patient-inmate. This vehicle is never used to transport patients. The rusted rear side and the
trunk doors were extremely difficult to open. The emergency bag was stocked with supplies
and equipment including a stethoscope, oral airways, ambu bag, bandage material, neck
braces, glucagon, EpiPen, and a blood glucose monitor. A full oxygen tank, an operational AED,
and current AED pads were in different sections of the vehicle. The emergency response bag
was not sealed. The emergency response bag, equipment, and supplies were not stored in an
organized, easily retrievable way in the vehicle. It was obvious that the bag was not easily
accessible. A review of the inspection logs for February and March 2018 (April’s log was
missing) documented no deficiencies concerning the van’s emergency response bag. However,
the inspections were not done on 17 (28%) of the 59 days in these months. The unsealed,
unchecked emergency response bag may not contain all the supplies, medications, and
equipment needed to effectively respond to an emergency. The emergency response bag must
be checked and sealed; the emergency equipment must be organized in the vehicle so that it
can be readily accessed. The aging vehicle’s doors must be repaired, or the vehicle must be
replaced.
A single AED at a correctional facility the size of LCC is not adequate to enable a timely and
potentially effective emergency response to a patient-inmate or a correctional or medical staff
member who has a cardiac arrest. An AED must always be kept in the medical building to be
able to expeditiously respond to emergencies in the high-risk infirmary and to the large number
of acute and chronic patients being treated in the ambulatory clinic. Additional AEDs should be
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placed in various locations on the LCC campus to minimize emergency response times. The
HCUA advised the experts that a request has been or will be made for six additional AEDs.
A correctional transportation van was inspected. The van had two rows of seats; all the seats
had seat belts. There was room in the first row to accommodate a wheel chair. A patientinmate in building #6 who has had multiple offsite specialty visits communicated that vans had
seat belts that she always used.
A few dated medical and pharmaceutical references were found in exam rooms. Providers
stated that they believe that there was a way to access UpToDate electronic medical reference
via the EMR, but they did not know how to do this. One nurse practitioner communicated that
she uses the physician assistant’s private purchase access codes to access UpToDate. The
physician stated that she uses Google to access clinical information as needed. All medical and
nursing staff at LCC should have ready access to current online medical reference systems such
as UpToDate.
A two-chair dental suite is situated behind the correctional office station at the entrance to the
medical building. (The physical space and the dental equipment will be addressed in the Dental
Services section).
Building #6 is a single-floor structure that houses 131 women, many of whom have difficulty
with ambulation or require ambulatory assistive devices (cane, crutches, wheel chairs, walkers).
The entrance of the building opens into a large common dayroom with tables, chairs, and two
flat screen televisions; the security desk is situated in the day room. Patient-inmates sign a sick
call list, noting only their names, not their health care concern, when they seek non-urgent
care. The list is kept at the security desk, picked up in the evening, and brought to the medical
building. Four women were interviewed; they all stated that they are generally seen by a nurse
on the next work day after they submit a sick call request. Women are housed in two wings that
open into the dayroom in rooms with two, four, and six-bed rooms. Women have keys to their
rooms. All the beds are bunk beds; women with disabilities or at risk for fall are assigned to the
lower bunk. Each wing has a common shower and toilet area. The showers are handicap
accessible with safety grab bars and shower chairs. At least one toilet in each shower/bathroom
was wheelchair accessible. There was a large patch of tile missing in one of the bathrooms that
would be difficult to adequately sanitize. It was reported to the Expert that a work order had
been placed to replace the missing tile. That same bathroom had a section of frayed insulation
of undetermined material wrapped around a pipe at about shoulder level height; this was
communicated to the facility engineer, who said that he would correct this concern.
The physical therapy (PT) room is located in building #6 at the back of the dayroom. The PT
room is moderately sized and is equipped with two exercise bicycles, one treadmill, a set of
parallel bars, and two exercise tables. Locating the PT room in building #6 is quite appropriate
and enhances access for the physically challenged population who are housed in this building.
However, the PT room is sparsely equipped, even obviously underequipped, when compared to
the physical therapy units serving the male populations at SCC and DCC. The physical therapist
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also goes to the infirmary and building #14 (mental health) to provide physical therapy services
as needed.
Because a partial electronic medical record is used, the medical record area consists of a single
room used to manage MAR documents and other paper documents such as outside consultant
reports. This room connects the dental, optometry, and supply storage areas with health care
administrative offices, conference room, and staff locker room/breakroom.
The 15-bed infirmary is located at the opposite end of the medical building from the
ambulatory care wing. The nursing station with an adjacent medication/supply/equipment
room is located at the beginning of the infirmary corridor. Four patient rooms had two beds per
room with a toilet in each two-person room. There were seven single-bed rooms; three of these
single person rooms were crisis/negative pressure rooms located directly in front of the nursing
station. Relatively new, excellent condition hospital beds with adjustable heights and head and
lower extremity sections were in all the single (non-crisis) and two-person rooms. Nurse call
devices were mounted on the walls next to each bed in the non-crisis rooms; four were tested
and found to be functioning. The infirmary nurse quickly responded to an unannounced
activated device. The three crisis/negative pressure rooms had concrete beds with a mattress.
There were no nurse call devices in the crisis rooms. All patient rooms in the infirmary were
clean, neat, and organized. The negative pressure monitor at the nursing station was turned on
and indicated that at least one of the negative pressure units was not operational. Utilizing the
tissue paper test used by the infirmary nursing staff, it was identified that two of the negative
pressure units were not functioning properly. A review of the April 2018 infirmary logs noted
that the negative pressure was not checked regularly but no deficiencies had been
documented. The facility’s engineer adjusted the control unit and all three negative pressure
units were fully operational before the end of the Experts’ visit.
A central infirmary nursing station had an open counter, computer monitor, and supply
cabinets. An adequately sized medication preparation, medical supply, and equipment room
was located immediately behind the nurse station. There were two Gomco suction machines,
two IVAC units, and one oxygen concentrator in the storeroom. One Gomco, one IVAC, and the
oxygen concentrator did not have current annual inspection labels. A single person shower
room that could accommodate a wheelchair was situated near the nursing station. A biohazard
room was located on the unit; the room was clean, waste material bagged, and sharps
containers locked. It was reported that a biohazard waste vendor removes the material one to
two times per week.
Monthly safety and sanitation inspections are being done in the health care areas, dietary, and
housing units. The rounds have appropriately identified problems with the maintenance of the
physical plant that could have a negative impact on the safety and health of the patientinmates and the correctional and medical staff. However, these environmental rounds do not
inspect or monitor the condition, function, and annual certification of clinical equipment,
functionality of the negative pressure rooms, integrity of bed and chair upholstery, completion
of medical cart and emergency response bag logs, the training of health care unit porters, and
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other health care issues. The safety and sanitation inspection should be expanded to focus
more attention on the beds, clinical equipment, and the training of the infirmary and health
care unit porters. Alternatively, separate healthcare-specific environmental rounds should be
initiated. The findings of environmental rounds and the safety and sanitation inspections should
be reported to the Quality Improvement Committee.
In summary, with the exception of the medication room, the medical building was generally
clean and organized. The clinical space was generally adequate to address the needs of the LCC
patient population with the exception of the five existing exam rooms which are not sufficient
to accommodate the facility’s 7.5 FTE clinical staff assigned to nurse and provider sick call,
specialty care, and chronic care clinic. The facility has an inadequate number of AEDs to provide
timely emergency response in the all clinical and housing units on the expansive LCC campus.
The medical vehicle is defective and needs to be repaired and/or replaced. All medical
equipment did not have evidence of current annual inspection. The emergency response bags
were not sealed and not checked on a daily basis. The infirmary negative pressure room logs
did not note that two of the negative pressure rooms were not functional and that the
monitoring panel at the nurse station was not accurately indicating the lack of adequate
negative pressure.
We agree with the recommendations of the First Court Expert. We have additional
recommendations found at the end of this report.

Sanitation
Methodology: The medical building, the physical therapy room in building #6, and the
reception center in the X-building were inspected. Nurses, infirmary patient-inmates, and
inmate porters were interviewed.
First Court Expert Findings
The First Court Expert reported that the infirmary porters were provided with orientation to the
health care unit that included proper cleaning and sanitation procedures.
Current Findings
• The clinical areas in the medical building, building #6, and building X’s reception center
were generally clean. One exception was the medication room. Floor and countertops
were dirty. The medication refrigerator was in need of cleaning. The staff food
refrigerator was very dirty, with liquid spills and food debris. The room was notably
cluttered and disorganized.
• One sink in the outpatient clinic and in the reception center has crusted mineral
deposits.
• The shower on one wing of building #6 ADA housing unit had a large section of tile
missing from the wall and a frayed insulation sleeve around an accessible water pipe.
This deficiency makes it impossible to fully sanitize this area.

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•

There was no documentation that the three infirmary porters had been fully trained in
the duties and risks of working on a health care unit with potential exposure to body
fluids or had received hepatitis B vaccination.

Overall, the clinical areas at LCC were clean, organized and well maintained. A few exceptions
were noted. One was the medication room used to store pharmaceuticals (see Pharmacy and
Medication Administration Section). Another area was the common showers/bathrooms in
building #6 had a large patch of missing tile on a wall. Although most sinks were clean, one sink
in an exam room in the medical building and another in the reception center were crusted with
mineral deposits. The shower wall and the crusted sinks are not able to be properly cleaned and
sanitized.
Inmate porters clean, sweep, and sanitize all clinical areas at LCC. Three porters in the infirmary
were interviewed. One had been the infirmary porter for a long period of time, the other two
were recently assigned to the infirmary. In addition to cleaning the infirmary, they wash patient
linens in the non-industrial washer and dryer in the infirmary and occasionally assist nurses
with patient transfers in and out of beds/chairs. The experienced porter remembered having
received some training in the past; the other two stated that they had only received some onthe-job-training. None were sure if they had been vaccinated against hepatitis B (or A). The
EMRs of the three porters were reviewed; we found no evidence that they had received blood
borne disease education or formal job duty training. There was no documentation in their
medical records that they were immune to hepatitis B (or A) or if they had been vaccinated
against hepatitis B (or A). The Wexford staff assistant who is responsible for the training of
infirmary porters also was unable to provide documentation that the three porters had been
trained or vaccinated.4
In summary, the sanitation of the health care units was adequate overall, but we identified
problems as noted above.
The First Court Expert made no specific recommendations concerning sanitation. We have
recommendations that are found at the end of this report.

Medical Reception
Methodology: To assess medical evaluation of newly arriving inmates, we toured the medical
reception area, interviewed health care staff, reviewed IDOC health record forms, and reviewed
10 health records.
First Court Expert Findings
The previous Court Expert found that the medical reception process timely took place following
the patient’s arrival, but there were opportunities for improvement. The initial nurse intake
screen took place in a noisy area that interfered with the nurse’s ability to hear the patient.
4

Infirmary Patients #5, 6, 7.

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Patients arrived without medical transfer information from the jail. There were deficiencies in
the quality of patient medical histories, problems with follow-up of medical conditions, and
untimely follow up of patients with chronic diseases.
Current Findings
We found that the medical reception process has improved from the First Court Expert’s report
and we also found areas needing improvement.
Medical reception is performed in the B-Wing of X-building. The room where nurses perform
intake screening has been moved from the main medical unit to B-Wing. The room is not
optimal. It is small and has no sink, but did have hand sanitizer. The examination room used by
the medical provider is larger and has an exam table and sink. The exam table cover is torn,
preventing inadequate infection prevention, and should be repaired or replaced. The
ophthalmoscope head is missing. The provider reported that he did not have a large blood
pressure cuff. There is no microscope for the provider to use to diagnose vaginal infections.
Both rooms had gloves, sharps, and biohazardous waste containers.
Medical records show that medical transfer information was sent with the patient and available
for nurse and provider review. Medications were usually ordered on the day of arrival, but
medication administration records (MARs) do not reflect that medications were received within
24 hours and in some cases, not at all. Nurses ordered intake labs according to protocols that
were typically performed within a day or two of arrival. Lab reports were generally available at
the time of the physical examination. A concern is that nurses do not consistently perform and
document urine pregnancy testing in the medical record, which may lead to missed pregnancy.
A provider performed a physical examination in seven days or less in eight (80%) of 10 records
reviewed (range=1-12 days). The provider generally addressed the patient’s medical history but
did not consistently perform a review of systems (ROS) to assess disease control at the time of
arrival. The medical provider performed thorough physical examinations including pelvic exam
and Pap smear. The provider tests patients with vaginal discharge for chlamydia and gonorrhea,
but did not have a microscope to diagnose patients with other common infections, such as
trichomonas, yeast, and bacterial vaginosis, and treated these infections empirically. However,
due to problems related to inconsistent transcription of medication orders onto a MAR, nurses
did not consistently document administration of medications for treatment of vaginal infections
onto a MAR.
The provider developed an appropriate treatment plan for each medical condition and followed
up on abnormal labs. Mammograms were ordered and completed in accordance with
recommended guidelines. The provider referred patients to the chronic disease program and
initial visits usually took place within 30 days. The medical provider initiated the problem list,
but did not consistently include all pertinent medical diagnoses, including TB infection.
Although there are opportunities for improvement, we were impressed with the physician
assistant who performs physical examinations. His medical care is very thorough and
conscientious.
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Nursing Sick Call
Methodology: We evaluated nursing sick call by reviewing IDOC Administrative Directive
Offender Health Care Services, (04.03.103K), Wexford Non-Emergency Health Care Requests
and Services (P-103), IDOC Treatment Protocols, and the Logan Offender Handbook. We also
interviewed health care leadership, staff, and inmates, inspected areas where sick call is
conducted, and reviewed tracking logs and health records.
First Court Expert Findings
The previous Court Expert found that nursing sick call was conducted seven days per week.
Inmates accessed sick all by submitting a health services request form that nurses triaged, and
then the patient was scheduled to be seen by a nurse. In X-house where segregation, maximum
security and reception inmates were housed, nurses conducted sick call cell-side, without
privacy or performing an examination, despite there being an examination room where sick call
could be performed. Licensed practical nurses (LPNs) performed independent nursing
assessments, which is beyond the scope of practice for an LPN in the State of Illinois.
Current Findings
Our review showed some improvements with respect to access to care and confirmed that
certain conditions found by the First Court Expert remain. The system does not yet ensure
timely access to care.
Sick call is still conducted seven days per week. The process for inmates to access sick call has
changed since the previous Expert’s report. To access sick call, inmates sign up for sick call on a
sheet of paper in the housing unit rather than submitting a written request with the nature of
the complaint. The exception is segregation, where the officer maintains control of the sign-up
sheet and writes the inmate’s name on the sheet. Health care staff pick up the sign-up sheets
each evening, but the replacement sign-up sheets are not delivered until the next morning.
Therefore, there is an approximately 12-hour gap where inmates are unable to sign up for sick
call. The Logan Offender Handbook has not been changed to reflect the new process.
Health care leadership reported that all inmates are supposed to be seen the day after signing
up; however, our record review showed that in some cases, inmates were not seen for two
days after they signed up. This is a concern because if health care staff cannot see all patients
within 24 hours, they need to be able to triage patients according to the urgency of their
complaint. However, this is not possible because inmates do not document the nature of the
complaint on the sign-up sheet.
We reviewed inmate sign-up sheets and noted that there were missing sign-up sheets each
month. For example, according to notes on the stacks of sign-up sheets, there were sign-up
sheets missing for 2/21, 2/23, 2/25, 2/26, 2/27, 2/28, 3/1, 2/2, 3/3, and 3/4/18. This is
significant because the sign-up sheet is the only documentation that the patient submitted a
health request. If sign-up sheets are missing, there is no record that the patient requested care.

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Review of available sign-up sheets show that on some days there were very high numbers of no
shows or refusals. For example:
• On 1/5/18, 56 inmates signed up for sick call and there were 22 (39%) no shows or
refusals;
• On 1/7/18, 62 inmates signed up and there were 35 (56%) no shows or refusals;
• On 1/26/18, 61 inmates signed up and there were 20 (33%) no shows or refusals; and
• On 3/6/18, 46 inmates signed up and there were 19 (41%) no shows or refusals.
These are extremely high no shows/refusal rates; however, these high no show/refusal rates
have not been studied under the auspices of the CQI program to determine whether barriers to
access to care exist. We interviewed staff and inmates as to why inmates no show for sick call.
One reason given is that inmates sign up to meet other inmates for social reasons, and then do
not come to sick call. Another reason given is that inmates wait long periods of time for their
appointments. Staff and inmate interviews indicate that the sick call nurse responds to
emergencies on the compound, and when this occurs, inmates waiting to be seen do not know
how long the nurse will be unavailable and therefore return to their housing unit. At least on
one occasion, a lockdown was a barrier to care. On 1/8/18, four patients were noted not to be
seen due a lockdown. We reviewed each of these records and found that patients were not
rescheduled for sick call and were not seen.
The HCUA reported that all inmates are escorted to an examination room to be assessed by a
nurse, either in the main medical unit or housing units. However, in X-building where
segregated inmates are housed, correctional officers do not escort inmates to a clinic area and
nurses still perform cell-front assessments which does not permit an adequate assessment.
We reviewed 26 health requests in 22 records, which included four patients noted above not
seen due to a lockdown (15%).5 Of the remaining 22 health requests, we found that in 14 (54%)
cases patients were seen the next day,6 four (15%) patients were seen in two days,7 and four
(15%) patients were not seen due to no show, refusal, or unknown reason.8 Thus, 69% of
patients were seen in one to two days, but 31% were not seen due to lockdown, no show or
refusal. Two of the patients seen by a nurse in two days were housed in segregation.
At LCC, both RNs and LPNs perform sick call using treatment protocols. In the State of Illinois,
LPNs are to practice “under the guidance of a registered professional nurse, or an advanced
practice registered nurse, or as directed by a physician assistant, physician…to include
“conducting a focused nursing assessment and contributing to the ongoing assessment of the
patient performed by the registered professional nurse.” LPNs may also collaborate in the
development and modifications of the RN or APRN’s plan of care, implement aspects of the
plan of care, participate in health teaching and counseling, and serve as an advocate for the
Sick Call Patients #5, 6, 7, and 8.
Sick Call Patients #1, 2, 3, 4, 9, 12, 14 (four separate requests), 15 (two separate requests), 16, and #21 .
7 Sick Call Patients #11, 19, 20, and 22.
8 Sick Call Patients #10, 13, 17 and 18.
5
6

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patient by communicating and collaborating with other health service personnel.9 However,
Illinois scope of practice does not permit LPN’s to perform assessments independent of a
registered professional nurse or higher level professional, as is currently being done at LCC.
Neither does the scope of practice permit LPNs to perform independent assessments according
to protocols. LPNs do not have requisite education and training, including physical assessment
skills needed to perform independent assessments.10 Thus, some LCC patients do not receive
evaluations by health care staff licensed to perform independent assessments. This increases
the risk of harm to patients.
Record review showed that some patients who require a medical diagnosis are assessed only by
a nurse and not medically evaluated by a provider and/or do not receive ordered medical
treatment. The following examples are illustrative:
•

A 28-year-old presented to a nurse on 1/16/18 for urinary frequency with foul-smelling
urine.11 The patient reported a history of urinary tract infections and that the nurse
practitioner told her at intake she might have a yeast infection. A urine dipstick was normal.
The nurse contacted a provider, who did not examine the patient but ordered Flagyl (which
is not used to treat yeast infections). On 1/30/18, a registered nurse saw the patient again
for the exact same complaint. The RN notified a provider, who did not see the patient but
again ordered Flagyl. This patient did not receive a medical diagnosis for her condition.

•

A 48-year-old woman with a history of left eye trauma and artificial eye was seen by an LPN,
who noted the patient had swelling of the upper and lower eyelids for the artificial eye.12
There is no documentation that the LPN contacted a provider, and a provider did not
examine the patient. There was an order for topical and oral antibiotics, artificial tears, and
referral to an eye doctor. On 1/18/18, an optometrist saw the patient and ordered another
five days of oral antibiotics. There is no January 2018 medication administration record
(MAR) in the record to show the patient received the medications. A provider has not seen
the patient for follow-up for her eye infection.

•

A 42-year-old woman signed up for sick call on 1/14/18 and a LPN saw her on 1/16/18. The
patient complained of a herpes infection. The LPN did not perform an examination but
called a provider, who ordered acyclovir. The medication order was not transcribed onto a
medication administration record and there is no documentation the patient received the
medication.13

Illinois LPN Scope of Practice. Section 55-30.
NCCHC defines Qualified Health Care Professionals to include nurses without distinguishing between registered and licensed
practical nurses. However, RN and LPN practice must remain within their education, training and scope of practice for their
respective state.
11 Nursing Sick Call Patient #15.
12 Nursing Sick Call Patient #12.
13 Nursing Sick Call Patient #11.
9

10

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•

A 54-year-old woman signed up for sick call on 1/20/18, but not seen due to No Show. On
1/25/18, a nurse saw the patient, who stated that on 1/20/18 she fell on her left wrist and
heard a “pop.” It hurt to move her fingers and wrist. The nurse noted swelling to her wrist
and hand. The nurse contacted a nurse practitioner, who did not see the patient but
ordered ice, an Ace wrap and x-ray that was performed on 1/31/18 and showed no fracture.
The patient had no follow-up for her wrist.14

•

A 36-year-old woman signed up for sick call on 2/19/18 and a registered nurse saw the
patient on 2/21/18. The patient complained of herpes simplex and the nurse contacted a
provider, who did not see the patient but ordered acyclovir. There is no February 2018 MAR
that shows whether the patient received the medication.15

These cases show a pattern of patients not being examined by a medical provider to establish a
medical diagnosis or see the patient for follow-up to determine whether the patient’s condition
had improved. Several records show that there is no documentation that ordered medications
were received.
In summary, while many patients have timely access to a nurse, not all patients are seen the
following day, and there are a high percentage of no shows and refusals. In addition, patients
requiring a medical diagnosis are not timely seen by a medical provider. Instead, providers treat
patients remotely and do not schedule patients for follow up to assess whether their conditions
have improved. This is a particular concern in light of the lack of documentation that patients
receive ordered medications.

Medical Records
Methodology: We reviewed multiple medical records and interviewed staff.
First Court Expert Findings
The First Court Expert had no findings with respect to medical records. The First Court Expert
did have three recommendations. The first was that medical records staff should track receipt
of all outside reports and ensure that they are filed timely in the health record. The second
recommendation was that charts should be thinned regularly, and MARs filed timely. The third
was that problem lists should be kept up to date.
Current Findings
This facility partially implemented the Pearl® EMR in 2014. The electronic record is an
improvement, but the partial implementation of the record has created other problems and
makes the electronic record ineffective in supporting the clinical program.

14
15

Nursing Sick Call Patient #13.
Nursing Sick Call Patient #19.

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The electronic medication administration component has not been implemented. As a result,
medication administration records are on paper. The First Court Expert’s second
recommendation that charts be regularly thinned is no longer pertinent. Many reports of
outside consultants are still unavailable in the medical record. This is not a problem of the
electronic record but is related to effort of Wexford management in obtaining these reports.
The First Court Expert’s recommendation to keep problem lists up to date has not been
effectively addressed.
The EMR has interfaces with the pharmacy and with the laboratory vendor. Doctors write
prescription orders electronically and these are received by BosWell, the pharmacy used by
Wexford. These orders appear in the record. The current list of medications appears in progress
notes. Laboratory results can be reviewed electronically and can be viewed in a flow sheet
format. The same is not true of problems. Although problems can be entered into the database,
these are not updated. Also, the list of problems includes items that are symptoms or
undiagnosed findings, which are not problems. For example, “weakness” can be listed as a
problem. Problems are medical diagnoses and weakness is not a diagnosis. Progress notes,
including for chronic illness visits, do not include updated problem lists. It is not clear whether
the software lacks this ability or whether it is not used. Also, the previously used paper problem
list is no longer in use. Therefore, there is no official problem list that we could identify.
Regardless, the electronic record system fails to include one of the major advantages of
electronic records, which is to track all of a patient’s problems and make those available to
clinical staff when they evaluate patients. Because the problem list in the EMR is not
maintained accurately, it is unusable for purposes of tracking or monitoring care. Clinicians do
not use problem lists when evaluating patients even though a patient’s problems can
presumably be entered as data elements in the electronic record. Policy should guide who is to
enter problems into the problem list and when they are to be entered and updated.
Because the problem lists are ineffective, the list of patients with chronic illness is not obtained
from the electronic record. Instead, patients in chronic illness clinics have their chronic illness
information manually entered into a security database. This security database is used by the
chronic illness nurse to track chronic illness. This is duplicative, risks loss of data by manual
entry operations, fails to make the patient’s updated problems readily available, and potentially
exposes health information to custody personnel. The electronic record should be utilized to
track chronic illness.
There are insufficient devices, specifically terminals for use of the record, in some clinical areas,
particularly on the infirmary. The providers go to their office to write their records. A device
survey needs to be done to ensure that there are sufficient devices for the number of
simultaneous users. The electronic record also includes a feature which is dangerous. This
record defaults vital signs to the last vital signs obtained. If a patient has vital signs performed
on January 1, 2018 and is evaluated on January 5, 2018, the vital signs from January 1, 2018 will
present on the January 5, 2018 note unless new vital signs are obtained. Vital signs should be
used only for the date and time for which they were obtained.

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Remarkably, the program has been unable to obtain data out of the medical record to support
the quality improvement effort. Visits, problems lists, laboratory data, and prescription data are
all present in the database of the electronic record. Yet, the program does not have the ability
to use these data in ways to measure performance. Implementation of an electronic record
reduces the need for medical record clerks. Four to five staff are still assigned to medical
records and involved with a variety of health information duties including offsite scheduling,
obtaining hospital and specialty consultation reports, and providing court ordered records and
release of information requests. However, to make the record effective, the program needs to
have information technology staff capable of using appropriate data queries of the electronic
record in order to obtain useful information on an ongoing basis for the purpose of measuring
quality and for tracking clinical data.
We noted extreme difficulty in obtaining information regarding patient immunization. One of
the advantages of an electronic record is to present immunization status so that preventive
measures can be easily taken. It was not clear whether this feature is unavailable or unused in
the current system. Nevertheless, it was easier for us to find immunization status in the paper
record at other IDOC facilities than it was in the electronic record at LCC.
The electronic record is only used at the female facilities and is only partially implemented. Yet
IDOC administrative directives do not address the electronic record or give guidance on its use
or what to do in the event of outages. Adequate policy needs to be developed to guide use of
this product.
Lastly, we note that the electronic record makes it easier to cut sections of a progress note
from a prior note and copy the cut piece to another note as a way to produce a note without
much writing. The problem is that every note must represent exactly the evaluation during the
episode of care being documented. When cut and pasted notes are used, it appears that the
doctor is using documentation from a prior episode of care to describe a current episode of
care. This is inaccurate and unprofessional documentation. We noted cut and pasted notes for
some patients on the infirmary that made it impossible to determine if they were an accurate
representation of the patient’s actual condition at the time of evaluation. We strongly
recommend against cut and pasted notes, as they appear inaccurate and appear to
misrepresent the actual condition of the patient.

Urgent/Emergent Care
Methodology: We reviewed records of four patients who nurses evaluated for urgent care
complaints. We also reviewed six patients who were hospitalized to assess whether the
hospitalizations may have been preventable with timelier or improved primary care.
First Court Expert Findings
The First Court Expert found that there was no log to track urgent calls from housing units or to
track patient send outs on an emergency basis.

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Current Findings
We found that nurses now track unscheduled evaluations on the nurse sick call log. We found
that LPNs and RNs independently managed patients with urgent medical symptoms and did not
notify a medical provider, increasing risk of harm to patients. LPNs exceed their scope of
practice by performing independent nursing assessments. Even when notified, medical
providers did not examine and evaluate patients with potentially serious medication conditions.
The following cases are illustrative.

16
17

•

A 51-year-old woman with a history of asthma, hypertension, and chronic hepatitis C
infection was a code 3 on 1/22/18.16 The patient reported burning in the center of her
chest radiating to her throat and vomiting x 1. The chest pain protocol instructed the
nurse to call the provider urgently for patients with a history of hypertension. The LPN
did not refer the patient to a provider but instead ordered Pepcid. On 2/17/18, an LPN
responded to a code 3. The patient was found sitting on the floor stating that she was
dizzy. The nurse did not perform any cardiovascular review of systems (e.g., chest pain,
SOB). The patient’s vital signs were normal. The LPN determined that the patient should
rest in her cell and did not contact a provider. On 2/19/18, an LPN responded to a code
3. The patient reported chest pain and dizziness. Again, the nurse performed no
cardiovascular review of systems. Vital signs were normal. The patient’s last EKG
showed nonspecific T-wave abnormality. The LPN did not contact a provider. These LPNs
independently managed this patient with dizziness and chest pain, which is well beyond
their scope of practice. We discussed this case with the HCUA.

•

This 53-year-old woman had a history of six hospitalizations for asthma as well as
diabetes, hypertension, hyperlipidemia, and hypothyroidism.17 On 12/6/17, the patient
presented to the HCU stating, “I need a breathing treatment.” A LPN evaluated the
patient whose vital signs were blood pressure 140/90mm Hg and pulse=90/minute. The
nurse did not ask about the frequency of symptoms. The patient had right lower lobe
wheezing. The LPN did not measure peak flow expiratory rates (PEFR) or oxygen
saturation. Apparently the LPN administered a nebulizer treatment and documented
“no wheezing after treatment.” On 12/9/17, a RN assessed the patient for shortness of
breath. The patient told the nurse, “At home I use steroid, here I am not on one.” The
patient’s PEFR’s showed her asthma was poorly controlled (Before treatment
PEFR=150/200/225). The patient had scattered faint wheezing throughout posterior
bases. The treatment protocol indicates provider referral “if peak flow less than 300
does not improve with Albuterol.” However, the nurse did not measure PEFR’s after
treatment and did not contact a physician for steroid inhaler or referral back to chronic
disease program. On 12/10/17, the patient presented again with SOB. The nurse did not
measure vital signs or PEFR. The oxygen saturation was 95% with wheezing upon
expiration. It is unclear from the note if the nurse treated and if so, there was no post
treatment assessment. On 12/19/17, a physician saw the patient and added prednisone,

Urgent/Emergent Patient #3.
Urgent/Emergent Patient #4.

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inhaled steroid and Xopenex. On 1/22/18, an LPN assessed the patient as a code 3 with
SOB. “I am having trouble breathing.” The patient had wheezing auscultated in all lobes
with oxygen saturation of 95%. No vital signs or PEFR were obtained. The LPN gave the
patient a breathing treatment and did not assess the patient afterwards, documenting
that the patient was to return to the clinic as needed. On 1/25/18, the patient
presented with a two-week history of a cold. The temperature was 99.5°F and blood
pressure was 158/100mm Hg. On 1/30/18, the NP saw the patient for chronic disease
management; patient noting that she used her steroid inhaler (Alvesco) three to four
times, and that the patient’s asthma was in fair control. The NP scheduled her for follow
up in six months. In this case, both LPNs and RNs performed inadequate assessments of
a patient with asthma and exceeded their scope of practice by independently treating
the patient and/or not timely referring the patient to a provider. The NP did not
schedule the patient for follow-up in accordance with her disease control.
•

A 45-year-old woman with a history of hypertension presented with chest pain on
1/3/18.18 An LPN saw the patient, whose vital signs were normal. The LPN performed
an EKG that was read by a nurse practitioner, who did not examine the patient or
medically evaluate the patient. On 2/6/18, the physician saw the patient and addressed
her hypertension and chest pain. This was not timely care.

•

A 23-year-old woman was seen by an LPN on Wednesday, 12/20/17 for sore throat,
body aches, and nasal congestion.19 The patient had a fever of 101.4°F with no other
vital signs measured. The patient’s throat was red with enlarged lymph nodes. The LPN
planned to refer the patient to a provider but a medical provider did not examine the
patient. An OB/GYN wrote an order for azithromycin the same day. It is unclear whether
and when the patient received the medication. On Saturday 12/23/17, the patient
presented urgently with sore throat and inability to swallow. A RN saw the patient and
noted a swollen soft palate that was deviated to the left. The patient was unable to
speak or able to swallow. The temperature was 100.5° F, the pulse was 125/minute, and
the blood pressure was 130/83. A registered nurse contacted a NP, who ordered the
patient sent to the hospital, where the patient underwent incision and drainage of a
peritonsillar abscess. On 12/23/17, the patient was sent back to the facility on
Augmentin and admitted to the infirmary for 24-hour observation. On 12/25/17, the
physician reviewed the note from the hospital, but did not see the patient until 1/13/18,
three weeks after she was hospitalized. A provider should have examined the patient on
12/20/17 and timely seen the patient following hospitalization.

In the six hospital records we evaluated, we noted delayed diagnosis in four of the six patients.
These delays included:
• A three-month delay in evaluation of pancreatic cancer
• A 10.5-month delay in treatment of a sigmoid-vaginal fistula
18
19

Urgent/Emergent Patient #2.
Urgent/Emergent Patient #1.

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•
•

A two-day delay in hospitalization for a life-threatening drug overdose
An 11-month delay in identification of colon cancer which likely resulted in
dissemination of the cancer.

In four of six hospitalizations there were incomplete or no hospital records. The delays in
treatment include systemic deficiencies, including:
• Failure to obtain records from transferring jails related to diagnoses of the patient and
failure to act on information obtained in transfer documents
• Failure to timely obtain diagnostic studies for serious illness
• Failure to establish an appropriate and timely treatment plan for abnormal findings
• Failure to appropriately assess or act on laboratory findings.
We note some of these problems in cases below. We also note that several of these cases are
discussed in the section on specialty care below.
•

The first patient was incarcerated at LCC on 1/11/17.20 The patient had a prior positive
tuberculosis skin test and therefore received a screening chest x-ray. This x-ray showed
a 6 mm nodule with streaking from the nodule and a small pleural effusion. The
radiologist recommended obtaining a CT scan, as this was suspicious for cancer. A PA
consulted a doctor, who told the PA instead of obtaining a CT scan to obtain a repeat
chest x-ray in three months. This was not appropriate care as the nodule was suspicious
for cancer. In three months, a repeat chest x-ray was done and showed a large right
pleural effusion with a large consolidation on the right lung. The effusion was
compressing the lung. The radiologist again recommended a CT scan. This patient
should have been admitted to a hospital for diagnosis and evaluation of the large
pleural effusion. Instead of admitting the patient to a hospital for a diagnosis, the doctor
admitted the patient to the infirmary and ordered routine blood tests, antibiotics,
presumably for pneumonia, and another chest x-ray. The radiologist had recommended
a CT scan on the second x-ray report, but this was not done.
Within four days of being on the infirmary the patient was short of breath, had
unilateral leg edema, and was wheezing. The unilateral leg edema was suggestive of a
deep vein thrombosis. This in combination with a large lung consolidation and pleural
effusion, should have prompted immediate hospitalization to evaluate for pulmonary
embolism and to perform thoracentesis for diagnosis of the pleural effusion. Instead,
the doctor initiated treatment for deep vein thrombosis (Lovenox), treated for
presumptive pneumonia, and ordered an urgent Doppler test and routine CT scan of the
chest. This was dangerous for the patient, as the doctor did not have a diagnosis for a
potentially life-threatening condition. Three days later, the urgent Doppler test had not
yet been done and the doctor ordered another chest x-ray, which was unchanged. This
resulted in the doctor finally admitting the patient to a hospital.

20

Patient #1 Hospitalization and Specialty Care.

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The patient had deep vein thrombosis, pulmonary embolism, adenocarcinoma of
unknown primary, and disseminated cancer to pleura and peritoneum. The patient
received the first cycle of palliative chemotherapy with a recommendation for follow-up
chemotherapy. It was somewhat difficult to follow the course of care, as the doctor was
writing notes not on the date of evaluation but at home from memory. The doctor was
also using cut and pasted notes, which created an impression of identical notes being
repeated, which may or may not have represented the actual condition of the patient or
evaluation of the provider. The doctor at LCC also did not prescribe pain medication
consistent with recommendations of the oncologist. Based on equivalency dosing, the
patient was receiving less pain medication than recommended by the oncologist.
In summary, this patient’s cancer diagnosis was delayed by about five months. It may
not have made a significant difference in ultimate outcome. However, the patient did
have a life-threatening presentation (pleural effusion, leg swelling, shortness of breath,
and wheezing) and was not admitted to a hospital for four days. This placed the patient
at significant risk of harm and is inconsistent with generally accepted guidelines for a
pleural effusion.
•

Another patient was a 43-year-old woman who had a history of HTN, COPD, and prior
gastric surgery in the past for unstated reasons.21 The intake history and physical
examination on 7/5/17 failed to identify the reason for the gastric surgery. Intake
laboratory results showed anemia and low white blood count. There was no follow up of
these significant abnormal laboratory results.
The patient had a mental health condition and within a month of incarceration, a mental
health staff member documented that the patient was not eating. The patient then
began complaining about her stomach hurting and not wanting to eat because of this
problem.
On 8/16/17, the patient was admitted to the infirmary by mental health for “failure to
thrive, R/O medical vs. psychosis.” Initial laboratory results showed pancytopenia.22 The
white count was low, and the absolute neutrophil count was 492, which is severe
neutropenia and a critical level. The laboratory tests also showed a critical value of
valproic acid at 154 (normal 50-100). This drug was being used to manage the patient’s
mental health conditions. The elevated valproic acid can be associated with
pancytopenia. Valproic acid toxicity is also known to result in central nervous system
dysfunction, low blood pressure, and liver dysfunction. The patient was not eating or
drinking fluid and a doctor ordered intravenous fluid, but the intravenous line was not
working well, and the IV fluid was not flowing. A doctor examined the patient on
8/17/17, and the patient had hypotension (94/81), which was unnoticed by the doctor.

Patient #2 Hospital and Specialty Care.
Pancytopenia is a low level of white blood cells, red blood cells and platelets. This is a serious problem that typically in all
cases requires prompt referral to a hematologist for consideration of a bone marrow biopsy.
21
22

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Hypotension can be caused by valproic acid toxicity and should have resulted in
hospitalization, as it was unsafe to keep a patient with critical, severe neutropenia and
hypotension on an infirmary unit. The patient was nevertheless kept on the infirmary for
two days despite the critical valproic acid level and pancytopenia. The patient eventually
began vomiting and developed altered mental status. She was lethargic, unable to
answer questions, and was speaking unintelligibly. The patient was eventually sent to a
hospital on 8/19/17, several days after critical blood pressure and pancytopenia in the
context of valproic acid toxicity were identified. There was no hospital report and it was
not clear what occurred at the hospital. Partial records documented elevated ammonia,
pancytopenia, encephalopathy, and valproic acid toxicity as initial problems. There was
no discharge summary, so the discharge plan was not available.
On return to LCC, a repeat blood count showed persistent pancytopenia. A doctor noted
that because the absolute neutrophil count was 1.2 the patient was “stable.”
Pancytopenia is a serious condition, and because the etiology of the pancytopenia was
uncertain, the patient should have been referred to a hematologist. There was no
documentation of why the patient was hospitalized or what occurred in the hospital.
The doctor did not address the pancytopenia in her assessment or plan. The weight was
not monitored. There was not a plan for the patient’s weight loss or pancytopenia.
The LCC Medical Director discharged the patient from the infirmary (when the doctor
was at home) at midnight without documenting the discharge diagnosis from the
hospital and without documenting a discharge plan to evaluate the pancytopenia. The
discharge date was 8/31/17, but the note was written on 9/7/17. The doctor’s note at
midnight appeared to be a cut and pasted note taken from a prior mental health note.
The only diagnosis was schizoaffective disorder. This is unacceptable documentation
and care.
The patient had two subsequent blood counts, the latest of which was on 10/2/17. This
test continued to show low white count, anemia, and absolute neutrophils of 760, which
is moderate neutropenia. This continued problem in light of correction of the valproic
acid toxicity warranted hematology consultation, but it was not addressed. The doctor
noted that the patient was “stable” and could “come to sick call if problem.” This was
indifferent to the patient’s serious medical condition. Low white count with anemia can
reflect a serious problem including cancers, immune disorders, or other serious
conditions.
•

23

Another patient transferred from Cook County Jail with information that the patient had
a pending appointment with colorectal surgery.23 The intake history failed to identify
why the patient had a pending colorectal surgery appointment. The patient gave a
history of significant weight loss, but the weight loss was not included in the intake
problem list and there was no diagnostic effort to evaluate for weight loss. This weight

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loss could be verified because the patient had a prior incarceration in the IDOC, and in
prior IDOC notes weighed 245 pound in 2014; the weight on admission on 5/18/16 was
189. The failure to address a verified 56-pound weight loss was unacceptable.
About three weeks later, on 6/6/16, a nurse practitioner took a history that the patient
had prior tumors identified during a cystoscopy performed earlier that year. The patient
also gave a history of a prior colonoscopy in December of 2015. The nurse practitioner
did request old records, which showed that the patient had a CT scan in December of
2015 showing a posterior bladder wall mass of 3.4 cm. The patient was sent to an
urologist and eventually that patient had a cystoscopy on 8/23/16, two months after
intake. This procedure was normal.
In the meantime, on 7/8/16, the patient began complaining of stool coming out of her
vagina. A doctor evaluated the patient on 7/25/16 and wrote that she would “consider”
a CT scan. Lacking the prior CT scan, a new diagnostic study should have been done, as
the patient had considerable weight loss, history of an abdominal mass, and stool
coming out of her vagina. Instead, the doctor waited for the cystoscopy. This procedure
was done on 8/23/16, but there was no report. There was also no report of a follow-up
visit on 9/7/16 to the urologist except the urologist wrote on the referral form, “no
malignancy in bladder… F/U prn [recommend] gyne eval.”
A doctor saw the patient on 9/7/16 and obtained a history that the patient had stool
coming out of her vagina for three months. On 9/15/16, a doctor referred the patient to
a gynecologist, who saw the patient on 9/23/16 and recommended an ultrasound to
rule out a recto-vaginal fistula. The ultrasound was done 10/3/16 and the radiologist
recommended a CT scan. The CT scan was done on 10/25/16 and showed a suspected
fistula between the sigmoid colon and the vagina. A doctor referred the patient to a
colorectal surgeon on 11/3/16. Notably, when the patient transferred from Cook County
Jail, the patient had a pending appointment to colo-rectal surgery which was ignored.
The colorectal surgeon saw the patient on 11/28/16, but again there was no report in
the medical record. The surgeon recommended an MRI and surgical exploration. On
12/12/16, the MRI was done, but there was no report. The patient had a colonoscopy
on 12/30/16, but there was no report and it was not clear what happened. The patient
went to colorectal surgery on 1/19/17 for follow up, but again there was no report. This
patient eventually obtained surgery to repair a sigmoid colon-vaginal fistula on 3/28/17,
but the failure to take an adequate history at intake regarding weight loss and to
address the pending colorectal surgery appointment at the Cook County Jail resulted in
a 10-month delay in treatment of the patient. The failure to obtain consultation reports
impaired the ability of the providers to understand the status of the patient.

Specialty Consultations
Methodology: We reviewed specialty care tracking logs, interviewed the scheduling clerk and
performed record reviews of persons who received specialty care.
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First Court Expert Findings
The First Court Expert found that when patients return from scheduled consultations, they are
not brought to the health care unit. Review of paperwork, including recommendations, and
scheduling of follow-up visits did not consistently occur, resulting in failed follow up. Also, the
process of offsite scheduling begins with the collegial review, and the referral date by the
clinician is not tracked. Record reviews showed that consultation reports were unavailable in
the medical record. In a review of records, the First Court Expert found that in three of five
records there was no follow up of the consultation by the primary care provider. Also, the First
Court Expert reviewed care of 13 patients referred by an outside attorney. Of these 13 patients,
six (46%) consisted of delayed or denied necessary specialty care.
Current Findings
Specialty care referrals are initiated via the electronic record. The scheduling clerk collects the
referrals electronically on the Tuesday before collegial reviews from an inbox in the electronic
record. The supporting data is obtained by the clerk and emailed to the Wexford UM reviewers.
The referral is placed on the tracking log only when the referral is approved by the utilization
reviewer. Referrals need to be placed into the medical record whether they are approved or
not.
Review of specialty care continues to be difficult.24 We examined the first month of specialty
referrals for 2017. There were 62 referrals for care. Collegial reviews occurred within five days
for 60 (97%) of referrals. However, we noted in a separate review of multiple consultations for
a single patient that referrals in seven of eight consultations occurred close to a day before the
approval, even when it appeared that the actual referral25 occurred weeks before the approval
indicating that the log is not accurately maintained. Fifty-five of these 62 (92%) referrals
occurred within a month of the referral. The log used by the scheduling clerk and presented to
us for our investigation does not contain all specialty referrals. In our interview with the
scheduling clerk, we were told that only completed consultations are maintained on this log.
Denials are not placed on the log. Though we were told that there are five or less denials in a
year, there were 31 denials provided to us over an eight-month period or approximately 46
denials pro-rated over the past year.
We evaluated a series of consultations in the medical record of one patient to assess whether
medical care was timely and appropriate.
24 It has been very difficult to investigate this area of service. We asked for the tracking log as used by the scheduling clerk at
the site in a spreadsheet format to include the name, Illinois Department of Corrections number, date of referral for specialty
care, date of collegial review, date of approval, date of service, and the service referred for. We again did not receive what we
asked for. We were sent a PDF file which could not be sorted. There were 39 pages of appointments not in chronologic order
for any of the items. This made it very difficult to use. After receiving this list, we asked again for the spreadsheet used by the
scheduling clerks at the site. I received an email on April 20, 2018 that the Wexford site team used the PDF file for tracking and
did not use a spreadsheet. This PDF was too disorganized to effectively use. Once at the site, we discovered that the site did use
a spreadsheet and asked for and received this document before we left. This delayed our ability to review this process.
25 When a consultant recommends a follow up or specialized test, we view that recommendation as a date of referral. Many
consultant recommendations do not appear to be evaluated timely and thus their new referrals for care may not be addressed
for weeks. LCC apparently uses the collegial review episodes to coordinate referrals rather than the physician review of offsite
consultation. This makes care appear more timely than it actually is.

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•

We examined a patient who had multiple consultations.26 This patient had multiple
sclerosis (MS). We examined eight of his consultations on the tracking log from 12/1/15
to 1/18/18, and three consultations occurring before the tracking log started. There
were two denials for referrals to neurologists in late 2014 (8/14/14 and 12/29/14). The
alternative treatment plan recommended was “conservative” therapy without any
explanation of what this might be for someone with MS. The doctor appeared unsure of
how to manage the patient. These denials prevented neurology consultation for MS,
which is generally accepted medical care.
Of the eight consultations on the tracking log, there were only five consultation reports
in the medical record. One of the reports was filed two months late. Six of eight referrals
were timely based on the tracking log. However, one referral was to UIC with a
recommendation for a four month follow up. This never occurred; instead the patient
was sent to a local neurologist, even though the local neurologist recommended that
the patient see a neurologist at a major medical center. Two of the eight referrals were
late. One was one month late and the second was five months late. Two of the eight
visits were for MRI tests. In neither was there documented evidence that a doctor had
reviewed the results. For two of the six neurology consultations there was no evidence
that a provider reviewed the consultation findings with the patient or reviewed what
occurred at the consult. After another consultation visit, the findings were not reviewed
for about six weeks after the consultation. After another consultation, a doctor saw the
patient but did not document review or understanding of what occurred at the
neurology consultation. After only two of the eight consultations was there evidence of
understanding of what occurred at the consultations. Referrals were documented on
the log on average about three weeks after the actual consultation was referred by the
consultant or LCC provider. The actual log documents six of eight approvals as occurring
the day following the referral, making it appear that the tracking log is maintained based
on collegial review events rather than based on the clinical referral itself.
Doctors at LCC did not document understanding of what occurred at neurology visits or
understanding of the MRI results. This lack of understanding of what occurred at the
consultations was important because the patient’s chronic condition was not being
monitored well in chronic clinics. This patient was being followed in chronic clinic every
six months, but providers were not consistently seeing the patient after neurology
consultations or documenting understanding of the consultant’s findings and
recommendations. The providers did not perform adequate history or assessment of the
patient’s MS. Providers inconsistently documented the therapeutic plan of the
neurologist and did not independently perform adequate assessments. Because it did
not appear that physicians at LCC knew how to manage this disease, the patient needed
to be followed by a neurologist. Indeed, physicians at LCC attempted to refer to
neurologists on four occasions because the patient was not getting better on prescribed
care. Yet, on four occasions when LCC physicians wanted to refer to a neurologist, the

26

Patient #4 Hospital and Specialty Care.

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Wexford utilization physician denied their referral. On two occasions the UM physician
asked that the LCC physicians use “conservative” management without advising what
this meant for this complex disease. On two other occasions, a neurologist wanted the
patient to be sent to a tertiary care neurologist for management. These requests were
also denied. These denials were not all tracked on the tracking log. The facility HCUA
had to intervene to get the Agency Medical Director to overrule this UM decision.
When the patient was sent to the neurologist at the major medical center (UIC), the
consultation took eight months to occur. The neurologist at UIC could only perform a
limited examination because correctional officers kept the patient in restraints during
the evaluation. The neurologist had no information available. MRI tests and
ophthalmology reports, requested to be sent, were not sent with the patient. The
neurologist stated that the patient might need a second line disease modifying agent.
The consultant recommended an MRI, different disease modifying agents, and a follow
up in four months, but this follow up never occurred and the patient was sent back to
the local neurologist. This specialized consultation was ineffective due to lack of
information and inability of the neurologist to perform an adequate examination.
The ineffective and inconsistent monitoring of the patient at the facility was
compounded by an unprofessional attitude of one of the physicians. After the UIC
neurology consultation, the LCC doctor believed that the patient was faking and failed to
undertake the recommendations of the UIC neurologist. The LCC doctor wrote, “In my
opinion voluntarily exhibits purposeful resistance to exam for secondary gain I see no
neurological finding.”
This patient appeared to deteriorate clinically over four years and had inconsistent
neurology management. There were four denials of care when doctors at LCC deemed
the level of care to be beyond their expertise. Wexford utilization physicians denied care
without providing LCC physicians appropriate alternative therapeutic plans. A cynical
and unprofessional attitude by one of the LCC physicians appeared indifferent to the
patient’s real and inconsistently treated disease.
We noted multiple episodes of care, which based on contemporary standards of care, should
have resulted in diagnostic testing or consultations, which were not referred. In at least two
cases, harm resulted to the patient. It is our opinion that this aversion to timely and
appropriate referral is related to the utilization process. We had an opportunity to observe a
“collegial review” process at LCC. The “collegial review” took only about five minutes and
consisted of the utilization doctor reciting the offsite referrals and giving approval or asking for
more information. There was little “collegial” discussion about the cases. This process appears
to be an approval meeting as opposed to a collegial discussion about cases. Staff told us that
this “collegial review” typically only takes a few minutes to conduct. Collegial review is a
misnomer, as there is no meaningful collegial discussion of cases. It is an approval process and,
in our opinion, does not contribute to patient safety. We continue to believe that this process
should be abandoned to protect patient safety. In our limited chart reviews, we identified four
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denials27 in a single patient for necessary care for multiple sclerosis without any documented
collegial discussion of alternative plans, a delayed diagnosis of colon cancer that likely resulted
in unnecessary spread of the colon cancer,28 failure to send a patient29 with necrotic foot
lesions to a podiatrist or to thoroughly evaluate for osteomyelitis, failure to evaluate a diabetic
patient30 with a draining ulcer over the tibia for MRI, bone biopsy, or infectious disease
consultation to evaluate for osteomyelitis, and a failure to obtain pulmonary function testing in
a patient31 with COPD.
•

Another patient was 50 years old.32 Earlier in her incarceration, on 8/15/13, she
weighed 250 pounds. On 12/1/16, the patient complained at an annual health
evaluation of abdominal pain and bloody stool. The only diagnostic screening that was
done was a rectal examination noting a guaiac negative stool.33 The patient should have
had a colonoscopy on the basis of symptoms and age.
Subsequent blood counts showed that the patient had anemia. When a doctor saw the
patient and took a history of bloody diarrhea for three months, the doctor ordered
metronidazole, apparently treating the patient for colitis on a presumptive basis. The
doctor failed to notice the weight loss. Also, bloody diarrhea warrants a CT scan of the
abdomen and colonoscopy, which were not done.
More than a month later, on 2/27/17, the doctor noted continued diarrhea and the
stool was positive for blood. This warranted colonoscopy. But the doctor diagnosed
hemorrhoids and prescribed hemorrhoidal cream. While the patient may have had
hemorrhoids, the more serious potential diagnosis (colon cancer) should have been
excluded with a colonoscopy. This was not done. The patient was not seen for over four
months, when a different doctor saw the patient for an annual physical examination.
The doctor performed a rectal examination but did not test stool for blood. The patient
now weighed 215 pounds (35-pound weight loss) and the weight loss was noted by the
doctor who wrote, “hemorrhoids, historically is a long-term problem without any red
flags to indicate a more significant condition.” This statement was grossly and flagrantly
unacceptable. A 50-year-old person with 35-pound weight loss and blood per rectum
with anemia needs to have a colonoscopy and possibly a CT scan of the abdomen.
Instead nothing was done. The patient had red flags unrecognized by this physician.
Two months later, the patient continued to lose weight and weighed 204 pounds. The
patient had abdominal pain with blood in her stool. The doctor diagnosed non-specific
pain and took no action. This also was grossly and flagrantly unacceptable practice.

Patient #4 Hospitalization and Specialty Care as discussed above.
Patient #5 Hospitalization and Specialty Care as discussed below.
29 Patient 6 Hospitalization and Specialty Care as discussed below.
30 Patient #7 Hospitalization and Specialty Care.
31 Patient #8 Hospitalization and Specialty Care as discussed below.
32 Patient #5 Hospitalization and Specialty Care.
33 Digital rectal examination even with guaiac testing will miss 90% of colon cancers. A colonoscopy was indicated.
27
28

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On 9/20/17, a nurse practitioner noted ongoing abdominal pain for the past seven
months. The nurse practitioner ordered a pelvic ultrasound and blood count. A
colonoscopy or abdominal CT scan were indicated, not a pelvic ultrasound.
On 9/26/17, the Medical Director saw the patient, who was complaining of abdominal
pain, nausea, vomiting, and diarrhea. The patient had 48-pound weight loss. The doctor
ordered blood tests and a plain abdominal x-ray, which is not a useful test when
evaluating anemia, weight loss, and bloody stool. It appeared that there was either
ignorance of an appropriate work-up or a reluctance to refer appropriately. We asked
the Medical Director what she would do for someone in her private practice for
colorectal cancer screening and she indicated that she would typically order
colonoscopy. She had no answer to why this was not being done at LCC. This patient
should have had prompt colonoscopy, but it was not done. Presumably the utilization
process is a barrier to adequate care.
The ultrasound was done 9/29/17 and only showed stool. A pelvic ultrasound is not an
appropriate diagnostic test to exclude colon cancer. Finally, on 10/7/17, the Medical
Director ordered a CT scan of the abdomen. On 10/16/17, the CT scan showed a large
circumferential thickening of the sigmoid and descending colon consistent with cancer.
MRI and colonoscopy were recommended. On 11/10/17, a colonoscopy showed a large
ulcerated rectosigmoid lesion suspicious for cancer. The scope could not be passed
beyond the mass. The patient was referred to an oncologist and had surgery on
11/28/17, where stage IV disseminated colon cancer was diagnosed. The patient saw
the oncologist on 12/28/17.
This patient had an 11-month delay in diagnosing colon cancer, likely resulting in
unnecessary dissemination of the disease, which harmed the patient. The patient had
symptoms consistent with colon cancer (weight loss, blood per rectum, abdominal pain,
and anemia) on 12/1/16, yet did not have a colonoscopy until 11/10/17. Providers saw
the patient seven times during that time interval and presumed a more innocent
diagnosis, even though the patient’s symptoms and findings were consistent with colon
cancer.
•

Another patient with diabetes, asthma, deep vein thrombosis, and hypertension was
incarcerated at LCC on 8/10/17.34 An intake nurse noted that the patient had recent
surgery on her leg for an infection. The wound was open and draining. The intake
physician assistant documented that the patient had repeated episodes of deep vein
thrombosis and required life-long anticoagulation.
At a subsequent evaluation, a doctor noted that the patient had the leg wound for over
two years and was told she had a bone infection by staff at Stroger Hospital in Chicago.

34

Patient #7 Hospitalization and Specialty Care.

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Osteomyelitis generally requires intravenous antibiotics. The prior record from Stroger
Hospital was not obtained. An initial sedimentation rate was slightly elevated at 27 (nl <
20) and an x-ray of the leg was normal. This patient should have had osteomyelitis
excluded unless prior records demonstrated that the patient was adequately treated.
Over the course of eight months the patient continued to have drainage from an ulcer
on her tibia. This indicated that the osteomyelitis was likely still present. A draining ulcer
over a bone in a person with diabetes must include exclusion of osteomyelitis. This did
not occur for this patient. The patient was treated with multiple different antibiotics
simultaneously, including, for example, Bactrim, Levaquin, metronidazole, and
fluconazole. Fluconazole is an antifungal therapy. We could not determine for what
reason this drug was being used. Treatment of osteomyelitis is typically intravenous
antibiotics for an extended period. There was not a reasonable effort to evaluate for
osteomyelitis.
The patient was hospitalized in late December of 2017 for a MRSA cellulitis of the leg,
but the hospital record was unavailable, and it was unclear if the patient received
evaluation for osteomyelitis. The patient continues to have drainage from the leg ulcer
with brawny skin changes. The patient has never had a thorough evaluation (MRI of the
leg, CRP, bone biopsy) for osteomyelitis. A doctor referred the patient to an infectious
disease doctor, but this referral was denied. The alternate treatment plan was to
perform another wound culture, which was unlikely to be useful in the contaminated
wound. The patient needed MRI, bone biopsy, ankle brachial index, and CRP.
•

Another patient was transferred to LCC from Jackson County Jail on 1/6/17 with a
history of mitral valve heart disease.35 The patient had a prior history of clusters of
blisters on her feet during a prior incarceration in 2015. The patient experienced
episodes of what sounded like a fugue state. A doctor saw the patient on 2/15/17 for an
episode of “temporary amnesia.” Without taking an adequate history and performing a
neurological examination, the doctor documented the patient as “neuro normal,”
diagnosed epilepsy, and enrolled the patient in seizure clinic and started Depakote, an
anti-epileptic drug. A nurse practitioner changed the Depakote to Keppra, another antiepileptic drug, at a later date. The patient remains on anti-epileptic drugs without ever
having a witnessed seizure and without having had an EEG, or CT scan. The latter tests
are typically required diagnostic studies for all new onset seizures. In this case, there
was little evidence that the patient had a seizure and no diagnostic evaluations to
diagnose this condition. The patient should have been sent to a neurologist, as the
facility providers did not appear to know how to evaluate a new onset seizure disorder
and the patient may not have epilepsy.
In addition, this patient again developed blisters on her feet on 1/11/18. Initially, a
doctor ordered Diflucan, an antifungal agent, and metronidazole by phone order,

35

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without evaluation. The blisters worsened and eventually on 2/8/18 a doctor diagnosed
“foot rot” between the toes. Vinegar soaks, metronidazole, Keflex, and fluconazole were
ordered. None of these antibiotics or antifungal agents is typically used for initial
treatment of skin and soft tissue infections which, in a prison, need to cover for MRSA.
A doctor continued to treat the patient with multiple antibiotics and Diflucan, an antifungal agent, for over three months. During our tour we evaluated the patient, who had
necrotic black tissue covering the webs between all the toes of her foot. We were told
that the HCUA pressured the Medical Director to obtain an infectious disease
consultation, which is scheduled for 5/1/18. The providers have not debrided the
necrotic tissue, which needs to be removed until healthy tissue is present. The depth of
the ulcerations on the feet has not been determined. If, after debridement, the wound
probes to bone, then evaluation for osteomyelitis needs to be initiated. The patient
should be treated with antibiotics appropriate for the type of infection and we agree
with the infectious disease consultation, which should have been initiated earlier in the
course of the infection and was only initiated at the urging of the HCUA.
•

Another patient was a 49-year-old with a history of diabetes, hypertension, prior deep
vein thrombosis, and presumed rheumatoid arthritis with long-term oral steroid use to
treat her presumed rheumatoid arthritis.36 This patient was incarcerated at LCC prior to
initiation of the EMR and her old record volume was inaccessible and could not be
reviewed. The patient had apparently been evaluated by a Wexford telemedicine
rheumatologist, although there were no documented notes of these encounters in the
medical record. The first documented chronic clinic visit was on 5/23/14, and the doctor
noted that the patient had been on prednisone for years and had not seen a
rheumatologist since 2008. It was unclear when the patient was incarcerated. The
patient was on 20 mg of prednisone a day, which is an extremely atypical therapy and is
not currently recommended.37 On 9/15/14, a doctor on the infirmary documented that
the Wexford rheumatologist recommended decreasing the prednisone dose from 20 mg
to 15 mg. This is still an exceedingly high dosage, likely to cause adverse effects.
On 5/14/15, the patient was finally referred to a rheumatologist. The rheumatologist
noted that the patient had no evidence for synovitis, yet had diabetes and Cushingoid
presentation. This was likely from excessive prednisone use. The rheumatologist
recommended stopping the non-steroidal medication and tapering the patient off
prednisone. The rheumatologist recommended blood tests to monitor the use of
methotrexate. The patient returned to the rheumatologist once more on 10/9/15. This
was two months later than recommended. The rheumatologist noted that the facility
physician had increased the dose of prednisone and again noted that there was no

Patient #6 Hospitalization and Specialty Care.
While short courses of oral steroids are used for rheumatoid arthritis, long-term steroid use is not recommended. Use of
disease-modifying anti-rheumatic drugs (DMARDs) are recommended. Use of glucocorticoids are recommended only as adjunct
therapy. Chronic use of steroids can cause increased risk of adverse events including osteoporosis, fractures, gastrointestinal
bleeding, diabetes, infections, cataracts, and impaired adrenal function.
36
37

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synovitis.38 Synovitis is a key feature of rheumatoid arthritis and not having synovitis
suggested that the patient might not have rheumatoid arthritis. The patient was still on
the non-steroidal medication and the rheumatologist recommended again to stop the
non-steroidal medication and to decrease the prednisone dose to 10 mg. The
rheumatologist recommended a six month follow up, with an accurate list of the
patient’s medications. There were no further rheumatology visits.
The patient was not referred back to a rheumatologist and yet was continued on
relatively high doses of prednisone, contrary to recommendations of the
rheumatologist. On 3/1/17, a nurse practitioner saw the patient in general medicine
chronic clinic for her rheumatoid arthritis. The nurse practitioner referred the patient to
a rheumatologist but sent the request via the Medical Director. This referral was never
made by the Medical Director. The Medical Director subsequently obtained x-rays of the
hands and ordered a sedimentation rate. The x-rays showed no evidence for
rheumatoid arthritis, and the sedimentation rate was normal. There were no erosions
and no evidence for rheumatoid arthritis. Thus, the patient had no evidence of
rheumatoid arthritis, as the patient had no evidence of inflammatory arthritis of any
joint and no residual bony defects (erosions) consistent with rheumatoid arthritis. Also,
a rheumatologist previously stated that the patient had no evidence of synovitis in any
joint.
Nevertheless, LCC physicians failed to refer this patient to a rheumatologist and
continued to treat the patient as if she had rheumatoid arthritis, with prednisone,
methotrexate, and eventually hydroxychloroquine, all of which had significant potential
adverse reactions. The Federal Drug Administration has assigned multiple black box
warnings39 for methotrexate and describes a multitude of adverse actions related to
prednisone. Hydroxychloroquine also has multiple potential adverse actions, especially
retinal toxicity that can result in irreversible retinopathy. While it was unlikely that the
patient had rheumatoid arthritis, the patient was experiencing multiple adverse
consequences of the treatment for presumed rheumatoid arthritis including diabetes,
elevated high triglycerides, and fatty liver; all consequences of prolonged high dose
prednisone use. The fatty liver was unrecognized as a problem. The elevated
triglycerides were initially treated with fenofibrate, which is not a first or second-line
therapy for elevated triglycerides. This drug should be used with caution in persons with
liver disease, but the fatty liver was unrecognized by the facility providers. Fenofibrate
was started apparently in December of 2016 and was eventually stopped in April of
2017. The diabetes, likely caused by the unwarranted use of prednisone, caused
additional problems.

This suggested that the patient had no active manifestations of rheumatoid arthritis and probably did not have rheumatoid
arthritis.
39 According to the FDA, a black box warning is a warning designated to call attention to serious or life-threatening risks that can
cause disability, be potentially life-threatening, and can result in hospitalization or death. As found at
https://www.fda.gov/downloads/forconsumers/consumerupdates/ucm107976.pdf.
38

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The patient also had diabetes with HbA1C levels demonstrating poor control as of April
of 2018 (HbA1C 8.3). The poorly controlled diabetes likely caused the fatty liver and
elevated triglycerides, which are a risk factor for heart disease. The patient also
developed a diabetic foot ulcer, first noticed on 11/30/15. The diabetic foot ulcer was
improperly treated, as the patient was allowed and even encouraged to walk on the
foot, when recommended therapy is to not have the patient walk on the affected foot.
The patient did have an evaluation for vascular insufficiency (ankle-brachial index) but
did not have an evaluation for osteomyelitis despite having the ulcer for at least 15
months. We stopped review of this record in April of 2017 and were unsure whether the
ulcer was present after this. A diabetic foot ulcer for 15 months needs evaluation for
osteomyelitis, which was not done.
This patient appears to be treated with multiple drugs for a condition it does not appear
that the patient has. If the patient has seronegative rheumatoid arthritis, there certainly
does not appear to be any adverse outcome (joint disease or erosions). Given that, this
patient should not be treated with high dose prednisone for years. The prednisone is
causing harm to the patient. The harm being caused is likely to cascade and cause other
problems. This patient needs to be evaluated by a rheumatologist to determine if
indeed the patient has rheumatoid arthritis, which appears unlikely, as there is no
evidence for this disease. If the patient still has a foot ulcer, the patient needs
evaluation for osteomyelitis.
•

Another patient is a 72-year-old woman who had a 10-year risk of heart disease or
stroke of 29% and should have been on a moderate-intensity statin, but was on a lowintensity statin.40 The patient had hypertension and an LDL cholesterol of 179, but
instead of placing the patient on a moderate to high-intensity statin, the doctor added
cholestyramine, a second line cholesterol medication, to a low-intensity statin dose.
Later, the patient was also treated with fish oil, a marginal anti-lipid drug. The patient
was never placed on standard treatment for her lipid disease. The patient had a
diagnosis of chronic obstructive lung disease (COPD), but was monitored as if she had
asthma. The First Court Expert made a recommendation that IDOC develop a guideline
for COPD as opposed to asthma, but this has not been done. In this patient’s case,
monitoring in chronic clinic was for asthma but the patient had COPD. There was no
evidence of the patient ever having a pulmonary function test, which is the cornerstone
of diagnosis for COPD. Every patient with COPD should have a pulmonary function test,
but this test is seldom done in IDOC for patients with COPD.

Pharmacy and Medication Administration
Methodology: We conducted a comprehensive review of pharmacy and medication services
from the time a medication order is written until medication is delivered to the patient. We met
with health care leadership and staff involved in pharmacy and medication services, toured
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pharmacy and medication administration areas, observed medication administration, and
reviewed medication administration records.
First Court Expert Findings
The First Court Expert Report did not include findings or recommendations related to pharmacy
practices or medication administration. The review did not appear to include a review of
medication administration records.
Current Findings
This review showed systemic issues related to pharmacy and medication administration
systems.
BosWell Pharmacy Services provides medication services at LCC through a “fax and fill” process.
Providers enter medication orders directly into the EMR and the order is electronically
transmitted to an offsite pharmacy. BosWell dispenses and ships prescriptions six days per
week (not on Sundays). Medications are either patient-specific or for stock supply. When new
medications arrive, medication assistants check medications received against a packing list of
what was shipped.
The medication room is of adequate size for its purpose. The floors and countertops were dirty.
The refrigerator used to store staff food was unlabeled (i.e., staff food) and filthy. The
medication refrigerator required cleaning. We found an injectable medication that expired in
January 2018 and two open insulin vials that were not labeled with the date of opening and
expiration dates. In a nearby cabinet we also found two opened Lidocaine vials that were not
labeled with the date of opening or expiration. A random check of sharps and controlled
medications showed that counts were accurate.
According to the HCUA, the area is staffed by unlicensed and uncertified medication room
assistants, not licensed pharmacy technicians or nurses. There is no formal training curriculum
and staff are provided on-the-job (OJT) training. This raises safety concerns, as these staff
deliver hundreds of KOP medications to patients on a daily basis. A major concern is that
medication assistants deliver medications to patients and do not consistently document
administration on the MAR. This is further described below.
Nurses administer medications to general population inmates in the chow hall, which is a
centralized location near the medical building. Nurses prepare medications by transferring
medications from pharmacy-dispensed, properly labeled containers into small white envelopes
that do not contain the same information as on the blister-pack label. Nurses then place
medication envelopes into small transport containers and carry them to the chow hall. Nurses
do not bring MARs with them to document medication administration at the time medications
are given.
We observed three nurses administer medications in the chow hall. Inmates arrived based upon
work or housing status. Nurses stood behind a metal rail and inmates approached a nurse
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based upon last name. Although inmates had identification badges, nurses did not positively
identify each patient by looking at the badge or having the patient state her name and a second
identifier (e.g., inmate number or DOB). Nurses did not use medication cups to administer
medications. Instead, nurses took the medication envelopes and poured the medication into
the patient’s hand. One nurse was observed to touch an inmate’s hands in multiple instances to
steady it as she poured the medication. This was unhygienic and neither this nurse nor the
other two nurses were observed to use hand sanitizer during any time in the course of
administering medications. One nurse got Milk of Magnesia on her hands and wiped her hand
on her pants.
As noted above, nurses did not bring MARs with them and did not document administration of
medications at the time they were administered. This increases the risk of error in documenting
medications.
In segregation, the nurse prepared medications in the same manner as in general population
and did not bring MARs with her. We observed this nurse make a medication error by giving
medication to the wrong patient. We interviewed the nurse, who reported that as she came
into segregation, an officer was escorting an inmate back to the unit who was due for
medication (Patient X). As this took place, another inmate approached her to receive her
medication (Patient Y). The nurse did not positively identify the patient and stated that she was
thinking of Patient X and retrieved and poured her medications into the hand of Patient Y.
Patient Y stated, “These are not my medications,” and gave them back to the nurse, who then
gave Patient Y her scheduled medications. It is unclear what the nurse did with Patient X’s
medications, as they had already been poured into another patient’s hand. This was a “near
miss” medication error, in that the nurse gave the patient the wrong medication and it was only
because of the patient’s refusal that the medication error was not committed. It is clear that in
both general population and segregation nurses do not positively identify patients prior to
administering medications. These findings were discussed with the HCUA during the site visit.
Medication Administration Records
As noted above, review of MARs showed lack of documentation that patients received KOP
chronic disease and other medications, sometimes for several months. Our interview with the
HCUA revealed that medication room assistants deliver KOP medications to patients without
consistently documenting administration onto the MAR. Instead, medication assistants note on
the BosWell pharmacy inventory list that the medication was given to the patient; however,
this is not part of the medical record. Therefore, in multiple records there is no documentation
that the patient received ordered chronic disease and other essential medications. In addition,
in many records previous months’ MARs had not been scanned into the record, including July
and August 2017 MARs.
For example, in 10 of 10 health records reviewed to assess the medical reception process, all
records were missing some MARs, including January and February 2018. In addition, several
patient MAR’s showed that they did not receive chronic disease medications, sometimes for
months. In addition, there were other documentation errors. The following cases are examples:
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•

An HIV patient who arrived in 10/18/17.41 That patient’s December 2017 MAR showed
that she did not receive HIV medications. There was no January 2018 MAR in the record.

•

A patient with hypertension and hyperlipidemia arrived on 1/5/18.42 There is no
documentation on her January and February 2018 MAR that she received Norvasc,
metoprolol, and gemfibrozil. In addition, on 2/5/18, the medication order for her
chronic disease medications expired and was not renewed until 2/20/18. As of 4/23/18,
there was no March 2018 MAR scanned into the record.

•

A patient with glaucoma and hypertension arrived on 11/21/17.43 A November 2017
MAR does not show the patient received her chronic disease medications. On 12/7/17, a
new order was written for glaucoma medication (Latanoprost), but there is no
documentation that the patient received the medication in December 2017.

•

A patient with hypothyroidism and hypertension arrived on 2/2/18.44 On 2/3/18, a
provider ordered the patient’s medications. Her February 2018 MAR does not show that
the patient received levothyroxine or Lisinopril. As of 4/23/18, there was no March 2018
MAR scanned into the record.

•

A patient with a history of hypertension and two heart attacks arrived on 2/27/18.45 She
was taking the blood-thinner Plavix, metoprolol, isosorbide dinitrate, and atorvastatin.
There is no February 2018 MAR to show that the patient received her medication. A
March 2018 MAR shows that on 3/1/18 she received isosorbide dinitrate and on 3/3/18
she received her other chronic disease medications. In addition, although the patient
was given metoprolol via KOP on 3/3/18, a nurse documented giving the patient the
medication on 3/4/18 and 3/5/18 via nurse administration. Another nurse wrote on the
MAR that the patient received the medication via KOP and not dose by dose, after which
nurses stopped documenting they were giving her the medication daily.

•

A patient with hypertension and mental health disorder arrived on 10/17/17.46 A
provider ordered her medications on 10/18/17. On 10/30/17, chronic disease
medications were received. The November 2017 MAR does not show the patient
received hydrochlorothiazide. The patient’s January 2018 MAR does not show that the
patient received hydrochlorothiazide and amlodipine. As of 4/23/18, a March 2018 MAR
had not been scanned into the record.

Medical Reception Patient #1.
Medical Reception Patient #3.
43 Medical Reception Patient #4.
44 Medical Reception Patient #6.
45 Medical Reception Patient #7.
46 Medical Reception Patient #9.
41
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•

Another patient with diabetes and hypertension arrived on 7/19/17.47 There is no July or
August 2017 MAR scanned into the record. The patient’s September 2017 MAR shows
the patient did not receive glipizide or Lisinopril. The January 2018 MAR shows the
patient did not receive any chronic disease medications, except inhalers.

We also found that not all medication orders were transcribed onto a MAR; therefore, except
for the original order, there was no documentation that the patient was due to receive or had
received the medication.
We found blank spaces indicating that nurses did not document the status (administered,
refused, etc.) of medication administration for that dose, including for patients taking insulin.
We found medication errors, in that nurses continued administering medications after a
provider discontinued the order.
Review of MARs also shows inconsistency with how nurses document discontinuation of
previous orders and new medication orders. When providers change or discontinue medication
orders, standards of nursing practice are for nurses to draw a line on the date of
discontinuation and write “Discontinued” or “D/C” after the line. If there is a new order for the
medication, it should be transcribed onto a separate line on the MAR with new start and stop
dates. However, we found that in some cases, nurses overwrite dates of a previous medication
order with the date of the new order. This defaces the MAR, making the dates of the previous
medication order illegible. It also increases the risk of medication error, as the provider may
have changed the dose or frequency of administration of the medication, and not simply
renewed the order.
In summary, our review showed systemic issues with medication administration that failed to
ensure that the right patient received the right medication, at the right dose, by the right route
at the right time. These issues included administration of KOP medications by unlicensed and
untrained staff, failure to document administration of medications onto MARs, failure to timely
scan MARs into the EMR, failure of nurses to document administration of medications at the
time of administration, failure of nurses to document each scheduled dose of medication, and
failure to properly discontinue and transcribe new medication orders.

Infection Control
Methodology: We inspected the clinical areas in the medical building, building #6’s physical
therapy room and patient common showers/bathrooms, and the #15/X-building’s reception
center. We interviewed nursing personnel, HCUA, facility engineer, Wexford staff assistant, and
infirmary porters. We reviewed the safety and sanitation reports for the months of July, August,
November, December 2017, and February 2018.
First Court Expert Findings
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Our findings are consistent with the First Court Expert’s findings. There is not a budgeted
infection control position and infection control duties have not been formally assigned,
although individual health care staff may perform duties such as completing public health forms
for reportable diseases. he First Court Expert raised significant concerns about the water
temperature in the infirmary’s non-industrial washer. The expert noted that the health care
unit laundry machines did not reach the required minimum temperature of 140 degrees with
bleach or 160 degrees without bleach, and thus could not adequately sanitize infirmary linens.
He noted that the infirmary porters are provided orientation to the health care unit which
includes proper cleaning and sanitation procedures, blood-borne pathogen training, and
communicable disease training.
Current Findings
We agree with the findings of the First Court Expert’s report. In addition, we identified
additional findings and confirmed some of the findings of the First Court Expert’s findings as
follows:
• Regular safety and sanitation inspections and reports are being done by the health care
team at LCC.
• A number of the safety and sanitation deficiencies in the physical plant at LCC that have
been reported, some repeatedly, since July 2017, including mold/mildew on ceilings and
walls, failure to change ice machine filters, missing cold and hot water showers knobs,
sinks that do not drain, infestations, and non-functional toilets in the housing areas.
These problems constitute patient and staff safety, and infection control risks for
patient-inmates and correctional and medical staff.
• There is no one formally assigned at LCC to the tasks of infection control.
• The three infirmary porters who were interviewed and whose medical records were
reviewed had no documentation that they received the hepatitis B vaccination series or
had been trained about blood borne pathogens prior to starting to provide sanitation
services.
• The infirmary porters at LCC are not offered hepatitis A vaccination even though they
will be cleaning the patient rooms and bathing areas where they will have a probability
of the contact with fecal waste.
• Two of the three negative pressure rooms in infirmary were not fully operational on the
first day of the site visit. The facility engineer had corrected this problem by the last day
of the site visit.
• Paper barriers were noted to be used on most but not all examination tables.
• The temperature of the washer in the infirmary laundry room was found to be
insufficient (120 F) to sanitize the infirmary patient linens.
Safety and sanitation inspections (environmental rounds) are performed by the health care
team on a monthly basis and reported by the HCUA. A number of reports from July 2017
through February 2018 were reviewed by the experts. These rounds identified concerns, some
of which appear to have been corrected or are being addressed. However, the inspection
reports repeatedly noted a number of deficiencies, including mold/mildew on walls and

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ceilings, missing cold and hot water knobs in common patient showers, and non-functional
toilets that do not appear to have resulted in correcting the deficiency.
Sharps boxes, gloves, handwashing sinks, or sanitizing gel was found in all clinical areas. Paper
barriers were being used on only three of the five examination tables in the outpatient clinic
exam rooms. Small tears in exam tables and crusted mineral deposits in two sinks in health care
areas make it difficult to fully sanitize these items.
Two of the three negative pressure rooms in the infirmary were not functional on the initial day
of the site visit. The facility engineer was summoned, and all three negative pressure units were
operational by the last day of the site visit.
Inmate porters perform sanitation duties. There is no schedule of routine clinic sanitation, and
disinfection activities are not consistently performed in clinical areas. During this site visit, the
pharmacy floors and countertops were dirty. The September 2017 CQI minutes include a Safety
and Sanitation report that focused primarily on whether housing unit showers, sinks, and toilets
are broken, but not on sanitation of clinical areas or housing units. We described the duties of
the porters earlier in the Sanitation section of this report. We note, however, that there was no
documentation in their medical records that they were immune to hepatitis B (or A) or if they
had been vaccinated against hepatitis B (or A). The Wexford staff assistant who is responsible
for the training of infirmary porters also was unable to provide documentation that the three
porters had been trained or vaccinated. All infirmary porters must be trained and fully
vaccinated prior to being assigned to duties in the infirmary, where there is higher risk of
exposure to pathogens and a more frequent and higher degree of sanitation is needed.48
CQI meeting minutes contain reportable disease statistics, but no analysis of prevalence or
incidence of new infections. As an example, there is no analysis of Methicillin-Resistant
Staphylococcus Aureus (MRSA) infections to determine whether infections are clustered in
certain housing units that might require further screening and intervention. LCC does not have
an effective infection control program.
In summary, LCC does not have an infection control nurse, the function of the negative pressure
rooms was not adequately monitored, the training of the infirmary porters about their job
duties and exposure and prevention of blood-borne infections was not documented, there is no
evidence that the infirmary porters had received hepatitis B (or A) vaccination or had immunity
to hepatitis B (or A), some deficiencies noted on safety and sanitation rounds do not appear to
be corrected, there are health care unit sinks with crusted mineral deposits, and exam tables
with torn upholstery, and CQI minutes lack analysis of infection control data.
We concur with the recommendations of the First Court Expert on Infection Control. We have
additional recommendations that are included at the end of the report.

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Radiology Services
Methodology: We inspected the radiology unit and reviewed x-ray logs.
First Court Expert Findings
The First Court Expert’s report did not include any findings about the radiology equipment or
services
Current Findings
• The Illinois Emergency Management Agency (IEMA) radiation safety inspections and
reports for the radiology units at LCC are current. The active x-ray equipment at LCC was
found to be in compliance with the Radiation Protection Act of 1990.
• The access to plain film x-rays at LCC is good.
• The turnaround time for radiologist readings and return of the reports is good.
• The lack of a shielded post to take panorex films has the potential for radiation exposure
to the radiology technician.
• The system decision not to have the x-ray technician wear radiation exposure
dosimeters may not be in accord with State of Illinois regulations and is definitely not in
accord with community practice.
IEMA inspected and certified the LCC radiology units in September 2017; this certification is
valid through September 2019. The x-ray technician produced his current license, which is valid
through July 31, 2018.
Plain film non-digital x-ray services and panorex studies are provided Monday, Wednesday, and
Friday during the daytime hours by a single radiology technician who staffs and manages the
unit. The technician estimated that 50 patients generating about 90 plain films receive x-rays on
a weekly basis. Mammography studies are performed on Tuesday and Thursday by a contracted
mammography technician. An intact lead apron to shield patients was inspected. Patients
requiring advanced or emergency studies are referred to local hospitals in Springfield or
occasionally to UIC Medical Center.
It was reported that there is not a waiting list for non-urgent onsite x-rays. Most x-rays are
reported to be taken within one to two days after receiving the order. Weekend and holiday
requests are completed on the next working day. The requests and the radiology log for 18
patients were reviewed. All 18 had films taken within one to four days of the request. Audits of
films taken on April 13 and April 18, 2018 revealed that all of the films were read and returned
to LCC in two to three days. Abnormal results are called in by the reading radiologist; most
results are faxed on the day of or after the reading is completed. The films are read by a local
contracted radiologist in Bloomington, Illinois.
The chest x-ray unit and the plain film table are in a room that has a shielded post for the
technician to stand behind while the film is being taken. The radiology technician has a dark
room and a work space immediately adjacent to the plain film suite. The panorex was added to
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the LCC radiology services after the radiology room had been constructed. It was located in an
interior hallway that connects to the other side of the technician’s work space. There is not a
shielded post that can be used when panorex films are taken; the technician has to stretch the
trigger cord as far as he can and then stand behind a cabinet in the work space to minimize his
risk of radiation exposure. He is not aware if IEMA or the IDOC has ever measured the radiation
exposure generated when panorex films are taken.
The x-ray technician was noted not to be wearing a radiation exposure dosimeter badge. They
stated they had been told by Wexford that the State of Illinois does not require the use of
dosimeters. They communicated that they are required to wear a dosimeters at their other
work site.
In summary, the radiology services at LCC have reasonable access to x-ray services and
reasonable turnaround time of radiologist readings and reports. The location of the panorex
and the absence of a shielded post to take panorex films raises concerns about the risk of
radiation exposure. The decision of the system to not provide radiation exposure dosimeter
badges is not in accord with community standards and needs to be further reviewed by the
State of Illinois IEMA and possibly OSHA.
The First Court Expert’s report did not have any recommendations about the radiology services.
We have noted recommendations that are noted at the end of the report.

Infirmary Care
Methodology: Accompanied by either the HCUA or the Wexford staff assistant, the Expert
toured the infirmary, inspected the clinical space and equipment, and audited infirmary charts.
Nursing staff, porters, and patients-inmates were interviewed.
First Court Expert Findings
The First Court Expert noted significant concerns about the condition of the paper medical
record in the infirmary. Information was kept in two files, reports and notes were loosely
dropped in the chart binder, forms were not in chronological order, admission orders could not
be found, consultation reports could not be located, and the SOAP charting method was not
utilized. The expert also reported that there was not a nurse call system, nurse admission notes
were inconsistently completed, and vital signs were not consistently performed. The expert
reported that the provider notes were thorough and written at least daily.
Current Findings
Since the visit of the First Court Expert, LCC has implemented an EMR system that addressed
most of the deficiencies related to the poor organization of the former paper medical record
and the inability to find clinical information. A nurse call system has been installed adjacent to
all the non-crisis infirmary beds. Vital signs are regularly taken. We identified the following
confirmatory and additional findings.
• The infirmary was clean and organized.
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•

•
•

•
•
•
•

•
•
•

An EMR has been implemented since the First Court Expert’s visit but there are an
insufficient number of devices to enter information into the EMR on the infirmary unit.
There needs to be as many devices as the number of potential simultaneous users. This
reflects on a poor EMR implementation process.
A nurse call device was mounted next to each non-crisis infirmary bed. The system was
verified as being operational. Patients demonstrated competency in activating the
system.
Nurse and provider admission and progress notes were written in accord with
established timelines. We did note, however, on record reviews that the provider
occasionally but routinely writes notes at home after work hours. Notes should be
written at the time service is provided.
There is a nurse assigned to the infirmary on every shift, seven days a week; however,
not all of the infirmary shifts were covered by an RN.
Vital signs in the infirmary were regularly taken and recorded.
The failure of the health care system and the providers at LCC to monitor and track
weights contributed to delays in initiating needed diagnostic testing.
The failure of the infirmary provider to timely consult with medical and surgical
specialists put infirmary patients at risk for disease progression and increased morbidity.
The collegial referral system added little value and contributed to delays in accessing
specialty consultation.
The provider’s use of antibiotics and antifungal agents was excessive and not in
alignment with current practice of care, and put patients at risk for complications of
antibiotics, superinfections, and resistance to antibiotics.
Offsite specialty consultation reports were not consistently retrievable in the EMR.
The utilization of warfarin for anticoagulation is logistically complicated and puts
patients at risk for serious medical complications due to failure to consistently obtain
therapeutic levels of coagulation. It is our opinion that the IDOC should consider newer
alternatives to warfarin for anti-coagulation.

The infirmary is located at one end of the medical building. The unit consists of single and
double bed rooms. There were three crisis/negative pressure rooms with large glass viewing
panels situated directly in front of the nursing station. The physical plant appears to be
unchanged since the First Court Expert’s site visit in 2014. With the exception of the crisis
rooms, hospital beds with adjustable heights and sections in good condition were universally
deployed in all infirmary rooms. The crisis rooms had concrete beds with intact mattresses.
Nurse call devices were mounted on walls adjacent to each infirmary bed. The system was
verified as being operational. Patients demonstrated full understanding of how to activate the
nurse call device. There were no nurse call devices in the crisis rooms, but the rooms were in
the line of sight and/or sound of the nursing station.
At the time of the visit, all of the patients housed in the infirmary were able to independently
perform their personal activities of daily living (ADL). This was in marked contrast to the

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infirmaries at previously inspected male IDOC facilities, where up to fifty percent (50%)
required total or partial care with their ADLs.
IDOC Policy 04.03.120 Offender Infirmary Services49 directed nurses to write admission notes at
the time of admission and progress notes no less than daily for acute patients and weekly for
chronic patients. Providers are to write admission notes within 48 hours and progress notes no
less than three times a week for acute patients and once a week for chromic patients. Review
of five current infirmary records with six infirmary admissions verified that each of these
patients had nurse admission notes on the day of admission and no less than daily progress
notes; most records had notes on each shift, on all patients. Provider admission notes were
written on the six admissions within 48 hours and the five chronic patients had progress notes
no less than weekly. The one acute admission was discharged on the day after admission. We
did note on record reviews, however, that provider notes are sometimes entered late at night;
sometimes around midnight. We were told that the provider will routinely write infirmary notes
after hours. For one episode, a provider wrote a discharge note from home for a discharge that
occurred 8 days earlier.50 We found several examples of this and were told that it is a routine
practice. As we noted in the medical record section, there are an inadequate number of devices
on the infirmary to access the electronic medical record and this is one contributing factor. We
also believe that there is inadequate physician staffing as this physician does not appear to
have time to write all her notes at the time care is administered.
One nurse is assigned to the infirmary on every shift, seven days a week. Although RNs covered
most shifts, LPNs were sometimes assigned to infirmary shifts. If the infirmary is near full
occupancy or the patients’ acuity level of care is higher, additional nursing personnel (LPN,
CNA) would be needed to address patient care needs.
Although the frequency of provider progress notes and quantity of documentation was
reasonable, we had a number of concerns about the quality of the provider’s clinical
judgement, accuracy of clinical diagnoses, rationale for therapeutic clinical decisions, and
understanding of when to consult outside specialists or refer patients whose conditions
warranted inpatient care. The provider ordered antibiotics or antifungal agents when there was
no justification for their use. These medications were continued for durations of time that were
not warranted by the patient’s condition. The provider prescribed confusing combinations of
antibiotics and antifungal agents that were not clinically justified which put the patient at
danger of serious gastrointestinal infections and antibiotic resistance. Patients whose
conditions warranted the early and ongoing involvement of specialists were treated in the
infirmary by the primary care provider in lieu of referral. Doctors utilized presumptive
diagnoses without obtaining diagnostic testing or consultative referral necessary to make a
diagnosis. The diagnostic testing or consultation necessary for a definitive diagnosis were either
Offender Infirmary Services.
Patient #2 Hospitalization and Specialty Care. In this case, the doctor wrote a discharge note on 9/7/17 for a discharge that
occurred on 8/31/17. This patient also had episodes in which the physician wrote notes at a later time for events that happened
the day before. In this 9/7/17 episode, the doctor also appeared to have cut and pasted a portion of a mental health note to
her note which made the note appear nonsensical.

49
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not timely done or not done at all. We had a number of concerns about the care provided to
infirmary patients which are provided below.
•

The first example is a patient who had complaints of persistent lower abdominal pain,
intermittent episodes of passing bright red blood from her rectum, and progressive
weight loss for almost a year without timely work up.51 She was noted as having anemia
as early as January of 2017. The providers failed to note her weight loss; she was initially
treated in January of 2017 for presumed diverticulitis without benefit of diagnostic
studies (CT scan, ultrasound or follow up colonoscopy). A CT scan should have been
done for a diagnosis of diverticulitis and colonoscopy should have been done for
symptoms of abdominal pain, passing blood, anemia, and weight loss and for follow up
screening for cancer if diverticulitis were diagnosed. From January to September of 2017
we noted 11 documented weights all showing progressive declining weight. Yet, only
one provider note mentioned weight loss, and this was recorded seven months prior to
her admission to the infirmary. In July of 2017 a provider noted that the patient had no
“red flags” when at that visit the patient had a 28 pound weight loss. Eventually, on
9/26/17 the patient was admitted to the infirmary with nausea, vomiting, and
abdominal pain. No diagnostic testing or consultation were ordered in the outpatient
clinics.
The initial therapeutic plan on the infirmary was to add ciprofloxacin to an ongoing
prescription of metronidazole. The infirmary provider’s plan was to continue antibiotics
without ordering diagnostic testing (CT scan and white count), which is typically
necessary to make a diagnosis of diverticulitis. Only after another 12 days in the
infirmary did a provider note that the patient had lost a significant amount of weight
and diagnostic testing was initiated. At this point the patient had lost 40 pounds. A CT
scan was not done for about three weeks for what was an urgent medical problem. The
CT scan showed a colon mass, likely cancer with metastases to lymph nodes and liver.
Biopsy was done electively. Over two months after admission to the infirmary the
patient was finally admitted to a hospital for surgery. Chemotherapy started a month
later. This patient’s complaints were not timely identified or evaluated, and resulted in
late diagnosis and treatment of cancer that likely significantly harmed the patient. The
metastases to the liver increased the probability of early death from this condition. The
failure to link the weight loss to her symptoms indicated either incompetence,
indifference, or negligence by the providers.

•

51

52

Another patient had clinical history of transient ischemic attack, mitral valve
replacement in 2006, severe tricuspid valve regurgitation, chronic atrial fibrillation,
chronic kidney disease, COPD, left atrial appendage thrombus, chronic anticoagulation
on warfarin, and chronic congestive heart failure (CHF), NYHA Class IV.52 This patient
was noted to have repeated episodes of bradycardia (slow heart rate) and multiple

Infirmary Patient #1.
Infirmary Patient #2.

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itchy, draining skin lesions. The patient was admitted to the infirmary in September
2016 after hospitalization for heart failure and severe non-operable tricuspid
regurgitation.
From October 2016 through April of 2018, the patient’s level of anticoagulation was not
therapeutic 29% of the time. Since July 2017, the patient had chronic itching with
excoriated draining skin lesions which failed to resolve. Yet despite being unable to
develop an adequate therapeutic plan or diagnosis, the patient was not referred to a
dermatologist. We noted that the patient was on a medication (torsemide) which can
cause a similar rash, yet this was unnoticed by providers. From July 2017 through March
2018, the patient had at least eight episodes of bradycardia. The slow heart rate was not
noticed based on provider notes and there was no history or evaluation for associated
symptoms of bradycardia. The patient was taking a medication (metoprolol) with a
known side effect of causing bradycardia, but this medicine was not stopped nor was
the dosage decreased. The provider did not document that any other heart condition
was considered as the etiology of the slow heart beats, nor was consultation with a
cardiologist requested.
In April of 2018, the patient was admitted to a hospital for tachycardia (130) and
hypoxemia (oxygen saturation 88%). At the hospital, bradycardia (pulse in the 40s) was
noted. Sick sinus syndrome53 was identified and a pacemaker was inserted. On return
from the hospital, the medication likely causing the rash was discontinued and the
metoprolol dose was decreased. Doctors at LCC failed to adequately evaluate the
patient’s skin rash, failed to identify potential medication adverse reactions, failed to
adequately identify or evaluate the slow heart rate with diagnostic testing, and failed to
timely refer the patient to a cardiologist for slow heart rate in a patient with atrial
fibrillation. These failures placed the patient at risk for harm.
•

Another patient, newly incarcerated at LCC, was admitted to the infirmary with severe
damage to her toes from frostbite.54 The patient was incarcerated on 1/30/18 and was
noted to have a one month history of black, swollen toes. She was admitted to the
infirmary and started on an antibiotic without documentation of the reason for initiating
the antibiotic. A progress note on 2/20/18 documented gangrene and another antibiotic
(cephalexin) was added to the metronidazole. On 3/6/18, fluconazole was added to
metronidazole and cephalexin. The reason for this was not given and there was no
apparent indication for adding an antifungal agent to the therapeutic plan, and the
doctor did not document the infection resulting in the decision to start metronidazole or
cephalexin. The 3/9/18 progress noted stated that right distal large phalanx was hard,
dry, and black. On 3/12/18, 42 days after admission to LCC and 27 days after admission
to the infirmary, the patient was seen by a general surgery consultant, who

53

Sick sinus syndrome is a cardiac arrhythmia that results in a slow heartbeat. This arrhythmia typically requires a pacemaker.
Notably this patient had a slow heartbeat for months which was not appropriately evaluated until emergency hospitalization
occurred.
54
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recommended that the patient be referred to a podiatrist. This referral was not timely.
Referral to surgical consultants with experience in managing frostbite needs to be
prompt to prevent unnecessary amputation. The LCC doctor continued antibiotics
without clear documentation of why they were being used. Cephalexin was
discontinued on 3/12/18 and metronidazole stopped on 3/16/18, but fluconazole was
ordered to be continued for another three weeks. On 3/23/18, metronidazole was
reordered. A podiatry consultation appears to have been scheduled on 3/27/18, but
may not have taken place (no consultation report, no provider progress note). On
4/14/18, the provider noted “no signs of infection,” but cephalexin was added to
metronidazole. The patient was seen by podiatry at Taylorville Podiatry on 4/19/18. The
podiatrist recommended elective amputation. The podiatry consultation report was not
located in the EMR. The doctor treated the patient with a changing and inexplicable
array of antibiotics, including an oral anti-fungal agent for which there was no
documented indication. The patient had black gangrenous toes and should have been
either hospitalized or promptly referred to a foot specialist experienced in managing
frostbite injury for early consultation to maximize the potential viability of her damaged
toes. The first documented podiatry appointment occurred 66 days after her admission
to the infirmary; the podiatrist immediately made arrangements to amputate one of her
large toes. The excessive use of combinations of antibiotics and antifungal agents was
unwarranted and exposed the patient to the risk of medication side effects. We note
that the consultation reports were not found in the EMR. We also noted several latenight after-hours notes were written for this patient.
•

55

Another patient is a 42-year-old patient had a history of total abdominal
hysterectomy/ovarian cyst in 2010, and obesity.55 She was admitted to the infirmary for
observation on 9/7/17 for abdominal pain and a complaint of an enlarged abdomen, but
was discharged the following day. She again complained of abdominal pain on 10/5/17
and was found to have mild anemia, for which iron was started without any other
diagnostic testing except a normal plain abdominal x-ray, which has little utility in
evaluation of abdominal pain. By January 2018, the patient still had abdominal pain and
was admitted to the infirmary. For the five month period from September through
January, we noted four evaluations for abdominal pain during which the weight loss of
the patient was not noted. We noted a 13.5 pound weight loss since August 2017. A
doctor initiated treatment for diverticulitis with ciprofloxacin and metronidazole,
ordered an elective abdominal ultrasound, but discharged the patient the same day
back to general population. This is an inappropriate therapeutic plan, as diverticulitis is
an urgent problem. The patient should have remained on the infirmary until the
conclusion of the diagnosis and the evaluation should have been promptly conducted.
Instead, the ultrasound was not done for almost a month and showed a large pelvic
mass. A subsequent CT scan showed an ovarian mass, possibly carcinoma.
Approximately six weeks passed before the patient was hospitalized on 4/3/18 for
exploratory surgery. This was a significant delay to diagnose and initiate treatment of

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the patient’s condition. After return to the infirmary post-hospitalization, a final
pathology report was not available in the medical record; a preliminary report indicated
a benign condition. We remain concerned about the lack of attention to weight loss.
This appears to be a systemic problem in the IDOC, as we have seen this on multiple
record reviews at multiple sites, including on multiple death records. Whether this is
due to indifference, lack of primary care training of providers, or some other reason is
unclear, but the IDOC needs to address this issue.
•

Another infirmary patient is a 28-year-old who had a history of four episodes of
recurrent deep vein thrombosis (DVT) and pulmonary emboli since 2012 requiring
continuous anti-coagulation therapy.56 Since 2015, the patient had a right lower
extremity ulcer. She had been on the infirmary for the past eight months for the nonhealing, draining leg ulcer. The doctor ordered a confusing and changing combination of
antibiotics without apparent indication. These included levofloxacin (9/20/1710/25/17), doxycycline (12/18/17-1/23/18), trim-sulfamethoxazole (1/23/18 to
4/23/18), levofloxacin plus trim-sulfamethoxazole (2/28/18 to 4/23/18), fluconazole
once weekly off and on, and metronidazole off and on for a number of courses. Over an
eight month period, the provider failed to evaluate the patient for osteomyelitis despite
the patient having a chronic draining ulcer over a bone. The doctor should have
considered or ordered bone scan, bone biopsy, MRI, and blood tests (white count, blood
cultures, CRP, or sedimentation rate). In March and April 2018, the provider submitted
several referrals to an infectious disease doctor which were denied by Wexford
utilization, even though it appeared that the doctor was uncertain how to manage this
condition. This patient clearly needed specialty consultation due to the doctor being
unable to diagnose the patient’s serious medical condition, but these requests were
denied without appropriate alternatives. With respect to anticoagulation for this
patient, the INR levels were in the therapeutic range only 47% of the time. Her
anticoagulant was modified 13 times in response to the high or low INRs. Given the
inability of physicians to maintain therapeutic control and the logistics of warfarin
anticoagulation in a correctional setting, newer alternative anticoagulants that are less
complicated and safer to administer should be used. The lack of timely evaluation for
osteomyelitis was a significant problem, as the patient has had the leg ulcer for over
eight months. This places the patient at significant risk of harm.

In summary, with the exceptions noted in the first paragraph of the current findings section
that the EMR had addressed many of the deficiencies in the medical record and nurse call
devices had been installed in most infirmary rooms, we agree with the recommendations of the
First Court Expert and have additional recommendations that are found at the end of this
report.

56

Infirmary Patient #5.

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Chronic Care
Methodology: The chronic care nurse was interviewed about the chronic care scheduling and
tracking processes. The current chronic care annual schedule, the chronic care patient lists, and
chronic illness medication lists were reviewed. The chronic care nurse practitioner was
interviewed. The records of 15 patients with chronic care illnesses and conditions were
reviewed. The Office of Health Services Chronic Illness Treatment Guidelines dated March 2016
and the IDOC Hepatitis C Guidelines December 2017 were reviewed as needed.
First Court Expert Findings
The First Court Expert noted that the chronic care program at LCC lacked oversight and
organization. The chronic care nurses’ duty to compile lists of patients’ degree of control was
not being done. There was a very large backlog in scheduling patients for chronic care
appointments. The part-time provider staffing the chronic care clinics only saw chronic care
patients one day a week. This provider’s notes were completely illegible. The Medical Director
was seeing the majority of the chronic care patients in sick call sessions; this was decreasing
patients’ access to sick call and urgent care services. The expert noted that it was impossible to
determine how many patients were enrolled in LCC’s chronic care program.
Current Findings
The First Court Expert’s finding of not having an assigned nurse for chronic care has been
resolved. Also, patients are now assigned to clinics and regularly seen. We identified current
and additional findings as follows:
• An EMR has been implemented at LCC. This addressed the First Court Expert’s strong
concerns about the legibility of provider notes.
• LCC now has assigned a single, dedicated nurse to coordinate the chronic care program.
• Patients assigned to chronic care clinics are regularly seen in these disease specific
clinics.
• The nurses pull the MAR’s for patients’ chronic care visits, but there is no
documentation that the providers review this important clinic data about medication
compliance and CBGs.
• The MAR is still completed manually by the nursing staff. Blank days, non-approved
codes, and illegibility were noted for dose-by dose medications and varying methods of
documentation were utilized for KOP medication delivery. The lack of accuracy of the
MAR’s is a barrier to verifying a patient’s compliance with medications and determining
the efficacy of the treatment.
• LCC does not reschedule chronic care appointments of patients who refuse a chronic
care visit until four to six months later, when the next disease specific chronic clinic is
held and does not have a process to monitor and track the status of these patients
during the intervening months.
• LCC primary care providers and nurse do not have access to current, comprehensive,
electronic medical references such as UpToDate in all clinical exam rooms and offices.
• LCC does not screen patients over 50 years of age or patients with high-risk clinical
conditions for colon cancer as is recommended by national guidelines. None of the four
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•
•

•

•
•
•
•

patients over 50 years of age whose records were reviewed had been screened for
colon cancer.
LCC does not calculate 10-year cardiovascular risks for adult patients as directed by the
ACC/AHA and IDOC treatment guidelines.
LCC does not administer age-based and disease-based adult preventive vaccinations,
including pneumococcal 13 and 23, diphtheria, tetanus, and pertussis, meningococcal as
recommended by the Center for Disease Control (CDC),57 or routine health maintenance
screening tests as recommended by the USPSTF.
Only one (9%) of 11 patients with chronic illnesses, including asthma, CHF, COPD, HIV,
diabetes, and cancer on chemotherapy had received pneumococcal 23 vaccination. The
only patient over 65 years of age whose chart was reviewed had not received
pneumococcal 13 or 23 vaccinations. Only one (33%) of three HIV patients had
documentation of having received pneumococcal 23 vaccination; none of the three had
received pneumococcal 13 or meningococcal vaccinations.
The current disease specific chronic care schedule contributes to delays in achieving
control of chronic illnesses.
Providers at LCC inconsistently document the rationale for clinical decisions and
diagnoses in the chronic care progress notes.
HIV patient with active hepatitis C are not timely advanced toward the evaluation and
initiation of hepatitis C treatment.
The process to determine eligibility for hepatitis C treatment is excessively lengthy and a
barrier to the initiation of treatment. It is not consistent with processes in other
correctional facilities and public health systems.

With the exception of the general medicine clinic, the non-baseline chronic care clinics (asthma,
cardiac/hypertension, diabetes, hepatitis C, high risk/HIV, seizure) are silos in which only a
single disease is managed. The schedule for these clinics is inflexible and not based on the
degree of control of a patient’s illness.58 This has the potential to harm patients, as patients are
evaluated on this schedule irrespective of the degree of control of their illness. Therefore,
persons who need greater attention because their disease is poorly controlled may not receive
it.
We view this as inefficient, wasteful, and potentially harmful. Patients should be evaluated as
frequently as is necessary to establish disease control and not based on an inflexible schedule.
Primary care doctors need to coordinate care for the patient, integrating treatment for all of
the patient’s conditions. When specialists manage a single illness, they typically list all of the
CDC Recommended Immunization Schedule Adults 19 Years of Older, United States, 2018.
LCC’s chronic care clinic annual schedule is as follows: asthma (January and July,) diabetes (April, August, and December),
cardiac/hypertension (A-L March and September; M-Z April and October), general medicine (May and November), hepatitis C
(June and December), high risk/HIV (monthly), seizure (February and August), and TB (monthly, annual education). LCC has
combined two conditions, diabetes/lipids and diabetes/hypertension, for simultaneous evaluation in the initial baseline clinic
but not in the follow-up chronic care clinic session. Hepatitis C patients who have not yet met the IDOC criteria for treatment
are seen in the June and December hepatitis C chronic care clinics. Other chronic illnesses (hyperlipidemia, anemia, cancers,
multiple sclerosis, sickle cell disease, neurological disorders, etc.) are treated and monitored in the general medicine chronic
care clinics.
57
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patient’s other medical conditions and medications, and consider the implication of all diseases
on the condition being monitored. In the IDOC, every single disease is managed as if it is the
only disease the patient has. Diseases are often interrelated such as metabolic syndrome.59
Drug-drug interactions need to be considered in management of medications. Some illnesses
have an effect on other illnesses. When IDOC providers evaluate patients in individual chronic
care clinics, they do not list the patient’s other illnesses and do not address any other
conditions, even when a condition may not be in control or may have an impact on the
condition being treated.
Some illnesses are managed in specialty clinics. All individuals with HIV and eligible patients
cleared for treatment with hepatitis C are managed via telehealth by the UIC infectious disease
telehealth clinic. UIC HIV telehealth clinics are held monthly. A monthly telehealth renal clinic
staffed by a consulting nephrologist is scheduled as needed. This kidney specialist also provides
telehealth consultation to other IDOC facilities.
The high risk/HIV chronic care roster was compared to the medication list to assess the
accuracy of the chronic care roster. Five patients were not on the chronic care roster who were
receiving HIV meds. Four of these five patients had recently been transferred to DCC; the other
patient had only recently been started on HIV medications. It appears that the roster is
accurate.
On April 6, 2018, the census of LCC was 1,617, with an additional 230 patients housed in
Reception & Classification (R&C) and Segregation. The March 2018 Chronic Care Clinic Roster
was as follows:
Clinic
Asthma
Cardiac/Hypertension
Diabetes
General Medicine
Hepatitis C
High Risk/HIV
TB
Chronic Care roster
*

Patients
183
362
91
195
174
16
30
1,141*

Percentage of ADC (1,617)
11.3%
22.4%
5.6%
12.1%
10.8%
1.0%
1.9%

Individual patients with more than one chronic illness are enrolled in a number of chronic care clinics.

These percentages reflect the prevalence of each chronic illness in the LCC population. The
chronic roster of 1,141 patients was not further analyzed to determine how many unique
women were on this roster. The percentage of individual women with chronic illnesses would
be significantly less than 1,141.
Metabolic syndrome is a combination of diabetes, hypertension, and high blood lipids. These inter-related conditions must be
treated as a single disease. When kidney disease, retinopathy, or neuropathy exist with diabetes, they are also treated as
diseases related to diabetes.

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The chronic care clinic scheduling processes were reported as follows:
1. Providers and nurses enter chronic illnesses into the EMR.
2. EMR generates the baseline chronic care list, nurses review the list, order lab panels,
and verify that labs are completed.
3. EMR sends a reminder for baseline appointments that are to be scheduled within 30
days, nurses manually enter the appointment in 360 (an IDOC program).
4. Chronic care clinic rosters are maintained by clinic in 360 (an IDOC program).
5. Nurse coordinator downloads and prints the next month’s follow-up chronic care
patient list from 360 and searches EMR to verify or order labs.
6. Once lab results are in EMR, nurse enters an appointment in the EMR.
7. A nurse schedules 13-15 patients per day for the chronic care provider (12-13 patients in
the morning and 1-3 patients in the afternoon).
8. Appointment schedules are printed, and administrative staff fill out movement passes
that are given to corrections 24 hours in advance.
9. IDOC transports patients to the clinic.
10. Nurses manually enter into 360 all no shows and patients seen; EMR also maintains and
tracks patients seen, no shows, and refusals.
Patients who choose to refuse to be seen in a chronic care clinic are to be transported to the
clinic to sign a refusal form; in practice, corrections is reluctant to force a patient to walk to the
health care building to sign the refusal. When a patient does not arrive for a chronic care clinic
session, nurses staffing the chronic care clinic call the officers in the housing units to remind
them to move the patient. If the officer informs the nurse that the patient is refusing, no
further action is taken. Providers are informed when a patient has refused a chronic care clinic
visit. The provider reviews the new lab reports in the EMR and reorders or adjusts any ongoing
medications for chronic clinic refusals. Even if the patient’s chronic condition is not controlled,
patients who refuse a visit will not be rescheduled until the next scheduled chronic care
session, which is as long as six months later. We were informed that this is done to instill
responsibility and accountability into the patient. The staff related that no focused review of
vital signs or capillary blood sugars or medication compliance are done during the many month
interim before the next disease-specific chronic care clinic to minimize the risk of clinical
deterioration for patients who have refused the chronic care visit. Patients who refuse chronic
care visits tend to fall into high-risk categories; many have mental health conditions. This
current practice puts patients at risk. LCC must develop and implement a process to
intermittently monitor patients who refuse chronic care appointments. Patients not brought to
clinic because of lockdowns or correctional or weather issues are rescheduled to be seen within
a week or two.
The chronic care clinics at LCC are primarily staffed by a full-time nurse practitioner, but the
physician provider also sees a number of complicated or special interest chronic care patients.
The nurse practitioner reported that her chronic care clinics run six hours per day and with up
to 20 patient appointments scheduled per day. Two nurses support the chronic care clinics;
scheduling patients, ordering labs, pulling medication administration records (MAR) mainly for
CBG results, and doing vital signs. Although it was reported that MAR’s are pulled for review at
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chronic care visits, the experts did not find any documentation in the visit notes that this
valuable information about medication compliance and CBG’s on the MAR’s were ever
reviewed. It was reported that the physician annually reviews and makes clinical suggestions on
all of the nurse practitioner’s chronic care charts. The provider mentioned that there is a need
for onsite podiatric consultation for foot and nail conditions that cannot be readily addressed
by LCC’s primary care staff. The physician stated that she did not have access to Up-to-Date but
occasionally accesses some of the other online, less comprehensive medical references. One
nurse practitioner and one physician assistant had access to personally purchased,
comprehensive, current (UpToDate®) electronic medical references. Another nurse practitioner
stated she did not have access to comprehensive electronic medical references.
In March 2018, 157 follow-up chronic care and 100 chronic care baseline visits were performed.
Based on a review of chronic care medical records, most patients with chronic illnesses at LCC
are seen by providers in the chronic care clinics approximately twice a year. Diabetic patients
were found to have HbA1C testing on a regular basis, documented foot exams, urine
microalbumin-creatinine ratio testing, and annual eye evaluations by an optometrist.
Providers were generally critical of the utilization management program that served as a barrier
to timely care. One provider questioned the need for collegial requests/approvals for specialty
consultation and to order onsite ultrasonography studies and non-formulary labs, in particular
certain tests to monitor cancers that have been requested by specialists. This process delays
access to these and other diagnostic studies and specialty consultations. We agree. One
provider reported that, with the exception of breast and cervical cancer screening, no one does
age-based routine health maintenance screening or age and disease-based vaccinations at
LCC.60 One provider stated that the current IDOC policy to perform rectal exams and a single
fecal blood test is not a valid screening test for colon cancer. The provider also communicated
that colon cancer screening using the three separate fecal occult blood cards methodology
could be used but is not because of the institution’s practice to make patients come to the
health care unit to defecate to obtain the specimen was too cumbersome. This practice was
reported to have been established because the women might tamper with the test if allowed to
gather the specimen in the housing unit. The provider was not aware of the new fecal
immunochemical test (FIT) that is available to screen for colon cancer. The failure of LCC to
screen for colon cancer does not meet the national and community standards of care.
The care provided to a number of patients with chronic illnesses had deficiencies. The providers
did not consistently document the rationale for clinical decisions, including the selection of
medications, changes in medications, and modification of medication dosages. It was difficult to
understand the reasoning for the treatment regimens that were being provided to some
patients. Some patients needed specialty consultation but did not receive it. Consultants
recommended additional diagnostic studies for a patient but there was no documentation in
the medical record that these tests were ordered and there was no documented clinical
rationale for not proceeding with the recommendations. Some patients were treated with
60

CDC Adult immunization schedule 2018, reference # USPSTF Colorectal Cancer Screening June 2016.

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medications without appropriate indication. Fenofibrate was used to treat mild elevations of
triglycerides in three patients, including two uncontrolled diabetics, when treatment was not
indicated. Some patients had uncontrolled disease but the intervals of scheduled appointments
were not appropriately shortened. Two patients with HIV and hepatitis C were not approved to
begin evaluation for hepatitis C treatment until four and eight months respectively after
admission to LCC. This is an excessive delay for HIV patients, who are considered at risk for
accelerated deterioration and listed as priorities for treatment of hepatitis C. Patients with
hepatitis C also do not receive HCV viral load testing as recommended in the IDOC Hepatitis C
guidelines.61 As recommended in the IDOC hyperlipidemia treatment guidelines,62 LCC
providers are not calculating the 10-year cardiovascular risk on older patients, diabetics,
hypertensives, and those with hyperlipidemia. This has resulted in the failure to initiate statins,
the proper dose of statins, or the proper intensity of statins on patients with a high risk of
having a stroke or heart attack in the next 10 years. Diabetics, asthmatics, HIV patients, and
patients over 65 years of age are not being offered protective pneumococcal vaccinations as is
the national standard in the USA. Patients over 50 years of age or otherwise at high risk are not
being screened for colon-rectal cancer; this is also not in accord with national standards of care.
Many of these are systemic problems found at all facilities we have visited.
The following patient summaries highlight the concerns and the findings noted above.
Chronic Care Patient Summaries
• This patient is a 36-year-old with a history of HIV and hepatitis C who was admitted to
LCC in July 2017 and followed in the UIC HIV telehealth clinic and the (LCC) hepatitis C
clinic.63 Her HIV viral load has been fully controlled and CD4 counts have ranged
between 692 and 805. She had immunity to hepatitis A and B. Her HCV RNA was
639,892 IU/ml. Her last APRI was 0.89 in April 2017 and it was noted that she could now
be worked up for hepatitis C treatment. This patient has not received pneumococcal 23,
13 or meningococcal vaccinations which are indicated for all patients with HIV. Her
discharge date is March 2019. It took eight months before she was deemed eligible for
the hepatitis C treatment process to begin. This delay put the patient at risk for
complications of hepatitis C. In the United States, patients with hepatitis C and HIV are
moved more expeditiously into hepatitis C treatment due to the more rapid progression
of hepatitis C in patients co-infected with HIV.
•

This 40-year-old patient has a history of HIV and hepatitis C.64 She was admitted to LCC
on 9/7/17; she did not agree to start HAART until 10/10/17. By 1/10/18, the viral load
was <20 and the CD4 improved to 443. She was given pneumococcal-23 vaccine but not
the meningococcal or pneumococcal 13 vaccines. At her first hepatitis C clinic visit on
9/28/17, vaccinations for Hep A and B were initiated. The HCV RNA was elevated,
7,727,120 IU/ml. In December 2017 the APRI score was 1.2 and at the 1/10/18 UIC HIV

61

Hepatitis C Guidelines December 2017.
Offender Health Services, Treatment Guidelines, Hyperlipidemia.
63
Chronic Care Patient #1.
64 Chronic Care Patient #2.
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clinic, the provider recommended that she be evaluated for hepatitis C treatment as per
IDOC protocol. As of 4/19/18, the patient has not started on hepatitis C treatment. In
summary, the patient is seen regularly in the UIC HIV and the hepatitis C clinic. Her HIV
is well controlled. She has not yet been offered meningococcal or pneumococcal 13
vaccinations. It took four months before she was deemed eligible for the hepatitis C
treatment process to begin and another three months have passed and she has not yet
started treatment. However, in many US medical centers, patients with hepatitis C and
HIV have liver fibroscans ordered quickly and are moved more expeditiously into
hepatitis C treatment due to the more rapid progression of hepatitis C in patients coinfected with HIV. Given that this patient did not start HIV treatment until October
2017, some time lag before initiating the evaluation for hepatitis C treatment was
justifiable, but the delay to initiating treatment is excessive.

65
66

•

This patient is a 35-year-old female with HIV.65 Since 5/12/17, she was seen four times in
the UIC HIV clinic. On 6/29/17, she agreed to start a new regimen of HIV meds. As of
12/18/17, she was still taking the meds; the viral load was undetectable and the CD4
817. There was no documentation in the UIC HIV notes reviewed that this patient had
been offered or vaccinated with pneumococcal 13, pneumococcal 23, or meningococcal
immunizations. She has not had a documented Pap smear since 7/28/15. In summary,
this HIV patient is now fully controlled with an undetectable viral load and an excellent
CD4 (817). She has not received pneumococcal 13, pneumococcal 23, or meningococcal
vaccines. She has not received a Pap smear since 2015. The IDOC protocol states that
women between 30-39 years of age are to have a Pap smear with HPV testing every
three years. However, US guidelines state that HIV positive women must have three
consecutive normal annual Pap smears before the testing interval is increased to three
years. There was no documentation identified in the medical record that this patient
previously had three normal annual Pap smears.

•

This patient is a 38-year-old female with seizure disorder, chronic hepatitis C, and
substance abuse.66 She entered LCC on no medications. Her intake history was done on
11/21/17 and the physical exam on 11/22/17. She reported that she has had seizures
occasionally accompanied by urinary incontinence since age 21. The seizures were
treated in the community with Xanax (alprazolam). She reported that her most recent
seizure occurred on 10/20/17. At that time the seizure was felt to have been
precipitated by Xanax withdrawal or possibly opioid withdrawal (patient reported that
she had stopped her methadone maintenance medications). LCC started the
anticonvulsant Keppra (levetiracetam) 500mg BID at the time of the provider intake
exam on 11/22/17. No additional workup was initiated to evaluate this history of seizure
disorder. She was followed in the hepatitis C and seizure chronic care clinics. At the
12/22/17 hepatitis C chronic care clinic, lab results were noted as: hepatitis C antibody
reactive, hepatitis A and B antibody positive (protective), liver enzymes elevated (AST

Chronic Care Patient #3.
Chronic Care Patient #4.

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41, ALT 48), INR 1.1, and APRI 0.5. There was no record that the HCV RNA was
performed as recommended in the system’s hepatitis C guidelines.67 She was deemed
not eligible for treatment at this time. She has been seen twice in the seizure chronic
care clinic. In summary, this patient has been seen in the hepatitis C and seizure clinics.
To date, her HCV RNA level has not been performed as directed by the Hepatitis C
Guidelines. If this test is negative, her hepatitis C has resolved, and she would no longer
need to be followed in the hepatitis C clinic. This test must be performed as per
protocol. This patient’s seizure disorder has not been appropriately evaluated. Based on
the patient’s history, her seizures have a high possibility of being caused by withdrawal
from benzodiazepines (or possible opioid withdrawal) such as Xanax (alprazolam), not
by underlying epilepsy. The decision to start an anticonvulsant is reasonable pending
further investigation into her seizure history, obtaining past medical records, and
consultation with a neurologist. However, consultation with a neurologist has not been
requested and there is no documentation that additional tests (electroencephalogram
or CT scan of the brain) or outside medical records were requested. Anticonvulsant
medications have multiple serious side effects. It is in the patient’s best interests to
determine if she really requires taking an anticonvulsant. LCC has not adequately
evaluated this patient’s seizure disorder; the level of care for this patient does not meet
the community standard of care.
•

This patient is a 66-year-old whose problem list includes seizures, diabetes, and
hypertension.68 Her medications included aspirin, metformin 500mg/d, simvastatin
5mg/d, and lisinopril 10mg/d. Although seizures are listed on her problem list, this
patient is not taking an anti-convulsive medication and there is no mention of seizures
or epilepsy in her medical record. This erroneous problem list entry must be corrected
or clarified. Pneumococcal 23 vaccine was administered in 2014. Her diabetes is very
mild and is controlled (median HbA1C 6.2). Her blood pressure has been adequately
controlled; so well controlled that she may not require the anti-hypertensive that she is
currently being prescribed. The LCC providers have not done this patient’s 10-year
cardiovascular risk scores as recommended in the IDOC’s hyperlipidemia treatment
guidelines,69 but it computes to 17.7%. She has been prescribed a very low dose (5mg)
of simvastatin, a moderate intensity statin. Based on national standards and the IDOC
hyperlipidemia treatment guidelines, a diabetic with high 10-year cardiac risk should be
prescribed a high intensity drug such as atorvastatin 40-80mg. This 66-year-old patient
has not been offered nor received age-based screening for colorectal cancer or
preventive vaccination against pneumococcal 13.
In summary, this patient has been seen regularly in the diabetes and hypertension
clinics. Both of these chronic illnesses are controlled with low doses of medication. Her
problem list erroneously listed “seizures;” this inaccuracy must be corrected. The LCC

Hepatitis C Guideline, December 2017.
Chronic Care Patient #5.
69 Office of Health Services, Chronic Illness Treatment Guidelines, Hyperlipidemia, March 2016.
67
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providers are not adhering to IDOC and national guidelines by failing to calculate this
patient’s 10-year cardiovascular risk score. This failure has resulted in this patient not
receiving the recommended high intensity statin medication that has the potential to
minimize her future risk of heart attack and stroke. This patient has not been screened
for colorectal cancer; national standards recommend that all patients 50 years of age or
older should be regularly screened for this potentially preventable cancer. IDOC policy
advises rectal exams for patients over age 40 as part of their periodic physical exams.
Rectal examination (with or without a single fecal occult blood test) is not a
recommended screening test for colon cancer. This patient had not received
pneumococcal 13 vaccination as recommended for all patients 65 years of age or older.
•

70

71

This patient is a 50-year-old female with diabetes and hypertension.70 Her medications
include 70/30 insulin 56U/am and 54U/pm, sliding scale regular insulin BID, metformin
1000mg BID, fenofibrate 54mg/d, amlodipine 10mg/d, glipizide 30mg/d, aspirin,
lisinopril 40mg/d, and triamterene/hydrochlorothiazide. She is followed in the diabetes
and hypertension clinics. Fourteen HbA1C tests have been done in the last four years;
not a single one has reflected adequate control. The HbA1Cs have ranged from 8.8 to
12.5 with a median of 10.2. The dose of 70/30 insulin has been steadily increased and is
currently 56U/am and 54U/pm. The patient is also prescribed a sliding scale dose of
regular (short acting) insulin before breakfast and dinner; this is in addition to the
17U/am and 16U/pm regular insulin that is being injected in the 70/30 combination.
Adding additional regular insulin to the 70/30 insulin is potentially dangerous and poses
a heightened risk of hypoglycemia. The patient is also receiving a high dose (30mg) of
the oral diabetic agent, glipizide, which has little practical value in this patient who is
already injecting very high doses of 70/30 inulin twice a day. Review of the 2018 MARs
indicates good compliance with the medication regimen. Capillary blood glucoses (CBG)
in 2018 have been consistently over 200. This patient’s diabetes has not been controlled
for the past four years. Consultation with an endocrinologist is needed but has not been
requested. The patient is receiving four anti-hypertensive medications but 50% of the
blood pressures recorded at the diabetes and hypertension clinic visits were not
controlled. The LCC providers have not calculated this diabetic, hypertensive patient’s
10-year cardiovascular risk scores as recommended in the IDOC’s hyperlipidemia
treatment guidelines,71 but it computes to 15.4%. The only anti-hyperlipidemia
medication (fenofibrate) that she has been prescribed has limited if any cardioprotective value. Based on national standards and the IDOC hyperlipidemia treatment
guidelines, a diabetic with high 10-year cardiac risk should be prescribed a high intensity
statin. This has not been done and there is no documentation in the progress notes that
this patient has any contraindications to the use of a statin. This 50-year-old patient has
not been offered or received age-based screening for colon cancer or preventive
vaccination against pneumococcal 23; vaccination that is recommended for all diabetics.
In summary, for the last four years this patient’s diabetes and hypertension have been

Chronic Care Patient #6.
Office of Health Services, Chronic Illness Treatment Guidelines, Hyperlipidemia, March 2016.

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uncontrolled. She is taking very high doses of injectable 70/30 insulin and a high dose of
glipizide (oral agent) which has not been able to control her blood sugars. Her HbA1Cs
persistently are in the 9-11 range. The use of a sliding scale in a patient injecting 70/30 is
potentially dangerous, creates a significant risk of hypoglycemia, and should be stopped.
Adding high dose glipizide to this patient’s diabetic regimen increases the risk of
hypoglycemia and has limited if any added value to the treatment of this patient’s
diabetes. An endocrinologist should be consulted to assist with the management of this
complex and uncontrolled diabetic patient. The patient should be prescribed a high dose
statin to minimize her risk of heart attack and stroke. This patient’s blood pressure is not
controlled; consultation with the telehealth nephrologist should be solicited. This
patient is not receiving a level of care consistent to what is provided in the community.
•

This patient is a 38-year-old female whose problem list includes diabetes and elevated
triglycerides.72 Her current medications include 70/30 insulin 20U/am and pm, sliding
scale regular insulin, metformin 500mg BID, and fenofibrate. She is followed in the
diabetes and general medicine chronic care clinics. Since 2014 she has been seen 13
times in the diabetes clinic and five times in the general medicine clinic since 2016. The
concomitant prescribing of 70/3073 insulin and sliding scale regular insulin before
breakfast and dinner puts the patient at risk for hypoglycemia. Metformin in varying
doses has been started, stopped, and restarted. Glipizide was started and stopped. The
70/30 insulin dose of 20U/am and pm has not been increased since 2016 even though
the four HbA1Cs in 2017-2018 have been 7.3 to 8.3. The provider’s rationale for these
changes or renewals were not documented in the progress notes. Her triglyceride level
was 326 in 2014 when the HbA1C was 9.7 and 10.2. Her cholesterol was 226, HDL47,
and LDL 152. Pneumococcal 23 vaccine has not been administered to this diabetic
patient.74 In summary, this diabetic patient has been seen regularly in the diabetes and
general clinic. There is no reason why her very straightforward lipid concern could not
be simultaneously managed in the diabetes clinic. The provider’s chronic care notes give
limited if any history about the patient’s status, symptoms, and CBG’s since the last visit.
This patient’s diabetes is only moderately controlled. The provider should have
modestly increased the 70/30 insulin dose at the 4/19/18 diabetes clinic; there was no
documentation in the progress note if this was considered or why this was not done.
There also was no written rationale for the changing doses and the
prescription/discontinuation of the diabetic oral agents. The continued use of
fenofibrate has limited indication. There is limited justification to have started and
continued fenofibrate for a moderately elevated triglyceride level in a diabetes patient
who was not adequately controlled at the time of the initial testing as out of control
diabetes raises the triglyceride level. Treatment should have been considered when the

Chronic Care Patient #7.
70/30 insulin is a combination of 70% isophane insulin and 30% regular insulin. When 70/30 insulin is used in combination
with regular insulin, the dosage of regular insulin thereby increases. This combination can unknowingly result in higher doses of
regular insulin than are realized.
74
Office of Health Services, Chronic Illness Treatment Guidelines, Diabetes.
72

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diabetes was under control. LCC providers have failed to administer pneumococcal 23 vaccine

to this diabetic patient as is directed in the policies.

•

This is a 50-year-old patient with non-insulin requiting diabetes and hypertension.75 Her
current medications include glipizide 20mg BID, metformin, lisinopril 10mg/d,
metoprolol, simvastatin 40mg, and ferrous sulfate. She is followed in the diabetes and
hypertension chronic care clinics. Since August 2016 she has been seen five times in the
diabetes clinic and four times in the hypertension clinic. In 2016 and most of 2017,
HbA1Cs were not at goal and ranged from 7.7 to 9.3. In December 2017, the HbA1C
result was 6.9, which now reflected good diabetic control. Over the last two years the
provider did increase, albeit belatedly, the doses of the oral diabetic medications.
Seventy-five percent of the eight blood pressures recorded in the chronic care clinics in
2016-2018 were at goal. The provider’s rationale to add a second BP medication,
metoprolol, on 3/3/17 when this patient’s BP was well controlled (123/83), was not
documented in the progress notes. The use of metoprolol, a beta blocker that can mask
the symptoms of hypoglycemia, is generally avoided in diabetics and no rationale for
this decision was documented. Pneumococcal 23 vaccine has not been administered to
this diabetic patient as recommended in the IDOC diabetes guidelines.76 On 1/15/16,
the patient (then 48 years old) was seen by the OB-GYN provider for heavy menses; the
gynecologic exam was normal. An ultrasound on 5/14/16 reported the presence of
uterine fibroids. The patient’s hematocrit (red blood cell level) on 6/1/16 was 43.4%,
hemoglobin 14.4, both normal levels. In November 2017, the now 50-year-old patient’s
blood counts (hematocrit/hemoglobin) had notably dropped to 24.5/7.0 and 24.3/6.9.
Her MCV was microcytic consistent with iron deficiency anemia thought to be due to
her menorrhagia (heavy menses). Iron supplementation was started, and the blood
counts returned to normal (43.0/13.6) by 4/3/18. Although it is likely that the cause of
the blood loss was heavy menses, this 50-year-old patient should have been
investigated for other causes of blood loss, including gastrointestinal bleeding due to
peptic ulcers or colon cancer. The failure to investigate alternate causes of blood loss
was below standard of care. To date, this patient in her fifty-first year of age still has not
been investigated or screened for colon cancer as is nationally recommend for all
patient 50 years of age or older.
In summary, this patient was regularly seen in the diabetes and hypertensive clinics;
there was no reason why these two conditions could not have been readily addressed in
a single chronic care clinic. It should not have taken the chronic provider two years to
get the patient’s diabetes under control. The chronic care provider should have
shortened the interval between visits and monitored CBGs in order to achieve control
more quickly. The delay in advancing medications and doses was not justifiable. The LCC
providers should have administered pneumococcal 23 vaccination to this diabetic as is
recommended by national and IDOC guidelines. The failure of the providers in 2017 to

75
76

Chronic Care Patient #8.
Office of Health Services, Chronic Illness Treatment Guidelines, Diabetes.

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consider alternate causes, such as gastrointestinal bleeding, for the patient’s severe
anemia put the patient’s health and life at risk. All persons 50 years of age or older
patients, should be screened for colon cancer. This has not yet been ordered.
•

This patient is a 39-year-old female asthmatic.77 Her current medications include
levalbuterol inhaler and ciclesonide. Since early 2016 she has been seen five times in the
asthma chronic care clinic. Her PEFRs (peak expiratory flow rate) have been between
340 and 450 L/min. Her asthma did not require any urgent care visits, emergency
department visits or hospitalizations. Wheezes were never detected at any of her
asthma clinic visits. At the 1/25/17 asthma clinic, she reported that she was having two
asthma attacks per week and the provider added ciclesonide to her asthma regimen. On
7/25/17, the patient reported that when the weather was hot she would use the inhaler
three to four times per night and that one inhaler only lasted for one month. The
provider noted that the patient should continue levalbuterol and ciclesonide inhalers.
However, the MARs for September 2017 through February 2018 do not list ciclesonide
as one of this patient’s medications. At her most recent asthma clinic visit on 1/25/18,
she reported that she was still using about one inhaler canister per month. The review
of the MARs (September 2017 – February 2018) indicated that the patient had not
requested any refills of the inhaler during this five-month period. There is no
documentation in the progress notes that the provider had reviewed the medication
administration records (MAR). If the MARs had been reviewed, the provider would have
been aware that the patient was not using one inhaler per month as reported on
7/25/17 and 1/25/18, but was more likely refilling her inhaler every six months. This
asthmatic has not received the pneumococcal 23 vaccine as is recommended for all
asthmatics.
In summary, this asthmatic patient is relatively stable. Her PEFRs were consistently
between 340 and 450. An additional asthma medicine was added when the patient
reported that she was having two attacks per week. The patient reported periods when
she increased her use of metered dose inhaler from one canister every six months to
one every month. The provider was not regularly reviewing the MARs. This resulted in
the provider not knowing that the patient was actually using up her inhaler less
frequently (every six months not every month) than she reported. This important clinical
information would have allowed the provider to delve more carefully into the patient’s
history of asthma attacks and self-treatment, and possibly might have resulted in a
decision to stop the use of one of her medications (ciclesonide). It is a national
recommendation that asthmatics receive the pneumococcal 23 vaccine; this vaccine has
not been offered to this patient.

•

77
78

This patient is a 49-year-old female with multiple sclerosis and hypertension.78 Her
current medications include monthly injectable Copaxone (glatiramer), vitamin B12,

Chronic Care Patient #10.
Chronic Care Patient #15.

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baclofen, oxybutynin, gabapentin, lisinopril, and fenofibrate. She has an unsteady gait,
experiences urinary incontinence and blurry vision, and uses a walker. She is followed in
the general medicine chronic care clinic mostly by the LCC physician and has had nine
general medicine clinic visits in the last four years. The chronic care provider generally
writes comprehensive notes commenting on the patient’s condition, the neurologist
consultations, and imaging reports. The LCC optometrist has seen the patient no less
than yearly since 2014. Physical therapy has been provided to the patient at LCC since
2014. The patient has had six or seven neurology consultations since April 2014. The
neurology specialist is managing the patient’s multiple sclerosis treatment regimen.
There have been possible MS flares in 2015 and 2017 that prompted the neurologist to
order repeat MRI studies, which showed evidence of demyelinating disease with no
active changes and cervical cord demyelinating plaques with a new lesion in the left
pons, no active demyelination, and cervical spondylosis with severe left foraminal
stenosis. Left C6 and C7 radiculopathy workup was advised but there is no
documentation that this evaluation was ordered. Almost all of the neurology
consultations were found in the EMR. The patient also saw a urology specialist for
urinary incontinence on 8/19/15. The urology specialist initiated medication to treat the
patient’s sudden losses of urine and advised cystoscopy, renal US, and urodynamic
studies. There is no evidence in the medical record that the urology procedures and
tests had ever been done. The patient has developed mild hypertension for which she
has recently been started on lisinopril, and she was given an appointment to the
hypertension chronic care clinic. Fenofibrate was initiated at the 3/16/18 general
medicine chronic care clinic; the rationale for this added medication was not
documented. The patient’s 10-year cardiovascular risk score was not done but
calculated 10-year cardiovascular risk was determined to be 3.0%, below the threshold
to initiate lipid therapy. The provider did not document why it had been determined
that the patient warranted treatment, but the choice of medications would have been a
statin, not a fibrate medication.
In summary, this multiple sclerosis patient has been seen regularly in the General
Medicine chronic care clinic at LCC and by a St. John’s SIU neurology specialist who
manages the treatment of the patient’s multiple sclerosis. MRIs have been done and
medications provided as ordered by the neurologist. The neurologist ordered tests to
evaluate cervical radiculopathy, but these tests were not done. A urology specialist was
consulted to evaluate the patient’s urinary incontinence. In 2015, the urologist
recommended a variety of additional procedures including cystoscopy, urodynamic
studies, and renal ultrasound; there is no evidence in the EMR that these
tests/procedures were ever performed. When the patient developed hypertension,
there was no reason that this additional chronic illness could not have been easily comanaged at the time of general medicine clinic appointments.

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Women’s Health
Methodology: Nurse practitioners were interviewed about the women’s health screening
practices. The Guidelines for Inmate (Female) Periodic Physical Exams were reviewed. The list
of current pregnant patients and the records of pregnant women were reviewed. The records
of patient-inmates were audited for PAP and mammogram screening records.
First Court Expert Findings
The First Court Expert noted that patients with or at high risk for women’s health issues were
not tracked in an organized way. Cervical cancer screening was not performed in a timely
manner, high-risk patients were not screened as frequently as warranted, and abnormal Pap
smears were not adequately followed up. The expert noted that the current staff (24 hours per
week OB-GYN) assigned to the provision of women’s health care was not adequate to meet the
needs of the LCC population and the addition of a women’s health nurse practitioner was
justified.
Current Findings
We agree with the findings in the First Court Expert’s report. We had additional findings that
are as follows:
• At the time of the site visit there were 11 pregnant women at LCC.
• One pregnant woman has been in LCC for 64 days and has not yet been seen by the OBGYN provider and her prenatal record has not been started. Prenatal labs, vital signs,
Pap, and fetal ultrasound have been done. Prenatal vitamins and iron supplementation
have been prescribed.
• Fourteen of 15 (93%) charts audited had a Pap smear that was done in the last three
years as per IDOC protocol.
• Four of five (80%) charts audited of women over 45 years of age had a mammogram
performed in the last two years as per IDOC protocol. In another record sample, 12 of
13 patients above age 50 were offered a mammogram.
• Two of the three (66%) HIV patient charts reviewed had a Pap in the last year or
evidence of three consecutive negative annual Paps in medical record.
• The existing needs for female-specific care have not been adequately addressed in the
past. Newly hired nurse practitioners are being assigned to women’s health
responsibilities. It was reported that the nurse practitioners will be soon be oriented by
the OB-GYN provider to the provision of prenatal care. This would enhance the coverage
of the prenatal clinic services. Additional provider staffing may be needed to cover the
services needed by this large and high-risk female population, which also has a
reception & classification center that requires gynecological screening of all patients.
• All providers do not have access to comprehensive online medical references at all
clinical and administrative work areas.
• The nurse practitioners have not been trained to evaluate wet mounts of vaginal
discharges and vaginal infections are treated presumptively. The single microscope is
seldom, if ever, used.

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The LCC women’s health periodic physical exam guidelines recommend Pap smears every three
years, without human papilloma virus (HPV) testing for women less than 30 years of age and
with HPV testing for women over 30 years old. Pap smears can be stopped after age 65.
Mammograms are to be done every two years beginning at 45 years of age through age 70. Pap
smears are performed on all new admissions over 21 years of age as part of the reception and
screening process and are updated per protocol at the annual physical exams. Mammograms
are scheduled as indicated for patients over 45 years of age along with the annual physical
appointment. The process to schedule annual physicals is as follows:
1. The Offender 360 IDOC program generates a list of all patients with birth dates in an
upcoming month.
2. Nurse practitioners review the patients’ medical records.
3. Women’s health “to do” list is created.
4. Based on the “to do” list, appointments are scheduled with the two nurse practitioners.
Audits of 15 women’s charts revealed that 14 (93%) have had Pap smears in the past three
years. One patient had not had a Pap smear in over four years. Three woman were found to
have abnormal Pap smears with low grade squamous intraepithelial lesions (LGSIL) and human
papilloma virus positivity. One had a colposcopy with a biopsy in November 2017 and is
scheduled for repeat colposcopy in May 2018. Another had colposcopy and biopsy in 2014, with
improvement to atypical squamous cells of undetermined significance (ASCUS) smears in 2016
and 2017. A third was found to have LGSIL in March 2018 and will have repeat studies done
after the delivery of her child in late May 2018.
Charts reviews showed that three of four (75%) women over 45 years of age had a
mammogram in the last two years. One additional patient under 45 years of age also had a
mammogram when she was 38 years old. One 49-year-old woman had not yet had this
screening test performed four years after she was eligible for a screening mammogram.
In a separate sample of 13 records randomly selected from a list of patients above age 50, in 12
of 13 cases women were offered mammograms. In the lone woman who was not offered
mammogram screening, the patient was admitted to LCC in early April 2018 and the
mammogram was not ordered at intake. In 11 of 12 cases in which mammogram was offered,
they were either completed or refused. In the remaining case there was an equipment failure
and the mammogram needed to be rescheduled. We reported this to the HCAU.
All of the prenatal care is provided by the OB-GYN specialist (approximately 50% FTE) who
provides onsite service and consultation. The OB-GYN provider uses a paper
antepartum/postpartum record to record patients’ progress, tests reports, vital signs, fetal
heart tones, uterine measurements, etc. This patient form is maintained in a binder in the
ambulatory clinic. A copy of the record is sent to the delivering hospital. This record is not
incorporated into the electronic medical record but should be. The OB-GYN provider was soon
to be temporarily away from LCC; a nurse practitioner reported that the OB-GYN provider will
soon be orienting the nurse practitioners to the provision of prenatal care to allow coverage
during the specialist’s absence. Colposcopy and cervical biopsy, cervical cryosurgery, obstetrical
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Doppler ultrasonography, pelvic ultrasound (contracted service), and mammography are
provided onsite.
There were 10 pregnant women at LCC at the time of the Experts’ visit. The charts of four
currently pregnant women were reviewed. Two have very high-risk pregnancies (recurrent
deep vein thrombosis with pregnancy, gestational diabetes); both have been appropriately
referred to and jointly managed with St. John’s SIU Medical Center’s maternal and fetal
medicine (MFM) specialists. No MFM consultation reports were found in the antepartum
record or the EMR on one of these patients. Another pregnant woman has had two previous csections and has been appropriately monitored. The fourth pregnant patient was admitted to
LCC on 2/22/18. Prenatal tests, Pap smear, fetal ultrasound, and vital signs have been done.
Prenatal vitamins and iron supplementation was prescribed. The first appointment with the OB
provider was scheduled for 4/6/18, but was cancelled due to provider absence. As of 4/26/18,
64 days after admission to LCC, this patient has not seen the OB provider and the antepartum
record has not been started. If additional providers (nurse practitioners) were trained to
provide basic prenatal care, this patient would have been fully evaluated by this time.
There is a functional microscope, but it was dusty and appeared not to be in use. It was
reported that the nurse practitioners had not been trained to perform wet mounts to identify
yeast, bacterial vaginosis, and trichomonas vaginal infections and thus were not using the
microscope. Not all providers at LCC have access to a comprehensive electronic medical
references such as UpToDate.
In summary, the provider staffing is not adequate to provide the volume of clinical work at this
large women’s facility and reception center. In the absence of the OB-GYN provider, there are
no providers trained to provide prenatal care. At least one of the nurse practitioners should be
trained and regularly assigned to prenatal clinic. Not all offsite specialty consultation reports
are being returned with the patient or retrieved by the LCC support staff; this should be
addressed. Women with HIV are not being screened for cervical cancer as frequently as is
nationally recommended. Most women are receiving Pap smears and mammograms in accord
with IDOC and national guidelines. It appears that a few women are not consistently being
screened as directed in the IDOC guidelines. The following chart summaries highlight the
concerns and findings noted above.
Women’s Health Charts
• This patient is a 35-year-old female with HIV and genital HSV.79 Her last Pap smear was
done on 7/28/15; the result was negative. No repeat or previous Pap tests were
identified in the record. In summary, this HIV patient should be having annual Pap
smears until three consecutive annual tests have been performed; then the interval can
be increased to three years. LCC is not following national guidelines concerning the
frequency of cervical cancer screening in this higher risk HIV patient.

79

Chronic Care Patient #3.

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•

This patient is a 66-year-old whose problem list includes seizures, diabetes, and
hypertension.80 Mammograms done in 2014 and 2016 were both reported to be Breast
Imaging Reporting and Data System (BIRAD) II. A Pap smear in 2014 was negative and
ASCUS/HPV negative in 2016. In summary, this patient has, to date, had mammograms
at intervals recommended in national and IDOC protocols. Even though she is older than
65 years of age, she should have another negative Pap smear before cervical cancer
screening is no longer recommended.

•

This patient is a 34-year-old pregnant female with history of DVT during previous
pregnancies, pre-eclampsia in the past, diet-controlled diabetes in the past, tobacco
use, and substance use.81 Her expected due date is 5/27/18. This patient was admitted
to LCC on 3/9/18. The patient was pregnant seven times in the past and had DVTS with
her pregnancies in 2010, 2012, and 2013, and at least one pulmonary embolus. She was
listed as a high-risk pregnancy. She was treated with Lovenox (enoxaparin,
subcutaneous blood thinner) during her prior pregnancies. Her intake Pap was read as
LGSIL/HPV+; this abnormality had also been previously identified at some time in the
past. The prenatal flow forms showed that the patient had seven visits with the LCC OB
provider between 3/14 and 4/24/18. Prior to admission to LCC, ultrasounds at
Northwestern Medical Center and Stroger Cook County Hospital revealed a single
umbilical artery. Post entry to LCC, two additional ultrasounds (St. John’s SIU Medical
Center and LCC) revealed a normal fetus. The patient was referred to Maternal Fetal
Medicine (MFM) at St. John’s SIU Medical Center where she has had two, possibly three,
visits to date, with two more visits prescheduled in May 2018. The visits are commented
on in the prenatal flow forms, but consultation reports from St. John’s MFM were not
located in the EMR. The patient is scheduled for induction of labor on 5/21/18 at St.
John’s SIU Medical Center. In summary, this high-risk pregnancy has been closely
monitored by the OB provider/team at LCC. Ongoing consultation with the MFM OB
specialists at St. John’s SIU Medical Center was initiated within two weeks of the
patient’s admission to LCC. Consultation reports from the specialist are not in the LCC
EMR; this deficiency must be addressed and corrected.

•

This patient is a 29-year-old pregnant female with diabetes who had taken insulin during
previous pregnancies, and a psychiatric disorder.82 An ultrasound on 3/19/18 showed
FHT 140 and a fetal age of 26 weeks +/- 4 days. The prenatal tracking form documented
OB provider/team encounters on 3/9, 3/19, 3/23/18. The patient was seen at the St.
John’s SIU Maternal Fetal Medicine (MFM) by specialists on 4/2/18; insulin was changed
to NPH 15U/am, 5U/pm and Lispro insulin 5U-6U-8U with the three meals. St. John’s
requested that capillary blood glucoses (CBG) be sent weekly for their review. On
4/6/18, the patient was admitted to the LCC infirmary for closer monitoring due to CBGs
above 300. On 4/20/18, the infirmary provider noted that CBG’s were still in the 200s

Chronic Care Patient #5.
Chronic Care Patient #11.
82 Chronic Care Patient #13.
80
81

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and increased the NPH insulin dosage to 20U/am and 10U/pm. Some improvement of
CBG’s were reported on 4/13/18. On 4/17/18, it was noted that CBG results were sent
to St. John’s SIU MFM service. The patient was again seen at St. John’s MFM on 4/18/18;
ultrasound showed FHT 148 and a fetal age of 31 weeks +/- 4 days. The MFM providers
recommended that the glucose treatment goals were fasting blood glucose (FBS) <90
and post prandial <120. In summary, this pregnant patient with gestational diabetes was
quickly placed under the care of the LCC OB provider and St. John’s SIU MFM specialists.
She is being appropriately tested and monitored to date. CBG results have been
communicated at least once to the MFM specialists.
•

This patient is a pregnant 21-year-old female with a history of tobacco use and possible
mental health disorder.83 Labs were ordered, blood pressure was normal, and prenatal
vitamins and ferrous sulfate prescribed. From 2/28/18 to 3/13/18, the patient was
placed on mental health crisis watch. On 3/6/18, onsite ultrasound revealed FHT 168
and a fetal age of 10 weeks +/-2 days. The OB provider appointment on 4/6/18 had to
be rescheduled by the provider, but a Pap smear was done on this date. As of 4/26/18,
the patient has not yet been seen by the LCC OB provider. Sixty-four days after intake,
the prenatal tracking form has not yet been initiated and the OB provider has not
examined this first trimester/early second trimester patient. In summary, this first/early
second trimester pregnant patient has had prenatal labs and tests performed, fetal
ultrasound done, prenatal vitamins and ferrous sulfate prescribed, and blood pressure
monitored. However, 64 days after admission to LCC, this patient has yet to be
evaluated by the OB provider who had to cancel one scheduled appointment. LCC now
has three advanced practice nurse practitioners (NP); it would be in the best interest of
patient care if at least one of the NPs was assigned to staff the prenatal clinic with the
OB provider and acquire skills and experience in managing OB patients in the absence of
the OB specialist.

•

This patient is a 49-year-old female with multiple sclerosis and hypertension.84 She has
been incarcerated since at least 2004 and transferred to LCC when it opened in 2013-14.
She had a normal Pap in 2014 but there have been no Paps in last four years. No
mammograms have yet been done even though the patient is over the age (45 years
old) when IDOC recommends starting mammography screening. In summary, LCC is not
following the IDOC Pap and mammography screening recommendations, which
recommend Pap smears every three years and mammography starting at 45 years of
age.

Dental Program
Dental: Staffing and Credentialing

83
84

Chronic Care Patient #14.
Chronic Care Patient #15.

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Methodology: Reviewed staffing documents, interviewed dental and other staff, reviewed the
Dental Sick Call Log and other documents.
First Court Expert Findings
•

•

LCC has two full-time dentists, two full-time assistants, and one full-time hygienist. This should
be adequate to provide meaningful dental services for LCC’s 2000 inmates.

CPR training is current on all staff, all necessary licensing is on file, and DEA numbers are
on file for the dentists.

Current Findings
We concur with the First Court Expert’s findings that staffing is adequate. LCC has 2.0 dentist
FTEs,85 one full-time dental hygienist and three full-time dental assistants; an increase of one
dental assistant.

Dental: Facility and Equipment

Methodology: Toured the dental clinic to assess cleanliness, infection control procedures, and
equipment functionality. Observed intake screening and clinical care. Evaluated the quality of xrays taken at intake. Reviewed compliance with radiologic health regulations.
First Court Expert Findings
• The clinic is small, with equipment that is more than 20 years old. Provider and assistant
had very little room to work. If both chairs were in use, the providers could interfere
with each other.
• Loose wires were strewn on the floor and plugged into a loose metal junction box,
upright on the floor next to the unit. It interfered with movement and was a real safety
hazard.
• Several areas of rusted metal were evident, and the cabinetry is worn. The chairs have
torn fabric and are not up to contemporary infection control standards.
• Metallic surfaces were rusty and stained, and corners were worn and frayed, which
impeded adequate surface decontamination and disinfection.
• The intraoral x-ray unit was inoperative, a deficiency that interfered with the provision
of dental care.
• The Panelipse [panoramic] radiographic unit was old and faded and the quality of x-rays
was poor.
• An EMR is in the early testing phase at LCC.
• The handpieces and instruments were adequate.
• There was a separate sterilization and laboratory room of adequate size with a large
work surface and a large sink to accommodate proper infection control and sterilization.
• Laboratory equipment was in a separate corner of the room. The staff had an office with
two desks.

85

Two dentists work four eight-hour days and one dentist works two eight-hour days.

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•

At the time of the visit, two additional units were being installed in another room
adjacent to the clinic area to be used for hygiene and prosthetics and has an extra chair
to accommodate patient overflow, e.g., emergencies and examinations.

Current Findings
Dental facilities and equipment have improved since the First Court Expert’s Report and are
adequate. We concur with the First Court Expert and note that that since then, the loose wires
have been secured, the EMR has been implemented, and the dental hygiene area has been
completed. We identified current and additional findings as follows.
There are two dental units in the main clinic and two in the dental hygiene area. The dental
hygienist’s unit is not in the dental clinic but rather in a small room in a corridor that is not
contiguous with the dental clinic, isolating the hygienist from clinic activity.
The two chairs in the main clinic are old, and one has torn upholstery which interferes with
surface disinfection. The light stanchion of the other unit was salvaged from another facility and
is mounted askew. In addition, the bracket table is unstable and cannot be maintained in place,
posing a hazard to patients and staff.
There are only four functioning high-speed handpieces (drills). Since two dentists are working
most of the time and handpieces must be sterilized between patients, this is insufficient, since
there are always some handpieces in various stages of sterilization that are unavailable for use.
There is one functioning intraoral x-ray unit mounted near one of the dental units. The dental
hygienist’s operatory does not have an x-ray unit. As a result, the hygienist, who is accustomed
to taking bitewing x-rays on her patients, cannot do so feasibly.
There is no stethoscope and sphygmomanometer in the clinic and when dentists want to
measure blood pressure, they borrow them from Nursing.

Dental: Sanitation, Safety, and Sterilization

Methodology: Reviewed Administrative Directive 04.03.102. Toured the dental clinic and
observed dental treatment room disinfection. Interviewed dental staff and observed patient
treatment.
First Court Expert Findings
• The surface disinfection was performed between patients and was adequate. Protective
covers were utilized on some surfaces.
• Instruments properly bagged, sterilized, and stored. Handpieces were sterilized and in
bags.
• The sterilization procedures were adequate, and flow from dirty to clean was
acceptable.
• Safety glasses were not always worn by patients.

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Current Findings
Dental sanitation, safety, and sterilization are unchanged since the First Court Expert’s Report
and are adequate. However, we identified current and additional findings as follows. Surface
disinfection performed between patients in the clinic was appropriate and protective covers
were used on surfaces. Sterilization procedures and instrument flow were adequate.
Instruments were properly bagged, sterilized, and stored. Patients did not always wear safety
glasses86,87. Sanitation at the intake dental examination was inadequate and will be discussed in
the Initial Examination section, infra.

Dental: Review Autoclave Log

Methodology: Reviewed the last two years of entries in autoclave log, interviewed dental staff,
and toured the sterilization area.
First Court Expert Findings
• A review of the past two year’s sterilization logs showed that autoclaving was
accomplished weekly and documented. They utilize a service from Henry Schein called
Crostex that does the testing and maintains the results. A spread sheet of the results is
available and provided annually. A biohazard warning sign was not posted in the
sterilization area.
Current Findings
Autoclave Log maintenance is unchanged since the First Court Expert’s Report and remains
adequate. We agree with the First Expert’s findings. The sterilization log was in order.

Dental: Comprehensive Care

Comprehensive, or routine care88 is non-urgent treatment that should be based on a health
history, a thorough intraoral and extraoral examination, a periodontal examination, and a visual
and radiographic examination.89 A sequenced plan (treatment plan) should be generated that
maps out the patient’s treatment. This plan should be updated after each treatment or
examination.
Why We Take Infection Control Seriously. UIC College of Dentistry. Viewed at https://dentistry.uic.edu/patients/dentalinfection-control, viewed February 2, 2018 “We use personal protective equipment […] as well as provide eye protection to
patients for all dental procedures.” (emphasis added).
87 Guidelines for Infection Control in Dental Health-Care Settings ---2003. MMWR, December 19, 2003/ 52(RR17):1:16; pp. 1718. (“PPE [personal protective equipment] is designed to protect the skin and the mucous membranes of the eyes, nose, and
mouth of DHCP [dental health care provider] from exposure to blood or OPIM [other potentially infectious materials]. Use of
rotary dental and surgical instruments (e.g., handpieces or ultrasonic scalers) and air-water syringes creates a visible spray that
contains primarily large-particle droplets of water, saliva, blood, microorganisms, and other debris. This spatter travels only a
short distance and settles out quickly, landing on the floor, nearby operatory surfaces, DHCP, or the patient. The spray also
might contain certain aerosols (i.e., particles of respirable size, <10 µm). Aerosols can remain airborne for extended periods and
can be inhaled” and “Primary PPE used in oral health-care settings includes gloves, surgical masks, protective eyewear, face
shields, and protective clothing (e.g., gowns and jackets). All PPE should be removed before DHCP leave patient-care areas (13).
Reusable PPE (e.g., clinician or patient protective eyewear and face shields) […]”). Emphasis added. Moreover, protective
eyewear prevents injury from objects dropped by the provider.
88 Category III as defined in Administrative Directive 04.03.102.
89 Stefanac SJ. Information Gathering and Diagnosis Development. In Treatment Planning in Dentistry [electronic resource].
Stefanac SJ and Nesbit SP, eds. Edinburgh; Elsevier Mosby, 2nd Ed. 2007, pp. 11-15, passim.
86

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Methodology: Interviewed dental staff, reviewed dental charts of inmates who received nonurgent care randomly selected from Daily Dental Reports.
First Court Expert Findings
• A basic and essential standard of care in dentistry is that all routine care proceeds from
a thorough, well-documented intra and extra-oral examination and a well-developed
treatment plan, to include diagnostic x-rays. In none of the 10 records reviewed was any
of this present.
• No comprehensive examination was performed, no treatment plans developed, and no
hygiene care performed before routine care.
• No diagnostic x-rays for caries were available. Restorations were provided from the
information from the panoramic radiograph and an inadequate screening exam. This
radiograph is not diagnostic for caries.
• A periodontal assessment was not done, and oral hygiene instructions were not
documented in the dental record as part of the treatment process.
Current Findings
Comprehensive care is materially unchanged since the First Court Expert’s Report and we
concur with the First Court Expert that it is inadequate. Moreover, we identified current and
additional findings as follows.
Dr. Zielinski said that while he “likes to take bitewing x-rays every year” in private practice, he
does not do so at LCC. The hygienist said that she would normally take bitewing x-rays;
however, she does not have an intraoral x-ray unit in her operatory. To take x-rays, she would
have to bring the patient to one of the dentist’s chairs; however, this is not feasible since 1)
typically, a dentist is seeing a patient and, 2) the dental hygiene operatory is separate from the
dental clinic.
Biennial exams are scanty and of minimal clinical value. Neither x-rays nor periodontal probing
are performed, and a sequenced treatment plan that involves periodontal treatment is not
produced. Moreover, there is no documentation that a soft tissue examination for oral cancer is
performed.90
The dental hygienist completes Dental Hygienist Progress Notes after treatment. The form is
organized in the SOAP format; however, it does not document Periodontal Screening and
Recording, a standard of care for dentistry and dental hygiene.91 Furthermore, the assessment
90 Appendix B shows the biennial examination form of Biennial Exam Patient #7 is typical of biennial exam entries. Other than a
box indicating that treatment has not been requested, the examination is of little clinical value.
91 Stefanac SJ. (A panoramic radiograph has insufficient resolution for diagnosing caries and periodontal disease. Intraoral
radiographs (e.g., bitewings) and periodontal probing are necessary), p. 17. Also, (Periodontal Screening and Recording (PSR),
an early detection system for periodontal disease, advocated by the American Dental Association and the American Academy of
Periodontology since 1992, is an accepted professional standard.), pp. 12-14. See American Dental Hygiene Association.
Standards for Clinical Dental Hygiene Practice Revised 2016, pp. 6-9. (Periodontal probing is also a standard of practice for
dental hygiene).

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is general and does not indicate the location and severity of the periodontal problem.
Consequently, there is no way to monitor disease progression or reversal.
Of 10 inmates who received comprehensive (routine) care, all had treatment plans; however,
the treatment plans were below accepted professional standards, since the sequence of the
prescribed care was not specified, and they were informed by neither bitewing x-rays nor
periodontal probing. As a result, caries and periodontal disease were underdiagnosed.
Oral hygiene instruction (OHI) was documented only in conjunction with treatment by a dental
hygienist and the two patients who were not treated by the dental hygienist had no
documented oral hygiene instruction. The Dental Hygiene Progress Note in the electronic
health record92 has several boxes corresponding to procedures that the hygienist can check:
Scaling and Root Planing, Prophylaxis, Perio-Prophylaxis, Full Mouth Debridement, and Oral
Hygiene Instruction.93
The dentists were unable to provide the definitions the clinic uses for these procedures and
referred me to the dental hygienist.94 The hygienist said that when she records “scaling and
root planing” it means that she removed some calculus with either hand instruments or an
ultrasonic scaler and a “perio-prophylaxis” is a deeper scaling for patients who have periodontal
disease. These are idiosyncratic definitions that do not comport with standard dental
terminology.

Dental: Intake (Initial) Examination95

Methodology: Observed intake screening process. Reviewed dental records of inmates that
have been screened recently. Reviewed Administrative Directive 04.03.102.
First Court Expert Findings
• The screening examination was performed within 10 days of arrival, and the intra and
extra-oral examinations were adequate. Panoramic x-rays were taken at the dental
clinic and APHA priorities were designated.
• In none of the records were oral hygiene instructions included. The examiner explained
orally and had written instructions available on how to access dental care.
Dental Hygiene Progress Note for Biennial Examination Patient #7 (Appendix C).
American Dental Association procedure codes show that the definitions of scaling and root planing (D4341 and D4342) are
clear and specify the scope of the procedure. This is not the definition used by the dental hygienist. In fact, her description
more closely resembles the definition of an adult prophylaxis (D1110).
94 This is problematic, since per the Illinois Dental Practice Act, dentists supervise dental hygienists and prescribe the
treatments the dental hygienists provide. "General supervision means supervision of a dental hygienist requiring that the
patient be a patient of record, that the dentist examine the patient in accordance with Section 18 prior to treatment by the
dental hygienist, and that the dentist authorize the procedures which are being carried out by a notation in the patient's
record [a treatment plan satisfies this requirement], but not requiring that a dentist be present when the authorized
procedures
are
being
performed.”
Illinois
Dental
Practice
Act
225
ILCS
25/4).
Viewed
at
http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1296&ChapterID=24 8/6/2018. Emphasis added.
95 The First Court Expert Report describes the examination performed at intake screening as a “Screening Examination;”
however, Administrative Directive 04.03.102 describes it as a “complete dental examination.” We use the terminology of the
Administrative Directive and refer to the intake or initial dental examination as a complete dental examination.
92
93

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•

The room where the panoramic x-ray was taken did not provide sufficient warning to
pregnant females that the area was potentially hazardous. Additionally, no consent
form was developed that explained the potential hazards and gave permission for the xrays to be taken on female inmates who might be pregnant.

Current Findings
The dental intake examination has not changed materially since the First Court Expert’s Report.
We agree with the First Court Expert that the intake exams were timely, oral hygiene
instructions were not documented, and that warning signs were not posted in the panoramic xray area. However, we find the most important problem (not addressed by the First Court
Expert) to be the overall inadequacy of the initial examination. We identified current and
additional findings as follows.
The dental intake examination is performed in a small room that has a dental chair and light. A
dental assistant asks health history questions and records responses. The dentist is gloved;
however, he does not wash hands or use alcohol wipes between changing gloves. No
disposable barriers were used on dental lights. Exams employ adequate light, a mirror, and an
explorer. A dental assistant records the charting. Oral hygiene instructions are not provided,
although a handout and oral instructions are provided relating to how to access dental care at
LCC.
The dentist does not perform a thorough soft tissue examination.96 For example, he does not
visualize the lateral and posterior regions of the tongue,97 a site of squamous cell carcinoma.
This is especially important at LCC, since “[s]uspect lesions in females younger than the age of
50 years, with no history of alcohol or tobacco use, have a greater risk of malignant potential
and often behave more aggressively. Lesions in this population of patients must be treated [and
a fortiori, diagnosed] very quickly and aggressively.”98 Performing a thorough soft tissue
examination is critical at the initial examination, since unless the inmate requests care within
two years, her next exam will be biennial.99
A dentist reviews the charting and panoramic x-ray later and records a treatment plan. This is
inadequate because it is not informed by bitewing x-rays and a periodontal assessment. Twenty
charts and panoramic x-rays of inmates who received oral screening examinations in the past
month were reviewed. All the chartings were adequate; however, four x-rays (20%) were
clinically inadequate.
96 Stefanac SJ. (“Evaluation of head and neck structures for evidence of tissue abnormalities or lesions constitutes an important
part of a comprehensive examination.”), p. 12. See also Shulman JD, Gonzales CK. Epidemiology / Biology of Oral Cancer. In
Cappelli DP, Mosley C, eds. Prevention in Clinical Oral Health Care. Elsevier (2008) (“Regular, thorough intraoral and extraoral
examination by a dental professional is the most effective technique for early detection and prevention of most oral cancers.
[…]”) p. 41.
97 Shulman and Gonzales, p. 31, Figure 3.7. This is generally done by holding the anterior portion of the tongue with 2x2 gauze
and reflecting the tongue with a mouth mirror. This is a professional standard for an oral examination.
98 Shulman and Gonzales, p. 41.
99 This deficiency is compounded by the fact that dentists do not document soft tissue examinations at biennial exams. See
section on Comprehensive Care, supra.

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None of the 10 biennial examinations reviewed were informed by bitewing x-rays or
periodontal probing. While seven patients100 did not request treatment, there was no
documentation of their treatment needs – if only to note that that no treatment was
warranted. None of the patients who requested treatment had an updated treatment plan.
There was no documented periodontal assessment or soft tissue exam for oral cancer. In short,
the examinations are substantially below accepted professional standards.

Dental: Extractions

Methodology: Interviewed dental personnel and reviewed 11 dental and medical records.
First Court Expert Findings
• A tenet of dentistry is that all treatment proceeds from a well-documented diagnosis. In
none of the 10 records examined was a diagnosis or reason for extraction included as
part of the entry. Too often, the dental record includes only the treatment provided
with no evidence as to why that treatment was provided.
Current Findings
Dental extraction care has improved since the First Court Expert’s Report and is adequate. We
concur with the First Court Expert’s findings but note that unlike those findings, of 10 records of
inmates who had extractions, all extractions were informed by adequate panoramic x-rays. This
aspect of the program has improved substantially since the First Expert’s Report. All progress
notes documented the reason for the extraction. We did, however, find that none of the charts
documented that the health history had been updated. All extractions were accompanied by
signed consent forms.

Dental: Removable Prosthetics

Methodology: Reviewed eight charts of patients who received partial dentures in the past year
that were randomly selected from the Prosthetics List and interviewed dental staff.
First Court Expert Findings
Removable partial denture prosthetics should proceed only after all other treatment recorded
on the treatment plan is completed. The periodontal, operative [fillings], and oral surgery needs
all should be addressed first.
• In none of the five records reviewed on patients receiving removable partial dentures
were oral hygiene instructions provided.
• Periodontal assessment is never included, but in three of five records a prophylaxis
and/or a scaling debridement was provided.
• Because there is no comprehensive examination, or any treatment plans documented in
any of the records, it is almost impossible to ascertain that operative or oral surgery
treatment is complete prior to fabrication of removable partial dentures.
100

Biennial exam patients #1, 2, 3, 4, 5, 7, and 9.

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Current Findings
Removable prosthetics care has not changed materially since the First Court Expert’s Report.
We agree with the First Court Expert’s findings with respect to the inadequacy of the provision
of removable prosthetics. We identified current and additional findings as follows.
Of six inmates who received partial dentures, all but one101 received oral hygiene instruction.102
All had extractions and fillings completed before the denture was fabricated. All but one
inmate103 had a periodontal assessment and received some treatment by a dental hygienist;
however, the assessment was inadequate since it omitted periodontal probing (specifically, the
PSR), a professional standard for dentistry and dental hygiene. Moreover, as discussed in the
Comprehensive Care section supra, the putative procedures documented do not correspond to
standard dental terminology; consequently, it is difficult to know what was done.
All had documented treatment plans; however, the Treatment Needed – Completed
Restorations form produced by the EHR does not indicate the need for periodontal treatment,
nor does it distinguish between the procedures that were planned and those that were
completed.

Dental: Sick Call/Treatment Provision

Methodology: We interviewed dental staff, reviewed dental sick call logs, daily dental reports,
and reviewed records of 10 inmates who were seen on sick call.
First Court Expert Findings
• Inmates access sick call through an inmate request form or via a direct call from a staff
member if it is perceived to be an emergency. The dental hygienist reviews all request
forms the following day from the collection of the forms, triages the complaints, and
schedules per the dentists’ direction or as soon as possible.
• By policy, all inmates who submit a request form are to be seen by dental staff within 14
days. LCC was not compliant with this policy. Toothaches or infections can be called in
from anywhere in the institution and the inmate will be seen that same day.
• In none of the dental records reviewed was the SOAP format used; as a result,
treatment was usually provided with little information or detail preceding it.
• Routine care was often provided at these appointments, always without a
comprehensive examination or treatment plan.
• The LCC dental department does not keep request forms; consequently, it was difficult
to review sick call records from more than a month ago.
Current Findings
Prosthetics Patient #4 did not receive documented oral hygiene instruction.
The only documented oral hygiene instruction in the charts I reviewed was at the dental hygiene appointment. Dentists do
not document the provision of oral hygiene instruction.
103 Prosthetics Patient #4.
101
102

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The dental sick call process has changed since the First Court Expert’s Report and is adequate.
Consequently, our findings diverge from those of the First Court Expert. Moreover, we found
that the SOAP format was used consistently, which represents an improvement in
documentation.
Inmates access dental care by checking the ‘Dental’ column on the nurse sick call signup form.
Since the form does not indicate the nature of the dental issue (e.g., the existence of pain),
dental staff pick up the forms daily and interview the inmates. Those with urgent care issues
are seen by a dentist, typically, the next business day, and the others are scheduled for a
routine visit, typically, within three weeks.
Inmates may also submit sick call requests (sick slips) which they place in locked boxes in the
housing areas. These forms are collected daily by nursing personnel. Since the forms state the
problem, dental staff call in those with urgent care issues and schedule the others for a routine
appointment as they do for referrals from nursing sick call.
Of 10 records of inmates who were seen on dental sick call, all had a diagnosis documented in
the chart; however, none had the health history reviewed or updated at the visit. The nursing
sick call lists from April 1 thru April 8 had 32 inmates requesting dental care, of which 10 (31%)
were either no-shows or refusals.

Dental: Orientation Handbook

Methodology: Reviewed the Orientation Handbook.
First Court Expert Findings
Dental care is not addressed in the Offender Handbook and Orientation Manual. This omission
should be addressed immediately. I was told that inmates were informed about the dental
program and how to access care at the reception intake screening examination. This is
inadequate.
Current Findings
Inmate orientation to dental care has not changed materially since the First Court Expert’s
Report. We concur with the First Court Expert with respect to the inadequacy of the Orientation
Handbook. We identified current and additional findings as follows.
The Offender Handbook’s only mentions of dental care are that dental care is available (p. 7)
and that there is $5.00 co-pay for non-emergency dental services for non-indigent inmates (p.
70). While the dentist provides an orientation to accessing dental care at the intake screening,
the information should appear in the Orientation Manual.

Dental: Policies and Procedures

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Methodology: Reviewed Administrative Directives that deal with the dental program.
Interviewed dental staff. Reviewed dental charts. Toured dental clinical areas. Reviewed LCC
organizational chart.
First Court Expert Findings
• The existing policy and procedure manual is old and outdated and does not address the
current state of how the clinic is managed, nor does it fully address the areas concerned
with managing a successful clinic.
• The policy addresses treatment plans, scheduling treatment, medications, dental care
for inmates (directly out of the Dental Administrative Directive), copay, security of
medication and needles, instruments, etc., infection control (from 1993), job description
for dentists and dental assistants.
• It does a poor job of defining and directing the management and running of the dental
program.
Current Findings
The Operations Policies and Procedures were last updated in 2016—after the First Court Expert
report; however, we concur with the First Court Expert that the clinic management guidance is
inadequate.
Oral Care Policy P-108, modeled on NCCHC Oral Care Policy P-E-06, specifies that newly
admitted inmates will “will receive an oral screening during the Receiving Screening process
and will include a visual observation of the teeth and gums noting any obvious abnormalities
requiring immediate referral to the dentist.”104 Furthermore, “[…] a complete dental
examination will be conducted within 30 days of admission (which will normally be provided
while the inmate-patient is at the intake center) and will include: 1) [a] review of the patient's
oral history, 2) [v]isual assessment of intra and extra oral condition, 3) [x]-rays when deemed
necessary by the dentist, 4) [p]atients ability to or limitations of mastication, 5) [c]harting of
presence/absence and condition of teeth, 6) [s]pecified priorities for treatment, [and] 7) [t]he
results of the dental examination will be recorded on a specific uniform dental record system
approved by the American Dental Association.”105
LCC is noncompliant with Policy P-108. First, while an oral screening is performed, a complete
examination is not performed within 30 days of admission, or for that matter, at any time. The
examination is far from being complete for reasons addressed earlier in this section; that is,
inadequate oral soft tissue and periodontal examination, the absence of intraoral x-rays, and
the absence of a sequenced treatment plan. Furthermore, the American Dental Association
procedure codes are not used.

Id. at ¶ II B.
Id. at ¶ II D. The ‘uniform record system’ sponsored by the American Dental Association is the Code on Dental Procedures
and Nomenclature. “In August 2000 the CDT Code was designated by the federal government as the national terminology for
reporting dental services on claims submitted to third-party payers.” American Dental Association Dental Procedure Codes,
2015, p. 1.
104
105

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Dental: Failed Appointments

Methodology: Reviewed dental sick call log. Interviewed dental staff. Reviewed daily dental
reports.
First Court Expert Findings
• A review of monthly reports and daily work sheets revealed a failed appointment rate of
about 17.5%. This is high and should be addressed. When asked, the staff related that it
is often difficult for inmates to be released from the housing units to come to their
appointment or there may be other program activities to prevent them from coming to
the appointment. The staff did not feel it was a purposeful no-show on the inmates’
part. A refusal form is signed if the inmate does not want to keep the appointment.
Current Findings
Failed appointments have not improved materially since the First Court Expert’s Report. We
concur with the First Court Expert that the failed appointment rate is too high. We identified
current and additional findings as follows.
The nursing sick call lists from April 1 thru April 8 had 33 inmates requesting dental care, of
which 10 (30%) were either no-shows or refusals.

Dental: Medically Compromised Patients

Methodology: Reviewed health history form and records from recent intake exams. Compared
the health history in the dental chart to the medical problem list. Reviewed randomly selected
charts of patients on the Chronic Care list for diabetes and anticonvulsant therapy.
First Court Expert Findings
• The dental record is maintained with the medical file, so all medical information is
available to the dental staff from the medical record. The health history on the dental
chart is updated at the time of what is called an “initial examination” at this institution.
This is a modified comprehensive examination from which a treatment plan is
developed.
• This health history is inadequate and does not directly address all the compromised
medical conditions that may affect how dental care is provided. There is no system in
place to “red flag” patients with medical conditions that can affect dental care. The
health history in the dental chart is poorly developed and not very thorough.
• When asked, the clinicians indicated that they do not routinely take blood pressures on
patients with a history of hypertension.
Current Findings
Documentation of the health history on medically compromised patients has not improved
materially since the First Court Expert’s Report. We concur with the First Court Expert that
documentation of the health history of medically compromised patients is inadequate. We
identified current and additional findings as follows.

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Of eight patients with diabetes or receiving anticoagulant therapy, four106 (50%) had dental
treatment without an update of the health history. Of the six107 diabetic patients, none had
documented periodontal probing. Dentists neither properly assess periodontal disease nor
develop an explicit treatment plan to address it.108 Dentists are inconsistent in updating the
health history at clinical encounters.109

Dental: Specialists

Methodology: Interviewed dental staff, reviewed CQI documents, and reviewed dental charts
of inmates who were seen by an oral surgeon.
First Court Expert Findings
Dr. Frederick Craig, an oral surgeon, is available on an as needed basis, usually once a month.
He was scheduled for the near future to see a group of patients. A review of these consultation
requests revealed that they were all referred to the oral surgeon for appropriate reasons. All
were for difficult extractions and removal of wisdom teeth that were beyond the scope of the
dentists’ practice. Dr. Craig is used by several other IDOC institutions. Pathology services will be
the same as for medical pathology. They will give the specimen to the appropriate medical
person for processing.
Current Findings
We concur with the First Court Expert that oral surgery consultations are adequate. Unlike the
finding by the First Court Expert, an oral surgeon does not provide care at LCC; rather, patients
requiring oral surgery services that cannot be provided by the dental department are referred
to a local oral surgery practice. This requires the approval of the Wexford Regional Medical
Director through a process referred to as “collegial review.” The reviewer for oral surgery
consultations is Dr. Karanbir Sandhu, who serves on a part-time basis as a Prosthetic Advisory
Dentist. Dr. Sandhu is neither an oral surgeon, a specialist in prosthodontics, or any other
dental specialty.

Dental: CQI

Methodology: Reviewed CQI minutes and reports. Interviewed dental staff.
First Court Expert Findings
The dental program only contributes monthly dental statistics to the CQI Committee. No CQI
study was in place at the time of this review. A recent mission change at LCC allowed only two
months of minutes to be reviewed.
Current Findings
Medically Comprised patients #1 (anticoagulant), #2 (diabetes), #3 (diabetes), and #8 (diabetes).
Medically Compromised patients #2, 3,4, 5, 6, and 7.
108 It appears that dentists refer patients to the hygienist without an appropriate diagnosis and prescribed treatment plan and
the dental hygienist determines the treatment sua sponte. See footnote 95 supra.
109 For example, Medically Compromised Patient #1 (10/30/17); Patient #2 (7/14/16); Patient #8 (3/23/17 biennial exam).
106
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We concur with the First Court Expert that the dental CQI program is inadequate. Moreover, it
has not improved materially. We identified current and additional findings as follows.
As noted by the First Court Expert, there were no CQI studies ongoing. The 2017 Annual
Governing Body Report reported a quality improvement study on “[t]he time frames for
dentures start to finish including healing. Is it within 3 months?”110 There were neither
recommendations nor a planned follow-up. The study was, at best, trivial. Given the inadequacy
of the clinical aspects of the dental program described in this report, a ‘study’ of how long it
takes to fabricate a denture ignores far more relevant issues such as inadequate health
histories, inadequate diagnosis of periodontal disease, and failure to use intraoral x-rays.
The dental service reports the total patients seen, the total procedures, backlogs and wait
times, and number of referrals to an oral surgeon.111 In addition, the monthly and annual total
treatments.112 The number of failed appointments was not reported.

Internal Monitoring and Quality Improvement Activities
Methodology: Interview facility leadership and staff involved in quality improvement activities.
Review CQI Committee meeting minutes, including the Annual Meeting minutes.
First Court Expert Findings
The First Court Expert found that the minutes showed no effort to engage in quality
improvement activity. The minutes consisted only of data collected on a variety of services.
There was no documented discussion, analysis, or effort to improve quality.
Current Findings
We do not completely agree with the First Court Expert’s finding that the LCC CQI minutes
showed no effort to engage in quality improvement activity. While the minutes mostly
consisted of data collection on a variety of services, there were attempts on a few studies to
evaluate for quality of services. However, these efforts fall short of demonstrating an effective
CQI program. Largely, we view this as not having staff dedicated to quality, not understanding
methodologies of performing quality studies, and not making quality improvement a systemwide program goal.
LCC does not have a CQI coordinator; the HCUA acts as the CQI coordinator. But her
responsibilities are so wide ranging (HCUA, regional coordinator, CQI coordinator, infection
control nurse, and nurse supervisor) that she is not effective in this role. LCC does not have a
CQI plan specific to LCC. It merely paraphrases or repeats verbatim sections of the AD on CQI.
This gives no indication of the CQI plan for LCC the upcoming year and is not a plan.

Annual Governing Body, Logan Correctional Center. July 19, 2017, p. 25.
Annual Governing Body, Logan Correctional Center, July 19, 2017, p. 299. (Annual governing 2017-2.pdf).
112 For example, fillings, extractions, dentures, biennial exams, intake screenings, panoramic x-rays. Id. p. 301.
110
111

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The First Court Expert was critical of the CQI program and found that there was no effort to
engage in quality improvement activity. We found that there was an effort to engage in quality
improvement, but the studies that were done either lacked understanding of how to perform a
quality study or used the quality study as a proxy for supervision as opposed to an effort to
create a systemic improvement. There were eight CQI studies pertaining to the medical
program.
Like other facilities, there was a misunderstanding of what outcome studies are. Five studies
were listed as being outcome studies. Clinical outcomes are end point measures of health
status such as mortality, hospitalization, an HbA1C level of 7 or less, or normal blood pressure.
An outcome study measures interventions based on the ultimate outcome measure. An
example would be to study the effect of colorectal cancer screening on colorectal cancer
mortality or the effect of increasing the interval of chronic clinic visits on obtaining a normal
blood pressure. The studies listed as outcome studies were:
1. Whether ordered injections were given.
2. Are glasses received within six weeks?
3. Whether patients discharged from the infirmary were evaluated within 14 days.
4. Did a provider see a patient within five days after a medical furlough?
5. Does the Medical Director sign off on injury reports?
6. Whether nurse referrals to providers were medically indicated.
None of these includes a clinical outcome. These are all performance measures which assessed
whether staff were performing their jobs. These are measures that are useful to analyze with
respect to whether operations are performing as expected. However, they are not outcome
studies. One study, signing off on injury reports, was listed once as a process study and once as
an outcome study.
One study, listed as a process study, was actually an outcome study. This study asked a
question; did HbA1C values improve at the next clinic after education was provided? An
intervention was studied as to whether it could affect an outcome – the HbA1C level. This study
was a credible study and posed a valid hypothesis. It attempted to evaluate the value of current
educational efforts to improve diabetic control. Over two months of study, the finding was that
11 patients had the same HbA1C level after education, 49 patients had an improved HbA1C,
and 43 patients had worse HbA1C values. These findings appear to demonstrate that education
had no effect on HbA1C values. However, there was no investigation of the reasons for the
results associated with this finding. Only the data was given. This was an interesting finding but
there was no study to determine why this result occurred. Was the study flawed? Does
education have no value? Was the education flawed? This study can have value, but it was not
thoroughly executed, apparently due to a lack of ability to conduct the analysis.
The remainder of the 2016-17 annual CQI report mostly gives statistics that have no inherent
value with respect to quality improvement. This is consistent with comments of the First Court
Expert, who stated that minutes consisted only of data collected on a variety of services. The
monthly meeting minutes consist only of data without any analysis or study.
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We also note that this facility does not perform some required studies as required by the IDOC
AD, including:
• There is no evidence of primary source verification of physician credentials.
• There is no evidence of evaluation of quality or appropriateness of 100% of offsite
referrals.
• Hospitalizations are listed but not reviewed with respect to quality.
We also note that there is no mortality review. The facility Medical Director writes a brief
summary of the death but there is no analysis of death with a perspective of attempting to
identify correctable problems in order to reduce preventable deaths or reduce problems that
place patients at risk of harm.
We evaluated one death from LCC.113 This is discussed in greater length in the mortality review
section of this report. However, this patient had several problems. The patient had known
pancreatic mass identified at Cook County Jail that was thought to be due to pancreatic cancer.
The patient had significant abdominal pain and on transfer was on approximately 90 mg of
morphine for pain control. On transfer to LCC, the patient had a pending follow up with the
gastroenterologist at Stroger Hospital. Instead of following up with a gastroenterology
consultation and obtaining or repeating a CT scan, LCC treated the pancreatic mass as a benign
lesion and took no diagnostic action. Also, the patient was treated with only one Tylenol #3
tablet three times a day, a pain medication reduction of approximately 80%.
About a month after arrival to LCC a doctor obtained a tumor marker test that indicated a high
probability that the patient had pancreatic cancer, a diagnosis suspected at Cook County Jail.
The doctor ordered a CT of the abdomen and a routine GI consultation. The GI consultation did
not occur until 3/21/17, four months after transfer from Cook County Jail. The biopsy was not
done until 4/14/17, five months after transfer from Cook County Jail. The diagnosis was delayed
for five months and should have been accomplished within a month of transfer.
The patient was undertreated for her increasing abdominal pain from the metastatic pancreatic
cancer throughout her incarceration at LCC, but especially over the last two months of life.
Despite being undertreated for pain throughout her five months at LCC, during the last two
days of life the patient was treated with palliative sedation without a documented discussion in
the medical record with the patient of what palliative sedation is or a consent for this process.
The patient, given only the equivalent of 15 mg of morphine during the prior months, was given
120 mg morphine a day and 2 mg of a benzodiazepine every two hours by intravenous infusion
during the last two days of life. This was a huge increase of dosage and was apparently
unrelated to existing pain symptoms of the patient. Palliative sedation is a last resort measure
at the end of life to relieve severe and refractory symptoms. However, treatment in excess of
symptoms can be problematic, especially if the patient does not agree to the excess treatment.
There can be ethical concerns using palliative sedation, including that it hastens death or is a

113

Patient #21 Mortality Reviews.

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form of euthanasia.114 For this patient, the lack of adequate pain control with the sudden
apparent excessive use of morphine with a sedative drug raises ethical concerns about the
purpose of this prescription. Despite this, there was no documented discussion with the patient
or consent of the patient that we could find.
These issues bring up three concerns with care of this patient that should have been identified
in the mortality review and should have resulted in a quality investigation as to why the
problem occurred with a goal of fixing the problem.
• There was a significant delay in continuation of the work up of a significant illness. It
took five months to make a diagnosis that should have taken much less time. There
should be a review as to why this occurred.
• There was a deficiency of pain management over the five months of incarceration. The
patient complained repeatedly of pain and endured pain unnecessarily over several
months despite having a likely untreatable cancer. The program should evaluate why
pain management was inadequate and review how pain is managed.
• The patient was treated with palliative sedation without documented informed consent,
which gives the impression of hastening death or engaging in euthanasia. The program
should review their end-of-life procedures to ensure that patients are treated with
respect and dignity.
The death summary documented that the patient “wish of DNR and the more recent wish of
palliative care” could not be found in the medical record. The Mortality Review Worksheet
found that there was no way to improve care. We disagree.

114

From section on Palliative Sedation from UpToDate an online electronic medical text.

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Recommendations
Leadership, Staffing, and Custody Functions
First Court Expert Recommendations
1. Seek approval and fill the Director of Nursing position as soon as possible. We agree
with this recommendation.
Additional Recommendations
2. LCC needs to fill its physician positions instead of converting them to nurse practitioner
positions.
3. A staffing analysis should be done to determine whether staffing is adequate for this
facility.
4. Nursing supervision needs to increase so that there are always supervisory nurses
present.
5. The IDOC needs to fill its central region nurse coordinator position so that the HCUA can
function full time at LCC.
6. LPNs should perform within the scope of their licenses.
7. Policies should be reviewed and revised as needed.

Clinic Space, Sanitation, and Support Services
First Court Expert Recommendations
1. Implement a nurse call system for each infirmary patient. This recommendation has
been addressed with the installation of battery powered nurse call devices in all
infirmary patient rooms with the exception of the crisis beds that are within sight and/or
sound of the nursing station.
Additional Recommendations
2. Develop and implement a plan to daily monitor and document negative air pressure
readings when the infirmary’s negative pressure room(s) is occupied for respiratory
isolation and otherwise on a weekly basis.
3. Create at least one additional provider exam room(s) in the ambulatory clinic in order to
accommodate all of the current (and future providers) at the same time.
4. Implement a plan to assure that all medical equipment and devices have documented
annual safety inspections.
5. Replace the existing colposcope.
6. Purchase sufficient quantity of additional automated external defibrillators (AED) in
order to place AEDs in the infirmary, ambulatory clinic, reception and screening, ADA
housing unit, emergency response bag(s) and other high-risk areas on the LCC campus.
7. Replace the deteriorating vehicle that is used to transport clinical staff and equipment
to emergencies on the LCC campus.

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8. Enforce and monitor the existing policy to keep all emergency bags sealed and inspect
and restock emergency bags that have been unsealed.
9. Expand the scope of the current safety and sanitation rounds or create separate rounds
to include focused inspections of clinical areas including clinical equipment, exam tables,
negative pressure, expired supplies, and medications, etc. and report the findings to the
Quality Improvement committee.

Medical Reception
First Court Expert Recommendations
1. There should be a space on the intake physical form to document the breast
examination.
2. There must be a more appropriate space where a nurse can interview a patient for the
nurse screen or a nurse practitioner for the history and physical in which there is no
auditory disturbance.
3. A system must be set up to insure that appropriate and timely follow-up from the
reception process does occur.
We agree with these recommendations.
Additional Recommendations
4. Repair or replace equipment in disrepair (e.g., examination table) and purchase needed
medical equipment (e.g., microscope, large blood pressure cuff).
5. Providers should order chronic disease and other essential medications on the day of
the patient’s arrival. Ensure that patients receive the first dose within 24 hours or
sooner as clinically indicated (e.g., insulin for diabetics).
6. Nurses should perform and document urine pregnancy screening on all newly arriving
inmates except those who are menopausal and/or documented tubal ligation or
hysterectomy.
7. In addition to performing a past medical history, providers should perform a review of
systems (ROS) for chronic diseases to determine urgency of referral to the chronic
disease program.
8. Providers should document the patient’s medical conditions onto the problem list,
including a history of TB infection and previous surgeries.

Nursing Sick Call
First Court Expert Recommendations
1. Develop a plan to implement an all “RN” sick call process.
2. In the X-house, develop and implement a plan to conduct a legitimate sick call
encounter, including listening to the patient complaint, collecting a history and objective
data, performing a physical examination when required, making an assessment, and
formulating a plan of treatment, rather than the current practice of talking to the
patient through a solid steel door and basing any treatment on the conversation only.

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3. Per Office of Health Services policy, assure all sick call encounters are documented in
the Subjective-Objective-Assessment-Plan (SOAP) style.
4. Develop and implement a plan to assure Office of Health Services approved, pre-printed
treatment protocols are used at each sick all encounter.
5. Develop and implement a plan of education for all nursing staff to address negative
attitudes towards inmates.
6. Develop and maintain logs for sick call.
7. Develop and implement a plan to ensure that daily wellness checks and the weekly
nurse practitioner rounds are documented in the segregation log and in the inmate
specific medical record if any treatment is provided.
8. Develop and implement a plan to conduct the daily segregation wellness checks
between the hours of 0700 and 2300.
We agree with these recommendations.
Additional Recommendations
9. Staff collecting sick call sign-up sheets at night should leave a new sheet, so inmates are
able to sign-up 24 hours per day.
10. Inmates in segregation should be able to sign-up for sick call in the same manner as in
non-segregation and not require the officer to enter the inmate’s name.
11. Officers must escort all inmates being evaluated for sick call to an adequately equipped
examination room that provides privacy and access to handwashing.
12. Nurses should document notification to medical providers and the provider’s response
to the notification.
13. Medical providers should examine patients requiring a medical diagnosis and document
the examination in the medical record. Providers should schedule patients for follow-up
as clinically indicated.
14. Health care leadership should perform CQI studies regarding the high rates of no shows,
or failure of correctional officers to escort inmates to medical appointments.
15. If health care staff are unable to see all sick call patients within one day, consider
returning to a written health request system that enables staff to triage and see patients
with urgent requests.
16. Revise the Offender Orientation Manual to reflect actual access to care practices.
17. Health care leadership should develop and monitor quality indicators associated with
each step of the sick all process.

Medical Records
First Court Expert Recommendations
1. There should be no loose filing inside the health records. Medical records staff should
adopt a “touch it once” philosophy when it comes to filing loose documents.
2. Health service request forms should be filed in the health records.
These recommendations are no longer pertinent because of the partial implementation of an
electronic medical record.

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Additional Recommendations
3. An electronic medical record should be fully implemented.
4. The record should be unified to include prenatal care documents in the electronic
medical record.
5. Sufficient devices need to be provided in all clinical areas that accommodate the
possible number of simultaneous users.
6. The practice of using default aged vital signs should be stopped.
7. Providers should be responsible for entering problems into the problem list. Every
patient should have an updated problem list that is accurate.
8. All hospital discharge summaries, specialty test reports, and consultation reports need
to be available in the medical record.
9. The program needs to be able to track immunizations in the electronic record.
10. The program needs to have the capacity to obtain data from the electronic record for
the purposes of quality review.

Urgent/Emergent Care
First Court Expert Recommendations
1. A system of nursing supervision with feedback must occur so that errors with regard to
the adequacy of the assessment or the appropriateness of the clinical decision making
are reduced substantially.
2. The administrator should develop a log that can be used to track unscheduled offsite
services. The log should have the time and date, patient identifiers, the presenting
complaint, what the disposition was in terms of being sent offsite and whether the
reports from the offsite service are retrieved.
3. There should be a method to track the follow-up visits with the primary care clinician
and whether they documented the discussion with the patient of the findings and plan
based on the offsite service report.
We agree with these recommendations. The second recommendation has been resolved.
Additional Recommendations
4. The program needs to develop a means of reviewing the quality of clinical care with an
aim to preventing unnecessary hospitalization and preventable clinical errors.

Specialty Consultations
First Court Expert’s Recommendations
1. The policy should require that patients returning from scheduled offsite services are
brought through the clinic area where a nurse receives the paperwork, interviews the
patient, and ultimately insures that a timely follow-up visit with the primary care
clinician does occur. We agree with this recommendation.
Additional Recommendations

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2. The current system of “collegial review” should be abandoned on the basis of patient
safety.
3. The program needs to monitor underutilization. All patients in need of specialty care
need to receive it. We noted so many cases of patients who were either not referred or
denied referral that underutilization was systemic and widespread. A root cause analysis
needs to be completed regarding this and it needs to be corrected.
4. The IDOC should establish a tracking system to be used for monitoring the timeliness of
specialty care. This should not be maintained by the vendor.
5. Quality of care for those needing offsite care needs to be monitored. The current
system of monitoring fails to identify existing morbidity that results from the specialty
care process.

Pharmacy and Medication Administration
First Court Expert Recommendations
The First Court Expert’s report contained no recommendations regarding the pharmacy and
medication administration. We do not agree with this assessment, as this review demonstrated
systemic issues regarding pharmacy and medication management.
Current Recommendations
1. A sanitation/disinfection schedule should be established for the medication room and
staff assigned to monitor completion of sanitation activities, including scheduled
cleaning of refrigerators.
2. Pharmacy inspections should be more accurately performed to identify expired
medications and unlabeled open vials.
3. Eliminate the process of transferring medications from properly dispensed medication
blister packs into white envelopes that are improperly labeled. Nurses should administer
medications from pharmacy-labeled blister packs maintained in medication carts that
are transported to the chow hall.
4. Medication administration records should be brought to medication administration.
5. Medication carts should contain supplies such as small medication cups and handsanitizer.
6. The medication administration process should be modified. Nurses should:
a. Wash their hands prior to medication administration and use hand sanitizer during
medication administration (e.g., after every fifth patient or if they contaminate their
hands in any way);
b. Positively identify patients with two identifiers, including the patient’s ID badge and
one other (e.g., date of birth). Have the patient state their name as they approach
the nurse;
c. Compare the MAR against medication blister packs to ensure the orders match.
d. Pour medications into a cup and give it to the patient without touching the patient.
Have the patient dispose of the cup in the presence of a nurse or officer;
e. With the assistance of officers, perform oral cavity checks to ensure ingestion,
preferably using a penlight;
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f. Document administration or refusal of medication onto the MAR at the time
medication is offered to the patient.
g. For medication administration in segregation, consider establishing a secure
medication room for storage of a medication cart and MARs. Nurses would transport
the medication cart and MARs into segregation/reception and inmates line up to
receive medications.115
7. All medication orders should be transcribed onto a MAR, including medications ordered
by a dentist.
8. Nurses or medical providers should document administration of all medications at the
time they are administered to the patient.
9. All medications, including KOP medications, should be administered or delivered by
licensed and trained personnel.
10. Healthcare leadership should retrain nurses regarding the procedure for transcribing
and discontinuing medication orders.
11. Nurses should refrain from defacing previous medication orders on the MAR as a short
cut for transcribing new orders.
12. Nurses should document discontinuation of previous orders and write new orders on a
separate entry on the MAR.
13. Nurses should document administration status for each scheduled dose of medication at
the time of administration.
14. Medical records personnel should timely scan patient MARs into the EMR within five
business days of the end of each month.

Infection Control
First Court Expert Recommendations
Develop and implement a post-description for an infection control nurse.
1. Assign a specific RN to the responsibilities of infection control.
2. Develop, implement, and maintain a plan to assure the proper laundering of infirmary
bedding and linens.
We agree with these recommendations.
Additional Recommendations
3. Health care leadership should establish, implement, and monitor a schedule for
sanitation and disinfection activities in all areas where health care is delivered.
4. All torn and cracked outer protective coverings of infirmary beds, wheelchairs,
examination tables and gurneys should be repaired or replaced to permit adequate
infection control.
5. An analysis should be performed of infectious/communicable disease statistics,
including prevalence of TB, HIV and HCV infection among newly arriving inmates.

When we went into segregation, several inmates were out of cell and congregating at tables, versus a policy that prohibits
inmates from interacting with others.
115

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6. Track and report skin infections due to all pathogens, not just MRSA, including
infestations with scabies or body lice.
7. Infection control and CQI meeting minutes should analyze communicable diseases (e.g.,
MRSA) to determine whether there are clusters of infections occurring in certain
housing units.
8. Fully train porters about blood borne pathogens, the proper methods of cleaning and
sanitizing clinical areas, and initiate appropriate vaccinations before they are assigned
to clean and sanitize patient rooms in the infirmary. The training should be documented
and maintained in the porters’ medical record.
9. Consider adding hepatitis A vaccination to the currently recommended Hepatitis B
vaccination for all porters.
10. Monitor all sick call areas to assure appropriate infection control measures are being
used between patients i.e., use of paper on examination tables which is changed
between patients or a spray disinfectant is used between patients
11. Develop and implement a plan to monthly monitor all patient care associated furniture,
including infirmary mattresses and exam tables, to assure the integrity of the protective
outer surface with the ability to take out of service and have repaired or replaced as
needed
12. Replace the cracked wall tiles in the ADA housing unit’s shared shower room that
interfere with proper cleaning and sanitation and create infection control hazards for
both patient-inmates and medical and correctional staff.
13. The current tuberculosis skin test should be replaced with interferon gamma testing
methodology.

Radiology Services
First Court Expert Recommendations
The First Court Expert had no recommendations concerning the radiology services
Current Recommendations
1. IDOC and the health care vendor must jointly contact the Illinois Emergency
Management Agency (IEMA) and Occupational Safety and Health Administration (OSHA)
to review the reported decision that IDOC x-ray technicians do not need to use radiation
exposure monitoring devices (dosimeters) while working in the IDOC radiology suites as
outlined in Illinois Administrative Code 32 -340 510 and 520. This current practice is not
in alignment with the radiation safety practices in the community.
2. Contract with a radiation safety expert to assess the safety for the panorex unit’s
current location in an unleaded interior corridor adjacent to the radiology suite without
a shielded area for the technician to stand when panorex films are being taken.

Infirmary Care
First Court Expert Recommendations

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1. More bed space is needed in the infirmary.
2. Rethinking the physical plant to create a more therapeutic, less chaotic environment
would be beneficial.
3. Develop and implement a plan to insure 24/7 RN staffing.
4. Implement a nurse call system for all infirmary patients.
5. Develop, implement, and maintain a plan for organization of infirmary medical records
including but not limited to:
a. the use of the infirmary record.
b. permanent filing of all documents in the record.
c. chronological filing of all documentation.
6. Develop and implement a plan of education for staff including but not limited to:
a. Per IDOC Office of Health Services policy, documentation to be provided in
the Subjective-Objective-Assessment-Pan (SOAP) format.
b. all documentation to be provided chronologically as to date and time.
c. documentation of vital signs as ordered by the physician
d. physician and nursing admission and discharge documentation required for
all infirmary patients.
Since the First Court Expert’s visit, the majority of the medical record related recommendations
have been addressed by the implementation of an EMR in all clinical areas of LCC including the
infirmary. We note that there are insufficient devices on the infirmary so the number of staff in
the infirmary do not have access to a device on the infirmary resulting in having to go off the
unit to write a note or review a record. This is addressed in the medical records sections. We
also note that the use of dated vital signs needs to be stopped. All episodes of clinical care need
current vital signs. This is also addressed in the medical records section. Nurse call devices have
been installed in all infirmary patient rooms with the exception of the crisis beds which are
within sight and sound of the nursing station and the infirmary bed space was now adequate.
However, an occasional infirmary shift is still cover by LPNs.
Additional Recommendations
7. Develop a plan to shift anticoagulation treatments from Vitamin K Antagonists
(warfarin) to newer types of anticoagulants that do not require frequent ongoing lab
testing to determine the adequacy of anticoagulation.

Chronic Care
First Court Expert Recommendations
1. Consider assigning the Medical Director to the poorly controlled chronic disease
patients, as this is clearly one of his strengths.
2. There should be a comprehensive tracking tool to monitor important indicators for this
at-risk population. This tool should be used to identify areas of poor performance in the
program to target interventions to improve quality.

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3. The chronic disease nurse should rarely if ever be pulled to other duties. This position
should be filled with a carefully chosen individual to actively track this at-risk
population.
4. Patients should be seen according to their degree of disease control rather than the
calendar month and all chronic diseases should be addressed at each chronic care clinic
visit. These are statewide policy issues.
5. Patients with active women’s health issues should be tracked in an organized manner,
perhaps in a chronic disease program.
6. Patients with HIV infection should have yearly cervical cancer screening.
We agree with these recommendations. Some of these recommendations have been addressed
by the fulltime assignment of a nurse to coordinate and manage the scheduling of the chronic
care patient appointments and the implementation of the IDOC 360 program and the EMR to
assist with scheduling, tracking, and statistical reporting of chronic care clinics and annual
physical exam clinics.
Additional Recommendations
7. Providers seeing patients with chronic diseases need to be trained in primary care.
When care needs exceed the training of the primary care provider, patients need to be
referred to a higher level of care.
8. Initiate a process to manage all chronic care diagnoses in a single chronic care
appointment. This should be done for all conditions unless the patient is being managed
in a specialty clinic, e.g. HIV clinic, hepatitis C treatment clinic, pre-natal clinic, etc.
9. Revise the current practice of not rescheduling chronic care patients who refuse a
chronic care visit until the next disease-specific chronic care clinic (four to six months
later), reschedule these individuals based the status of their clinical problem, and
implement a process to monitor and track the status of these patients during the many
months before their next appointment.
10. Implement and utilize current Center for Disease Control (CDC) age-based and diseasebased standards for the administration of adult immunizations.
11. Implement and utilize current United States Preventive Services Task Force (USPSTF)
guidelines for screening adults for cancer and other conditions (abdominal aortic
aneurysm, etc.).
12. Calculate and document the 10-year cardiovascular risk score on all appropriate adults
to assist with the decision and timing to initiate preventive HMG-CoA reductase
inhibitors (statins).

Women’s Health
First Court Expert Recommendations
The First Court Expert had no recommendations.
Current Recommendations
1. Improve provider staffing.

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2. Ensure that at least one onsite full-time providers is trained and can substitute for
prenatal care when the obstetrician is unavailable.

Dental Program
Dental: Staffing and Credentialing

First Court Expert Recommendations: None.
Current Recommendations
1. Dental staffing should be reviewed after dentists incorporate intraoral x-rays and
periodontal probing into their practice.

Dental: Facility and Equipment

First Court Expert Recommendations
1. The space that is used for the clinic proper and houses the two main dental units is too
small to allow efficient care flow and any sense of privacy. Enlargement of this space
should be considered for efficient care delivery and safety considerations. We agree
with this recommendation; however, we acknowledge that this is not feasible given the
physical constraints of the clinic.
2. All electric outlets should be wall-mounted or protected by the cover for the junction
box at the foot of the chair. Loose wires should be neatly arranged and out of traffic
flow. This has been done; consequently, the recommendation is moot.
3. All the units, chairs, and cabinetry should be replaced, and surface areas should be
better able to accommodate disinfection. We agree with this recommendation.
4. Replace the radiograph unit in the clinic immediately with a wall-mounted unit capable
of digital radiography. We agree that the wall-mounted unit should be replaced;
however, the replacement should be mounted between the dental chairs so it can be
used by both dentists.
5. The Panelipse radiograph unit should be replaced. This is critical for a reception center.
We agree with this recommendation.
Additional Recommendations
6. An intraoral x-ray unit should be installed in the dental hygienist’s operatory
immediately.
7. The dental clinic should purchase four high-speed handpieces to supplement the four
currently in use.
8. All new dental x-ray units should be digital.

Dental: Sanitation, Safety, and Sterilization

First Court Expert Recommendations
1. The loose metal junction box on the floor should be wall-mounted where it does not
interfere with traffic flow. Electric cords should be neatly arranged. This problem has
been resolved; consequently, the recommendation is moot.

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2. Patients should always wear eye protection during treatment. This is important for
patient safety. We agree with this recommendation.
3. A biohazard warning sign should be posted in the sterilization area. We agree with this
recommendation.
Additional Recommendations: None

Dental: Review Autoclave Log

First Court Expert Recommendations: None.
Additional Recommendations: None.

Dental: Comprehensive Care

First Court Expert Recommendations
1. Comprehensive ‘routine’ care should be provided only from a well-developed and
documented treatment plan.
2. The treatment plan should be developed from a thorough, well-documented intra and
extra-oral examination, to include a periodontal assessment and detailed examination
of all soft tissues.
3. Appropriate bitewing or periapical x-rays should be taken to diagnose caries.
4. Hygiene care should be provided as part of the treatment process.
5. Care should be provided sequentially, beginning with hygiene services and dental
prophylaxis.
6. Oral hygiene instructions should be provided and documented as part of the treatment
process.
We agree with these recommendations.
Additional Recommendations
7. All inmates should have a comprehensive examination within 30 days of intake. This
exam should use the criteria of the American Dental Association Procedure Code D0150
(Comprehensive Oral Evaluation).116
8. Oral prophylaxis and non-surgical procedures such as scaling, and root planing should
comport with the definitions set forth in the American Dental Association Procedure
Codes.
9. Biennial examinations should be informed by intraoral x-rays, a periodontal assessment
that includes a PSR, and a soft tissue examination for oral cancer and use the criteria of
Procedure Code D0120 (Periodic Oral Examination).

“It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. […] This includes an evaluation
for oral cancer where indicated, the evaluation and recording of the patient's dental and medical history and a general health
assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, existing
prostheses, occlusal relationships, periodontal conditions (including periodontal screening and/or charting), hard and soft tissue
anomalies, etc.”
116

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Dental: Intake (Initial) Examination

First Court Expert Recommendations
1. Oral hygiene instructions should be provided at the time of the screening [intake]
examination.
2. The area where x-rays are taken should have warning signs posted that clearly warn of
potential radiation hazards to pregnant females.
3. Consent form should be developed and used for pregnant females that explains
radiation hazards and gives the examiner permission to take the x-ray.
We agree with these recommendations.
Additional Recommendations
4. Dentists should wash their hands or use an alcohol wipe between changing gloves.
5. Disposable infection control barriers should be used on the examination light and be
changed between patients (as is done in the dental clinic).
6. The dentist should perform a soft tissue exam for oral cancer that includes holding the
anterior portion of the tongue with 2x2 gauze and reflecting the tongue with a mouth
mirror to visualize the posterior portion and lateral borders of the tongue.

Dental: Extractions

First Court Expert Recommendations
1. A diagnosis or a reason for the extraction should be included as part of the record entry
using the SOAP note format, especially for sick call entries. This deficiency has been
corrected since the EHR used at LCC forces dental providers to use the SOAP format.
Additional Recommendations: None

Dental: Removable Prosthetics

First Court Expert Recommendations
1. A comprehensive examination and well-developed and documented treatment plan,
Including bitewing and/or periapical radiographs, should precede all comprehensive
dental care, including removable prosthodontics.
2. Periodontal assessment and treatment should be part of the treatment process and that
the periodontium should be stable before proceeding with impressions.
3. Oral hygiene instructions should be provided as a precursor to removable prosthodontic
impressions.
4. All operative dentistry and oral surgery should be completed before proceeding with
impressions.
We agree with these recommendations.
Additional Recommendations: None.

Dental: Sick Call/Treatment Provision
First Court Expert Recommendations

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1. Use the SOAP format for sick call entries. It will insure that the inmate’s chief complaint
is recorded and addressed, and a thorough focused examination and diagnosis precedes
all treatment. The EMR forces dental providers to use the SOAP format; consequently,
the recommendation is moot.
2. Inmate request forms should be retained in the dental record.
3. Provide only immediate or palliative care on sick call appointments. Do not use these
appointments for routine care. Provide a dedicated schedule for these inmates.
We agree with these recommendations.
Additional Recommendations
4. The sick call failed appointment rate should be monitored and reported monthly.
5. The reasons for the high failed appointment rate should be studied by the Quality
Improvement Committee.

Dental: Orientation Handbook

First Court Expert Recommendations
1. Insure that information about the dental program and how to access dental care is
included in the Offender Handbook and Orientation Manual. We agree with this
recommendation.
Additional Recommendations: None.

Dental: Policies and Procedures

First Court Expert Recommendations
1. The dental program should develop a detailed, accurate policy and procedure manual
that defines how all aspects of the program are to be run and managed. Once
developed, it should be updated on a regular basis and as needed for new policies and
procedures. We agree with this recommendation.
Additional Recommendations
2. The “complete” examination should comport with the American Dental Association
Code D0150 (Comprehensive Oral Examination – New or Established Patient). Revised
policies should incorporate ADA procedure definitions.
3. The initial examination should comprise a complete oral cancer examination that
includes an inspection of the lateral border and ventral surface of the tongue.

Dental: Failed Appointments

First Court Expert Recommendations
1. The dental staff should investigate the reasons for failed appointments and then put in
place corrective action to lower the rate.
2. A continuing quality improvement study would be a good methodological technique.
We agree with these recommendations.

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Additional Recommendations: None.

Dental: Medically Compromised Patients

First Court Expert Recommendations
1. The medical history section of the dental record be kept up to date and that medical
conditions that require special precautions be red flagged to catch the immediate
attention of the provider.
2. Blood pressure readings should be routinely taken of patients with a history of
hypertension, especially prior to any surgical procedure.117
We agree with these recommendations.
Additional Recommendations
3. Diabetic patients should receive thorough periodontal assessments by a dentist annually
as part of the chronic disease program and those with periodontal disease should have
a sequenced treatment plan with six-month follow-ups.

Dental: Specialists

First Court Expert Recommendations
1. Thoroughly document in the dental record all findings and reasons that led to a referral
to the specialist required. Provide all information pertinent to the condition being
referred. We agree with this recommendation and note that the dental referral requests
we reviewed had all pertinent information.
Additional Recommendations
2. The dental program should maintain an oral surgery log to include the date of the
request for approval, the results of the collegial review (that is, approval or disapproval)
the date of the appointment/treatment, the condition to be treated, and any postsurgical complications.

Dental: CQI

First Court Expert Recommendations
1. Evaluate program deficiencies and needs as outlined in this report through ongoing
continuous quality improvement studies that address these deficient areas. Develop
corrective actions and procedures to improve those areas.
We agree with this recommendation.
Additional Recommendations: None.

Internal Monitoring and Quality Improvement
First Court Expert Recommendations
117

The dental clinic does not have a stethoscope and sphygmomanometer.

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1. The staff should be trained in CQI methodology, specifically with regard to how to
perform studies, how to identify subthreshold performance, how to analyze the data in
order to determine the causes of subthreshold performance, and then how to develop
improvement strategies based on the identified causes and finally how to restudy to
determine whether the improvement strategy had the required effect.
2. The leadership of the continuous quality improvement program must be retrained
regarding quality improvement philosophy and methodology, along with study design
and data collection.
3. This training should include how to study outliers in order to develop targeted
improvement strategies.
We agree with these recommendations.

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Appendix A
Logan Staffing
Position

Budgeted

Filled

Vacant

Health Care Unit Administrator

1

1

0

Medical Director

1

1

0

Director of Nursing

1

1

0

Medical Records Director

1

0

1

Registered Nurse Supervisor

1

1

0

Obstetrician

0.5

0.5

0

Nurse Practitioner/Physician
Assistant

4

4

0

Registered Nurse

5

5

0

Licensed Practical Nurse

18

18

0

Medication Room Assistant

3

3

0

Dentist

2

2

0

Dental Assistant

3

3

0

Dental Hygienist

1

1

0

Licensed Physical Therapist

0.25

0.25

0

Certified Mammography
Technician

0.4

0.4

0

Optometrist

0.2

0.2

0

Office Coordinator

1

1

0

Staff Assistants

8

8

0

Phlebotomists

1.2

1.2

0

Radiology Technician

0.6

0.6

0

53.15

52.15

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Appendix B

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Appendix C

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Menard Correctional Center
2nd Court Appointed Expert Report
Lippert v. Godinez

Visit Date: May 21-24, 2018

Prepared by the Medical Investigation Team
Mike Puisis, DO
Jack Raba, MD
Catherine M. Knox RN, MN, CCHP-RN
Jay Shulman, DMD, MSPH

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Table of Contents
Overview............................................................................................................................... 3
Executive Summary ............................................................................................................... 3
Findings................................................................................................................................. 7
Leadership, Staffing, and Custody Functions.............................................................................. 7
Clinic Space ................................................................................................................................. 9
Sanitation .................................................................................................................................. 16
Radiology Service ...................................................................................................................... 17
Medical Records........................................................................................................................ 18
Medical Reception and Intrasystem Transfer ........................................................................... 20
Nursing Sick Call ........................................................................................................................ 22
Chronic Disease Management .................................................................................................. 25
Urgent/Emergent Care.............................................................................................................. 39
Specialty Consultations ............................................................................................................. 51
Infirmary Care ........................................................................................................................... 62
Pharmacy/Medication Administration ..................................................................................... 66
Infection Control ....................................................................................................................... 71
Dental Program ......................................................................................................................... 75
Internal Monitoring and Quality Improvement Activities ........................................................ 90
Recommendations .............................................................................................................. 93
Leadership, Staffing, and Custody Functions............................................................................ 93
Clinical Space............................................................................................................................. 93
Sanitation .................................................................................................................................. 94
Radiology Services .................................................................................................................... 94
Medical Records........................................................................................................................ 94
Medical Reception and Intrasystem Transfer ........................................................................... 95
Nursing Sick Call ........................................................................................................................ 95
Chronic Disease Management .................................................................................................. 96
Urgent/Emergent Care.............................................................................................................. 97
Specialty Consultations ............................................................................................................. 98
Infirmary Care ........................................................................................................................... 99
Pharmacy and Medication Administration ............................................................................. 100
Infection Control ..................................................................................................................... 101
Dental Program ....................................................................................................................... 102
Internal Monitoring and Quality Improvement ...................................................................... 107
Appendix A........................................................................................................................ 108

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Overview
From May 21 to May 25, 2018, the Medical Investigation team visited the Menard Correctional
Center (MCC) in Chester, Illinois. MCC is a maximum security prison. MCC houses 3029 inmates.
The capacity of the prison is 3812 and the prison is at 79% of capacity. Eighty-one percent of
inmates are classified as maximum security. Approximately 10% of inmates are medium security
and approximately 9% are minimum security. Only 49 (1.6%) inmates were in the reception
housing unit on the day of our visit. MCC had an infirmary unit, which on the day of our visit
housed eight patients.
This report describes our findings and recommendations. During this visit, we:
• Met with leadership of custody and medical
• Toured the medical services area
• Talked with health care staff
• Reviewed health records and other documents
• Interviewed inmates
We thank Warden and staff for their assistance and cooperation in conducting the review.

Executive Summary
Based on a comparison of findings as identified in the First Court Expert’s report, we find that
except for minor improvements in nursing sick call and infection control, all areas were either the
same or worse than the First Court Expert’s findings. Clinical care in all areas of record reviews
appeared worse and, in some cases, resulted in harm. Mortality review identified preventable
and possibly preventable death. We find that overall, the Menard Correctional Center (MCC) is
not providing adequate medical care to patients, and there are systemic issues that present
ongoing risk of harm to patients and result in preventable morbidity and mortality. The
deficiencies that form the basis of this opinion are provided below.
There are an extraordinary number of vacancies (33%) at this facility. This includes two physician
positions, nurse practitioner positions, Director of Nursing, medical records director, Dental
Director and 39% of nursing positions. It takes approximately 10 months to fill a state position,
and the IDOC needs to reduce that timeframe or it will be unable to timely fill positions. The
Medical Director does not provide clinical leadership at the facility. The Wexford regional team
does not appear to participate in identification or resolution of operational problems. A staffing
plan needs to be done, as it is unclear how many staff are necessary to provide services.
In order to accommodate custody, sick call and provider visits are conducted in housing units.
But these housing unit examination rooms are not all appropriately equipped, were not well
maintained, and were cluttered, making them inappropriate for clinical care. Some examinations
occur with the patient in a chair. The panorex unit in intake is not shielded, which increases risk
of radiation exposure to staff and other inmates. The infirmary has no examination room and
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patient rooms have no nurse call devices. Equipment is not maintained or routinely inspected.
Showers in the infirmary and in American for Disability (ADA) units were not well maintained and
are in need of repair. There was a lack of automated external defibrillators. There was a lack of
maintenance and repairs throughout all clinical areas, which we were told was a result of funding.
Most but not all examination tables had paper barriers. Sharps, gloves, sinks, and paper towels
were available. Maintenance of equipment and physical plant was not being done. Sanitation
rounds were being done but findings were not corrected. Environmental rounds need to include
clinical equipment, electrical safety, emergency bags, negative pressure rooms, and clinical areas.
Radiology equipment, inspections, and safety were adequate except for the panorex in the
reception area, which lacked shielding, making it a potential safety risk. Access to radiological
services was adequate. The need for dosimeters should be reviewed with the State of Illinois
Emergency Management Agency.
Medical records are properly thinned but the number of volumes of medical records is so large
that additional storage space is needed to accommodate excess volumes. This makes access to a
complete medical record extremely difficult. An electronic medical record is needed. Medical
records are not available for nurses performing sick call in housing units. They write their notes
on blank progress notes without access to review medical record information. Their notes are
filed at a later date. All staff need to have access to a medical record for every clinical encounter.
Any staff is authorized to pull or re-file medical records, which violates confidentiality and
promotes loss of medical documents. Hospital and consultation reports are only available 50% of
the time. This adversely affects clinical care.
Intake physical examinations are not timely; only 60% of new inmates have their intake physical
examination within a week. As with NRC, although HIV testing is supposed to be opt-out, it still
requires consent and may account for only 50% of incoming inmates being screened.1 This is not
trivial. We found on death reviews a man from MCC who was never screened for HIV despite
having multiple risk factors. He died of unrecognized advanced AIDS and his death was
preventable if he had been screened.2 Although there were additional problems with the care
of this patient, the lack of HIV screening was significant. The Center for Disease Control
recommends opt-out screening as the optimal testing method for HIV in correctional centers and
this should be put into place in the IDOC.3 Follow up of tuberculin skin testing was not always
done and occasionally is not administered. Follow up of abnormal findings was inconsistent.
There is no system to monitor these deficiencies.

In our experience, opt-out testing typically results in rates greater than 95% acceptance. This is borne out by the experience in
Rhode Island Department of Corrections, which had a rate of acceptance of testing of 98%. This is found in the following article.
Beckwith CG, Bazerman L, Cornwall AH, Patry E, Poshkus M, Fu J, and Nunn A: An Evaluation of a Routine Opt-Out Rapid HIV
Testing Program in a Rhode Island Jail. AIDS Educ Prev June 23, 2011 23(30): 96-109 and found at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734962/.
2 Patient #22 Mortality Review.
3 HIV Testing Implementation Guidance for Correctional Settings; Centers for Disease Control and Prevention, January 2009 as
found at https://www.cdc.gov/hiv/pdf/group/cdc-hiv-correctional-settings-guidelines.pdf.
1

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Since the First Court Expert’s visit, MCC now has properly equipped rooms used to conduct
nursing sick call evaluations. All sick requests we reviewed were seen timely, including urgent
sick call requests. We verified this in interviews of inmates. Nurses failed to appropriately assess
and examine patients in 20% of sick call requests we reviewed. We also found that licensed
practical nurses independently perform sick call even though it is not within the scope of their
license. This places inmates at risk of harm. Nurses also evaluate inmates for their requests
without having the medical record with them during the evaluation. This violates IDOC protocols
and MCC’s policy. Only 20% of nurse referrals to providers occurred timely
About half of chronic illness patients are still managed in one-disease-only clinics. We examined
hepatitis C chronic clinics at MCC and found that patients are unmonitored for ongoing harm of
hepatitis C, including complications of cirrhosis and hepatocellular carcinoma. These failures have
caused death.4 The insertion of a Wexford corporate hepatitis C physician into the process of
referral to UIC is an additional barrier that serves to delay treatment of patients with antiviral
medication. Facility physicians are not adhering to IDOC hepatitis C guidelines and fail to obtain
required testing necessary to evaluate patients for treatment. Physicians seeing patients in
chronic care clinics failed to consistently document rationale for their treatment decisions, failed
to document review of the medication records, failed to review blood glucose levels in diabetics,
failed to refer diabetic patients for annual retinopathy screening, failed to prescribe statins based
on current IDOC guidelines, failed to screen for colon cancer, and failed to vaccinate patients in
accordance with current recommendations. We found many deficiencies on record reviews.
Emergency supplies and equipment are standardized but bags are not sealed. Emergency bags
are routinely checked but we did find some outdated supplies in these bags. All automated
defibrillators were routinely checked and were found functional. Emergency response drills are
performed as required. Although critiques of these drills were adequate, there was no discussion
of analysis or plans for improvements in CQI meetings. Tracking of emergency evaluations ceased
in 2017. In records reviewed of nursing evaluation of urgent episodes of care and in physician
care of persons hospitalized, there were numerous deficiencies of clinical care.
Specialty care was not tracked, so it was not possible to evaluate timeliness of care. MCC had the
second lowest rate of referral of all facilities we reviewed but the highest rate of denials. We
found that many denials were inappropriate. In record reviews we noted delayed specialty care,
lack of follow up after consultations, including noting the status of the patients and failure to
describe the therapeutic plan developed by the consultant, failure to timely schedule specialty
care, and failure to obtain specialty care reports. Access to care appeared so poor that we
recommend abandoning the collegial review program.
We found that some patients on the infirmary had conditions that required a higher level of care,
such as a skilled nursing unit. Provider notes on the infirmary failed to include adequate history,
examination, or plans, and had limited clinical information or rationale for treatment plans.
Infirmary beds are inadequate for the type of patients housed on this unit. The infirmary had no
4

Mortality Review Patient #23.

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examination room. The fixed infirmary beds are so close to the ground that it was difficult to
imagine how an adequate examination could be accomplished. There are no call devices on the
infirmary and rooms had padlocks on them, creating an evacuation-safety hazard and making it
impossible for bedridden patients to gain the attention of a nurse in an emergency.
We noted that medication rooms were clean and orderly, and that storage of medication was
appropriate. Medication administration, however, is not safe and medication services do not
meet standards of practice. We found that morning medication administration starts at three in
the morning, which we find unwarranted. There are numerous transcription errors on medication
records that can result in errors in providing medication. Pre-pouring of medication, including
crushed and floated medication, is inconsistent with good nursing practice. There were
numerous other problems with administration of medication that make this practice unsafe. The
use of a list to prepare controlled substances and the placement of doses for multiple patients
into a collective container is dangerous and should be stopped immediately. The MAR is not
available during medication administration and therefore medication is not documented as given
when the medication is actually administered. Instead, nurses document medication
administration as given when they pre-pour the medication. We noted lapses of medication
continuity in several patients and noted that chronic disease patients are not monitored to
ensure continuity of prescribed medication.
There is a dedicated full-time nurse assigned to infection control, and important improvements
have been made to the program. MCC tracks infectious disease and has the most advanced
tracking of persons with infectious disease of all the facilities we have visited. This nurse could
provide a better service if she worked in coordination with an infectious disease doctor so that
her work could be guided by current infection control practices. Analysis of surveillance data
needs attention, and repair and maintenance of clinical areas needs to improve.
Dental staffing is grossly inadequate; consequently, wait times for fillings and dentures is greater
than 15 months. Patients who were prescribed antibiotics for dental infections do not have the
teeth extracted timely. Two dentist positions should be filled immediately, and an additional 0.5
FTE dental hygienist position should be established. Routine dental treatment is inadequate since
it is not informed by a comprehensive oral examination (i.e., intraoral x-rays, a periodontal
assessment using probing, and a sequenced treatment plan). The failures of the dental program
documented in this report place patients at risk of preventable pain and tooth loss by fostering
widescale underdiagnosis and under-treatment of dental disease. The program has deteriorated
markedly since the First Court Expert Report, and the treatment provided to IDOC inmates
remains substantially below accepted professional standards, and is not minimally adequate.
The quality improvement program coordinator has no training in quality improvement and no
knowledge of current quality improvement methodology. Half of the Governing Body of the
quality improvement program consists of custody trained staff. This body needs to be
predominantly medically trained. Staff performing studies did not appear to know the difference
between outcome and process studies. CQI activities did not address major problems of the
facility. Mortality review is not performed and there is currently no critical analysis of deaths,
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even though we found that four of seven death records reviewed had preventable or possibly
preventable mortality.

Findings
Leadership, Staffing, and Custody Functions
Methodology: We reviewed the Schedule E. We interviewed leadership staff and custody
leadership.
First Court Expert Findings
There were no primary care physicians on staff. The Medical Director was a surgeon and the two
staff physicians included another surgeon and an ophthalmologist. The Health Care Unit
Administrator (HCUA) also served as the Director of Nursing. One of the supervising nurse
positions was vacant. This left a lack of supervisory nurse staff. The vacancy rate was
approximately 9%.
Current Findings
The medical leadership team is still incomplete. Currently, the Medical Director position is filled
with a board-certified internist and the HCUA position has been filled by the same person since
2014. The Director of Nursing (DON) position, however, is vacant. There is no medical records
director; a medical records technologist acts as the medical records director. The three
supervisory nurse positions are all filled but two of these positions have been recently filled. The
Dental Director position is vacant.
The HCUA position is filled by a nurse who is competent and well qualified for her position. Her
effectiveness is diminished by not having a DON, an effective Medical Director, or a reliable
quality improvement resource person knowledgeable in continuous quality improvement (CQI)
methodology. There was no evidence of support by the vendor in improving programmatic
deficiencies.
The Medical Director is not providing administrative clinical leadership. This position is filled by
an internist who has been Medical Director since June of 2017. He sees patients on the infirmary
and in the clinic, performs peer reviews for the nurse practitioners, addresses grievances, and
attends the collegial review conference calls. There is no evidence of any participation in other
administrative medical functions, particularly related to quality improvement or solving medical
clinical problems. He was unaware of the plan for quality improvement and told us that the
facility had no ongoing quality problems. He seemed unaware of any programmatic issues of the
facility and saw his role with respect to quality improvement as providing good care. As an
example, when asked if getting consultation reports was a problem he answered yes. His solution
to this was to tell the scheduler about the lack of reports. He presumed that the Regional

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Manager and Regional Medical Director knew of the problem but was unaware and not involved
in any effort to correct this deficiency.
The IDOC Regional Nurse Coordinator was present for our visit. She does spend time at the facility
and was aware of problems that the facility faced. However, she also serves as the full-time HCUA
at Vandalia and does not spend full-time as the Regional Coordinator. She did indicate that she
has trained staff at Vandalia to assume most of her functions at Vandalia; however, we were
unable to verify the extent of time she spends in each of her positions.
The Wexford Regional Manager was present for our visit. She has been with Wexford for three
years. She has no medical training or medical administration training. She previously worked as
a warden in the IDOC. When asked what the top five problems were at MCC, she said that there
were no problems at the facility and no areas of concern from her perspective as Regional
Manager. She does not participate in quality improvement activity and has no role in mortality
review. She said that no one has brought to her attention any problems with respect to mortality.
She knew of no clinical issues with respect to the previous Medical Director, who was a surgeon.
With respect to the current Medical Director, she knew that he needed additional training in
order to be able to perform suturing of lacerations. From her perspective, operations worked
well and were without problems. In our opinion, custody-trained personnel should not be hired
to manage the medical program, as they have no experience or training in the provision of
medical care.
The Wexford Regional Medical Director was not present for our visit. According to the HCUA, he
rarely is present at the facility. He comes for annual Continuous Quality Improvement (CQI)
meetings and rarely comes when there is a coverage issue. There was no evidence of his
participation in clinical oversight at the facility based on documents we reviewed. He is available
to the Medical Director by phone.
There are 91.1 staff positions at MCC. Sixty-six are state staff and 25.1 are Wexford staff. A table
of staffing is present as an appendix to this report. There are 29 vacant positions and one longterm leave of absence, yielding approximately a 33% effective vacancy rate. This is a deterioration
and a significantly higher vacancy rate than the 9% rate cited in the First Court Expert’s report.
This vacancy rate is extremely high and makes it impossible to effectively manage the program.
State positions have a 33% (22 of 66) vacancy rate, most of which are nursing positions. Wexford
has a 28% (7 of 25.1) vacancy rate. Both of these vacancy rates are extremely high. The vacancies
for Wexford included the Dental Director, a dentist, and two physician positions, which are
critical clinical positions. We were told that there have been applicants for many of the state
vacant positions but that the state hiring process is so cumbersome that prospective employees
take other positions before the state hiring process is completed. We were told that for a recent
hire it took 10 months from the time of application to the time the employee started work.
Wexford has been unable to provide adequate physician coverage for this facility. The First Court
Expert reported that all three positions were filled by non-primary care trained physicians and
the Medical Director was a surgeon. This was deemed inadequate, which we agree with. The
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current Medical Director is board certified in internal medicine, but the other two physician
positions are vacant. We received a contract monitoring report covering seven months from June
2017 to December of 2017. This report documents that the physician position has been vacant
since September of 2014. We were told that one of the two vacant physician positions was
downgraded to a nurse practitioner position because it also could not be filled; this change is not
evident in the Schedule E provided to us. That nurse practitioner position is currently vacant as
well. The contract monitoring report for MCC shows that the Medical Director hours have mostly
been filled. Only approximately 50% of the staff physician hours have been filled and only
approximately 50% of nurse practitioner hours have been filled. Downgrading the physician
position to the nurse practitioner position has apparently not resulted in additional provider
staffing as expected. The current vacant physician position is partly covered by a coverage
physician who received one year of a rotating internship and one year of a pathology residency
in 1976. This facility still lacks adequate physician coverage and one of the coverage physicians
has no primary care training. In terms of hours filled, physician coverage is worse than in 2014
but is slightly better with respect to coverage with primary care trained physicians. The lack of
primary care physicians is evident in problems found in record reviews and mortality reviews,
and this results, in our opinion, in preventable morbidity and mortality.
Nurse supervisory budgeted staffing is deficient. There are three nurse supervisory staff but there
is no weekend or evening coverage. On-call nurses act as proxy evening and weekend supervisory
staff. Nurse staffing is also deficient. Though 21 (39%) of 54 nurse positions are vacant, we believe
that there remains a deficiency of budgeted nurse staff. The HCUA was unaware of any staffing
plan developed for this facility. In addition to nursing positions, clerical positions also appear to
be deficient. The number of medical appointments is large at this facility due to its size, and the
one scheduling clerk is insufficient to adequately manage the paperwork and scheduling duties.
As with other facilities, a staffing plan based on the expectations of the administrative directives
with relief factor adjustments needs to be done to accurately determine staffing levels.
We did not review officer staffing. As with other facilities, we believe an officer staffing
assessment needs to be done to ensure that all appointments timely occur, and officers assist
nurses in a standardized manner when nurses administer medications.

Clinic Space
Methodology: Accompanied by a correctional officer, a nurse manager, and occasionally the
HCUA, the experts inspected the nurse and provider sick call rooms on the housing units, the
three-story health care unit which housed medical exams rooms, telehealth room, treatment
room, physical therapy, nurse medication preparation room, phlebotomy room, dental clinic,
sterilization room, medical records department, health care administrative offices, and the
infirmary, optometry room, and radiology suite.
First Court Expert Findings
The First Court Expert found that the then 30-year-old health care unit was well maintained but
aging, the nurse and physician sick rooms in the cell houses lacked privacy and were not
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adequately equipped, and the Reception and Classification Unit was small but appropriately
equipped. He noted that all of the clinical areas in the cell houses should be renovated to provide
clean, private clinical settings.
Current Findings
• The location of the nurse and provider sick calls in the housing units maximizes the
patient-inmates’ access to sick call and chronic care services.
• The provider and nurse sick call rooms in the cell houses are generally small; some were
not well organized and not in good physical condition.
• The only two exam tables (one is actually a gurney) in one cell house (North) were
cluttered with supplies and medical charts, and were not usable for patient examination.
Exams, if needed, were performed while the patient was in a chair.
• All of the clinical rooms, including the nurse and provider exam rooms, in the cell houses
were wired for computers, but none had computers.
• Some exam rooms in the cell houses had been recently painted but others had cracked
paint and walls, frayed wall paper, an electrical outlet without a cover plate, and a missing
ceiling vent cover.
• Torn upholstery was noted on three exam tables on the campus.
• Missing or non-functional oto-ophthalmoscopes were noted in four exam rooms on the
campus.
• Only three of the 26 beds in the infirmary had adjustable head and leg sections. One was
an aged metal bed and the other two were hospital beds.
• There are an inadequate number of adjustable hospital beds to meet the needs of the
complicated patient-inmates admitted to the infirmary.
• There is not an exam room in the infirmary.
• The low level of the beds makes it difficult and unsafe for the clinical team to properly
examine and transfer patients.
• There were no nurse call devices in the infirmary patients’ rooms. The HCUA stated that
consideration is being given to installing wall-mounted bedside audible alarms that are
currently in use at LCC.
• Not all medical equipment had documentation of annual electrical safety inspections.
• Out-of-date medical references were found in a number of clinical areas.
• The group shower in South Lower used by older men, some with physical impairments,
was in poor repair that created safety and sanitation concerns.
• The infirmary shower was poorly ventilated, had a clogged ceiling vent, a non-functional
shower head, a rusted grab bar near the tub, and no safety grab bars near the functioning
shower.
• The anterooms in both infirmary isolation rooms were dirty and cluttered.
• The negative pressure units in the infirmary isolation rooms were functional and had
regular documented inspections.
• The layout of the radiology room in the Reception & Classification building predisposes
the staff and patients to the potential risk of radiation exposure.

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•

There are no automated external defibrillators (AEDs) in the Reception & Classification
building or in every cell house.

At the time of the site visit, MCC housed 2,580 maximum security male inmates on the main
campus and an additional 440 men at its Medium Security Unit located a few miles from the main
facility. MCC serves as the Reception and Classification Center for a number of detention centers
and jails in southern Illinois, receiving 90-150 new admissions per month. It also accepts transfers
from all of the IDOC facilities and directly from the North Reception Center (NRC) near Chicago.
The Reception and Classification Center is located in a separate building with an adjacent housing
wing that temporarily houses 30-50 new admissions until their intake screenings have been
completed. The clinical screening is provided in four rooms (medical, TASC, mental health, and
dental) along a single corridor. The medical exam room has an exam table with torn upholstery,
paper barrier for the exam table, a desk, two chairs, a scale, sink with eye washing attachment,
and paper towels. The wall mounted oto-ophthalmoscope was not functional. Unprotected
paper directives were taped on the wall; this is a fire safety hazard. Vital signs and clinical histories
and exams are performed in this room. Dental screening is provided one day per month. Panorex
x-rays are taken in an unshielded, unleaded room. Prior to taking an x-ray, the radiology
technician has to stop foot traffic in the corridor and pull the trigger cord into the corridor to
minimize the risk of radiation exposure. The radiology technician does not wear a radiation
exposure dosimeter badge. An automated external defibrillator (AED) is not kept in the R&C
building.
Men are housed in two long, multi-story housing structures that have been subdivided into seven
cell houses. One structure houses North 2, North Lower, North Upper, South Lower, and South
Upper cell houses; the other has the East and West cell houses. Each of cell houses has two galleys
on each side, each galley had two tiers that are not connected. The cell houses hold from 250400 patient-inmates. Each cell has a toilet, a sink, and a bunk bed with two men; some inmates
are housed alone. The doors are barred. Large open showers are located on each floor. There are
steep stairs to each of the upper levels, but there is also an elevator for those who are unable to
navigate the stairs. Men are allowed access to the shower three times per week. The group
shower in South Lower that is used by an older population, including some individuals with
physical disabilities, was inspected. The shower room had five shower chairs, safety grab bars,
and ramps to access the showering area. The area was poorly ventilated, the ceilings were
peeling, the concrete floor had large cracks, and metal doors, fans, and vent covers were
completely rusted. The cracked floors pose a safety risk to this aged patient-inmate population
and to staff. The rusted metal fixtures and the peeling ceiling are not able to be fully sanitized
and create a risk for mold and the growth of bacteria and fungi. The correctional staff stated that
the state funding has been inadequate to perform routine maintenance and repair of this shower
and other service areas on the campus.
Each of cell houses has a clinical space where nurse and provider sick call and chronic care clinics
are held; these clinic spaces vary from cell house to cell house in size, privacy, equipment, and
upkeep.
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North 2 medical area is located on an upper floor and serves the cell house’s segregation unit, a
general population unit, and an older patient, some with disabilities, unit. The area has a 10person waiting room. The space is relatively tight but has two medical exam spaces, a tele-psych
room, a single chair dental suite, and three mental health interview rooms. This is the most
expansive clinical space in the cell houses. A provider uses one of the medical rooms one to two
days per week. This room has a gurney covered with medical charts that serves as the exam table,
a desk, two chairs, no computer, a sink with soap and paper towels, and a blood pressure unit.
This exam room did not have an oto-ophthalmoscope; it was reported that it was broken. There
was 13-year-old Physician Desk Reference (PDR) in the room. When questioned about the
availability of electronic medical references, the physician stated that he can access online clinical
references from the computer in his office in the health care unit, but he was unable to list even
one comprehensive online resource that he uses. The gurney that reportedly serves as the exam
table was so completely covered with medical charts that it was unlikely that it would or could
be used during this session. Nurse sick call is performed in an adjacent exam room with an exam
table which has tears in the upholstery and is covered with medical supplies; this exam table
could not be readily, if at all, used for patient examination. The room had paper barriers, scale,
BP unit, peak expiratory flow rate (PERF) meter, pulse oximeter, sink, desk, two chairs, phone,
sharps box, and a stair chair. There was a functioning otoscope. An unsealed emergency bag with
an ambu bag, EpiPen, glucose gel, expired glucagon, Accu-Chek machine (no safety inspection
label) was inspected. There was no AED in the bag: it was reported to be broken. The nurse
reported that the bag is checked every shift, but a log could not be identified. There were 18 and
19-year-old PDR’s on the nurse’s desk; she stated she does not have access to online medical
references. The nurse holds daily sick call and sees most patients within one to three days after
a request is submitted.
The medical area in North 1 Upper (population 350-370) had a small waiting room and two small,
clean, recently painted, similarly equipped exam rooms. Each had exam tables with intact
upholstery, paper barriers, two fixed chairs, and no computer. There was not a sink in the rooms.
In the atrium just outside the exam rooms was a scale, and a sink with soap and paper towels,
and a locked medical cabinet with a functional oto-ophthalmoscope, PEFR meter, stethoscope,
digital thermometer, and medical supplies.
North 1 Lower (population 247) sends its general population patients to North 1 Upper for sick
call and chronic care clinics and its second floor medical area serves the protective custody
patients (62 individuals) housed in this cell house. This clinic has only a single exam room with an
exam table with intact upholstery, paper barrier on the table, desk, two chairs, phone, hand
sanitizer, paper towels, a functional oto-ophthalmoscope, scale, BP unit, a stethoscope, and no
computer. There was no PEFR meter or mouthpieces or a pulse oximeter or Accu-Chek unit in
this clinical area. The paint was cracked on the wall and an electrical plate was missing just above
the exam table.
South Lower (population 316) has two clinics. A clinic on the first floor serves an older population,
some with physical disabilities, housed on the adjoined lower levels of this cell house. The clinic
has a single exam room with an exam table with intact upholstery, a sink with soap, scale, BP
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unit, stethoscope, pulse oximeter, gloves, desk, two chairs, phone, and no computer. Wallpaper
in the clinic was frayed, preventing the walls being properly cleaned. South Lower also has a clinic
on the second floor that serves a general population and a worker/porter housing unit. This clinic
has a single exam room with an exam table with intact upholstery, paper barrier on the table,
scale, eye chart, functional otoscope, BP unit, pulse oximeter, two PEFR meters, desk, two chairs,
phone, and no computer.
West Cell House (406 population) has a second floor clinic with one small exam room with an
exam table with intact upholstery, paper barrier on the table, functional otoscope, PEFR meter
with mouthpieces, pulse oximeter, desk, two chairs, and hand sanitizer. The space was cluttered,
unprotected paper directives were taped on the walls, paint was cracked, the ceiling vent did not
have a cover, and cardboard boxes filled with toothpaste nearly touching the ceiling were piled
on top of a file cabinet. The accompanying West Cell House correctional officer stated that he
would have the boxes and the paper directives removed immediately. He stated that the state
funding has slowed down the completion of non-urgent repairs throughout the campus. The
boxes and paper taped on the walls posed a fire safety hazard. The cracked paint made it
impossible to properly sanitize this clinic space and creates an unprofessional work environment
for the clinical staff.
East Cell House (310 population) has a second floor clinic with a tele-psych room with a counter
and one chair, and an additional exam room that is shared by medical and mental health staff.
The exam room has an exam table, a desk, and two chairs. The exam room is cramped and
cluttered due to the presence of three large correctional metal file cabinets, water damaged
cardboard boxes stacked on top of these cabinets, and an ancient refrigerator used by
correctional staff with a totally rusted front. These items should not be located in a clinical exam
area. The East Cell House Major who joined our inspection stated that he will have the file
cabinets, cardboard boxes, and refrigerator removed from the exam room.
Patient-inmates interviewed in the cell houses were all knowledgeable about the sick call request
procedure. Most stated that they are seen by a nurse within a few days after they place a request
in the locked box. If they were referred by the nurse to see a provider, it will take three to four
days up to a few weeks before they were seen in a provider sick call.
The health care unit is a three-story building located in the central section of the MCC campus.
The first floor has four exam rooms, one of which is used for HIV, hepatitis C, and renal telehealth
consultation. Only the telehealth room is now actively used for the delivery of medical care. The
other three exam rooms are primarily used as mental health interview rooms and by at least one
LPN as a storage and staging area. Since the provider sick call and chronic care clinics were moved
into the cell houses, three of these exam rooms are only occasionally, if ever, used by nurses for
the delivery of sick call and after-hours care. All the exam rooms have desks, chairs, sinks, soap,
paper towels, exam tables, and oto-ophthalmoscopes. A scale was identified in one exam room.
The exam tables in two of the rooms had torn upholstery. Only two of the four otoophthalmoscopes were functional, and one lacked a currently safety inspection label. Some of

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chairs had torn and frayed upholstery. Only the telehealth room appeared to be organized and
optimally clean. Nineteen and 13-year-old PDR’s were noted in one of the exam rooms.
The first floor also has a sterilization room that also stores trauma bags, crutches, transport cots,
a backboard, two autoclaves with current safety inspection labels, a dental suite that will be
reviewed in the dental care section, medication storage and preparation room, medication
records, a lab room with a current CLIA certificate, a phlebotomy chair, four centrifuges with
current safety inspection labels, and a treatment room. The treatment room serves as the urgent
care center for the MCC campus. It has an adjustable gurney, three oxygen tanks, a Gomco
suction machine, pulse oximeters, digital thermometer, Accu-Chek machines, ambu bag, AED, an
ECG machine, a functional oto-ophthalmoscope, and a variety of medical supplies. An emergency
bag with emergency supplies, medications, and equipment, and an AED with pads were kept in
the treatment room. None of the medications inspected had expired. Two new stair chairs and a
backboard are stored in this area, cluttering an already tight space. An oxygen storage room
within the treatment care area was packed with large and small tanks; only the small tanks were
held in safety racks. The unracked large tanks pose a safety risk to patient-inmates and staff. It
was reported that the Accu-Cheks are calibrated daily, but this activity was not logged. The ECG
machine did not have an electrical inspection tag. Two additional gurneys and one additional stair
chair were kept in an alcove in an adjacent corridor. There was no crash cart in the treatment
room. MCC does not have a crash cart; the institution performs basic CPR, applies the AED, and
calls 911 for cardiac arrests. This is an acceptable option for responding to codes/cardiac arrests.
The second floor of the health care unit houses physical therapy, optometry, radiology suite, and
clinical administrative and provider offices. The physical therapy room is small and has two
matted tables, a cold/hot pack unit, steps, exercise balls, door mounted pulleys, a desk, chairs,
and a storage cabinet. The radiology suite performs non-digital plain film x-ray examinations and
panorex studies (see radiology section for further information). The clinical administrative and
provider offices have computers that have access to the internet.
The third floor of the health care unit houses the 26-bed infirmary. The infirmary offices and
patient rooms were generally clean. Room 304 emitted a smell of urine. This room houses the
only restraint bed in the infirmary. The porters were directed to buff the floor. Twenty-three of
the 26 beds were low fixed-position metal beds. The infirmary beds are low to the floor and
cannot be raised. The head of the beds cannot be elevated. There were only three adjustable
beds; one was an aged metal bed and the other two were relatively new hospital beds. This is an
insufficient number of hospital beds to meet the needs of the complicated patients that are
admitted to the infirmary. There is no exam room in the infirmary; patients are examined in their
beds. The low to the ground fixed-position metal beds make it difficult and even unsafe for the
staff to properly examine and transfer patients into and out of the bed. The bed mattresses were
relatively thin and covered with an intact cleanable covers. Because of a lack of appropriate beds,
one patient, with fall risk, had his mattress placed on the floor. His mattress had an uncovered,
deteriorating foam head rest that was impossible to sanitize. This patient should be assigned to
an adjustable hospital bed with safety railings. There were two negative pressure/isolation
rooms. The negative pressure units were turned on and demonstrated to be operational using
both the pressure gauge and the tissue paper test. The negative pressure units are checked and
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logged daily. There were no patients in the negative pressure rooms. Both negative pressure
room anterooms were dirty and cluttered with gloves, chucks, and paper forms. Both rooms had
full red waste bins. These anterooms had not been used in quite a long time and need to the
cleaned and kept ready for use.
The floor of the shower and tub room was clean. One shower head was not functional. There
were no safety grab bars in the shower; the grab bar near the tub was totally rusted. The ceiling
ventilation covers were rusted and the return vent near the tub was densely clogged with debris.
The staff directed the porter to clean the vent. It was reported that the more frail patients in the
infirmary have live-in inmate aides who assist them with bathing and other activities of daily
living.
The clean and soiled utility rooms and an equipment room were organized and clean. Only one
of the two IVAC units in the equipment room had a current safety inspection label; it was
reported that the other one was new. A scale that could accommodate a wheel chair was
demonstrated to be functional. The laundry room has a non-boosted washer and a dryer. Bleach
is added to all laundry loads; significantly soiled sheets are sent to the main laundry, which
washes clothes at a higher temperature. Cleaned sheets in the laundry room were noted to be in
good condition.
There a linear nursing station that connects into the two long corridors of the rectangular shaped
infirmary. The doors at each end of the nursing station are kept closed. The patient rooms have
solid metal doors with a small viewing window. There are no rooms that are in the direct line of
sight to the nursing station and only a few are possibly within sound of the nursing station.
Correctional officers are housed in the corner of one of the corridors. The officers also do not
have direct line of sight into patient rooms from their desk. The nurse station has a long counter
with two work areas, a medication cart, an operational AED with non-expired pads, oxygen tanks,
ambu bag, functional Gomco suction machine, and a number of out of date nursing textbooks.
An office at the entrance to the infirmary was soon be assigned to a nurse manager who provides
oversight of the infirmary. This room has a computer with access to the internet.
In summary, the relocation of all nurse sick calls, provider sick calls, and chronic care clinics to
the cell house allows for improved access to primary care services. The physical condition of the
some of these exam rooms is deficient and needing of repair of cracked paint and wallpaper, and
replacement of missing and rusty vents, and missing electrical plates. The correctional staff
repeatedly commented that repairs of the clinical areas had been requested but were not readily
done because of inadequate State of Illinois funding. The types of medical equipment and
supplies varied between cell house clinics; all of the cell house clinical areas need to be equally
equipped and stocked. The staff do not have ready access to current clinical references while
they are providing care in the cell houses or in the health care unit; decades old textbooks and
PDRs were noted in many clinical areas. This could be readily corrected by installing computers
in the already wired exam rooms in the cell houses and health care unit. Two showers were
inspected (South Lower and infirmary); both needed repairs and improved ventilation, and both
create safety and sanitation risks for patient-inmates and staff.
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Sanitation
Methodology: The sick call and chronic care rooms on the housing units, the infirmary rooms,
the health care unit, and the showers were inspected. Nurses, correctional officers, infirmary
patient-inmates, and inmate porters were interviewed. Monthly Safety and Sanitation reports
from January through April 2018 were reviewed.
First Court Expert Findings
The First Court Expert reported that the facility was generally well maintained.
Current Findings
We did not find that the facility was well maintained. We noted additional findings.
• The infirmary is generally clean with the exception of the anterooms in both isolation
rooms, which were dirty and cluttered.
• Paper barriers were consistently used on most but not all examination tables throughout
the facility.
• The upholstery on a number of exam tables in clinical areas had tears in their protective
outer surfaces and could not be adequately sanitized.
• An uncovered foam head rest in one infirmary room could not be adequately sanitized.
• Physical plant deficiencies including peeling paint, cracked paint and walls, rusty and
missing vents, frayed wall paper, missing electrical outlet cover plate, torn upholstery,
rusted cabinets, and missing ceiling vent cover were noted in the clinical areas in the cell
houses and the HCU. These deficiencies create a non-professional work environment for
the clinical staff and make it impossible to adequately sanitize the clinical areas.
• Monthly Safety and Sanitation rounds and reports were being completed. Many of the
same findings were noted and went unaddressed from January through April 2018.
• There are no environmental rounds that focus on the inspection and documentation of
non-functional clinical equipment, the presence of current electrical safety inspections,
and the completion of logs of inspections of clinical concerns, including emergency bags
and equipment, negative pressure units, organization of clinical areas, etc.
The nurse and provider sick call and chronic care areas in the cell houses were generally clean,
but the physical plant had a number of deficiencies (also noted in the Clinical Space section) that
interfered with the ability to fully sanitize these areas. The reception and Classification clinical
area had torn upholstery on an exam table. North 2 clinical area needed to be repainted. North
1 Lower had cracked paint and walls, and a missing electrical outlet cover plate just above the
exam table. South Lower had frayed wall paper. West had cracked paint, no cover on the ceiling
vent, and boxes stacked on top of file cabinets. East had the clinical space cramped with
correctional file cabinets, deteriorating boxes with correctional logs and papers, and a totally
rusted correctional staff refrigerator. The HCU was generally clean, with some missing ceiling tiles
and uncleaned infirmary isolation anterooms. The showers in South Lower had peeling paint,
cracked floors, rusted vents and metal doors, and poor ventilation. The infirmary had no safety
hand grab bars, clogged ceiling vent, and poor ventilation. These physical plant deficiencies pose
safety and infection control risks.
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Inmate porters sweep, mop, and buff the floors of the infirmary rooms two to three times a week
or more frequently as needed. They report that they spray with cleaning agent and bleach
mixture. They clean the toilets, sinks, and showers on a regular basis.
In summary, the First Court Expert made a number of specific recommendations concerning
sanitation and infection control. We have added recommendations that are found at the end of
this report.

Radiology Service
Methodology: We reviewed the radiology unit.
First Court Expert Findings
The First Court Expert’s report did not include any findings about the radiology equipment or
services.
Current Findings
• The Illinois Emergency Management Agency (IEMA) radiation safety inspections and
reports for the radiology units at MCC are current. The active x-ray equipment at MCC
was found to be compliance with the Radiation Protection Act of 1990.
• The access to plain film x-rays at MCC is acceptable.
• The turnaround time for radiologist readings and return of the reports is acceptable.
• The lack of a shielded post to take panorex films in the Reception and Classification area
has the potential for radiation exposure to the radiology technician and other staff.
• The system decision not to have the x-ray technician wear radiation exposure dosimeters
may not be in accord with State of Illinois regulations and is definitely not in accord with
community practice.
The radiology equipment had current IEMA inspection and certification. Plain film non-digital xray services and panorex studies are provided Monday through Friday during the daytime hours
by a single full-time radiology technician who staffs and manages the unit. Patients requiring
advanced or emergency studies are referred to the nearby Chester Memorial Hospital or to other
health care systems, including Southern Illinois Health Care (SIHC).
It was reported that there is a three to five day waiting list for non-urgent onsite x-rays. The five
x-rays ordered on 5/17/18 were being taken on 5/22/18, three working days after being ordered.
Most x-rays are reported to be taken within one to two days after receiving the order. Weekend
and holiday requests are completed on the next working day. The requests and the radiology log
for eight patients who had films taken on 5/21/18 were reviewed. The waiting time for this small
sample, between x-ray ordering and being taken, was 7.6 days, with a range of four to 10 days.
Films are sent to a contracted radiologist in Bloomington, Illinois for reading. Reports are initially
faxed back to MCC on the same or next day, with the hard copies sent within two to three days.
Audits of films taken verified that the reading turnaround time was one to two days.

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Onsite ultrasound exams are provided once a month by a contracted vendor. Ultrasound
examinations must be reviewed and approved by the Wexford collegial review process. On the
day of the inspection there were four patients on the ultrasound schedule. Some were awaiting
Wexford approval.
The chest x-ray unit and the plain film table are in a second floor HCU room that has a shielded
post for the technician to stand behind while the film is being taken. The radiology technician has
a dark room and a work space immediately adjacent to the plain film suite. An additional panorex
is located in an exam room in the Reception and Classification building. This room does not have
a shielded post that can be used when panorex films are taken; the technician has to stretch the
trigger cord as far as she can out the exam room door and into the main clinical hallway to
minimize her risk of radiation exposure.
The x-ray technician was noted not to be wearing a radiation exposure dosimeter badge. She
stated she had been told that the State of Illinois does not require the use of dosimeters as long
as she was more than five to seven feet away from the unit. This radiology technician does not
work at an outside medical center.
In summary, the radiology services at MCC have reasonable access to x-ray services and
reasonable turnaround time of radiologist readings and reports. The location of the second
panorex in a clinical exam room in the Reception and Classification building, which does not have
a shielded post to take panorex films, raises concerns about the risk of radiation exposure. The
decision of the system to not provide radiation exposure dosimeter badges is not in accord with
community standards and needs to be further reviewed by the State of Illinois IEMA and possibly
OSHA.
The First Court Expert’s report did not have any recommendations about the radiology services.
We have recommendations that are noted at the end of the report.

Medical Records
Methodology: We inspected the medical records room, interviewed medical records staff, and
reviewed multiple medical records.
First Court Expert Findings
Charts were thinned so that the size of the medical record was manageable. Problem lists were
cluttered with redundant information and with items that were not medical problems. The
facility rarely received consultant reports or hospital reports. Sick call slips were not maintained
in the medical record.
Current Findings
All of the findings of the First Court Expert are still present. Paper medical records are used and
were thinned to a reasonable size. The problem lists were still incomplete and filled with

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unnecessary, redundant information. Hospital and consultant reports are still not consistently
obtained and sick call requests are still not filed in the medical record.
MCC does not have a medical records director position in their budget, but a health information
technologist is a licensed medical records professional and serves in that capacity. The medical
records room is insufficiently sized to accommodate all volumes of records and only the most
current volume of a record is kept in the medical records room. Additional warehouse storage
spaces are used for additional volumes of the current records and for death records. During
record reviews, when we wanted a particular consultant report or other document, we had to
ask for the additional volume, which took some time to obtain. The delay would be significant for
clinical interactions with active patients. The inability to easily obtain all volumes of a record
during every clinical encounter was a problem and is a reason why an electronic medical record
should be installed statewide.
We confirmed the First Court Expert’s finding that medical record volumes are thinned.
Whenever a volume reaches two inches in depth, medical record staff thin the volume, and for
all charts we reviewed, volumes were thinned to two inches or less. Charts we used for medical
record reviews came apart much less frequently than occurred at other sites, but this still
occurred.
There was minimal filing backlog. For most record documents there was only approximately a
half inch of back filing. For medication administration records (MAR), there was two to three
inches. This is not a significant volume of backlog filing.
With respect to access to the record, medical records staff pulls medical records for provider
scheduled appointments. Nursing sick call evaluations occur without the availability of a medical
record, which is inappropriate and subjects the patient to risk. When nurses perform health
request evaluations in remote sites, they need to know the conditions of the patient, recent
problems, and medications. For health request evaluations, nurses write notes on a single
progress note and bring these at a later time to the medical records office. Some nurses will file
the progress note in the patient’s chart and some nurses will give the documents to records staff
to file. Any staff is authorized to pull or re-file a medical record. This violates medical record
confidentiality and promotes loss of medical information. All clinical encounters should occur
with the availability of the medical record.
The First Court Expert found that the facility rarely received consultation or hospital reports.
Obtaining these is the responsibility of the scheduling clerk, who indicated that approximately
50% of reports were obtained. In our record reviews, consultation and hospital reports were not
consistently present and providers did not consistently document the status of the patient after
consultation. Based on record reviews, the lack of consultation and hospital reports appeared to
significantly and adversely affect clinical care.

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Sick call requests are not filed in the medical record. In our opinion, the patient requests for care
have clinical information and are therefore a medical record document and need to be filed in
the medical record.
The lack of timely access to medical record documents for clinical encounters and lack of timely
access to a complete medical record support the need for an electronic medical record. Lack of
timely and accurate documentation in the MAR, which will be described in the medication section
of this report, also supports use of an electronic medical record with an eMAR function.

Medical Reception and Intrasystem Transfer
Methodology: To assess medical evaluation of newly arriving inmates we toured the medical
reception area, interviewed health care staff, reviewed IDOC health record forms, and reviewed
15 health records. Records were selected from a log documenting referral from the reception
nurse to the provider due to a history of chronic disease, since October 2017.
First Court Expert Findings
The previous Court Appointed Expert found problems with the quality of the intake process,
particularly the recognition and work up of abnormal findings.5
Current Findings
Our review showed that the quality of the intake process is still hampered by omissions in
screening and failure to follow up on the information obtained. We also found that intake
physical examinations were not completed timely. Finally, IDOC has adopted a policy of opt-out
HIV testing, but the procedure still requires written consent for testing.
MCC receives an average of 86 inmates a month.6 Intakes arrive generally Monday through Friday
from county jails or directly from the community as parole violators. According to staff
interviewed, usually they have several hours’ notice of inmates who will arrive as new
admissions. Parole violators may arrive without notice.
Intake screening takes place in three rooms on a corridor adjacent to the booking and holding
cells. There is a dental examination room, a medical examination room, and a room to complete
the mental health evaluation. Other offices in the corridor include classification, and alcohol and
drug screening. The medical examination room is used by nurses to conduct receiving screening
and collect lab samples. It is also used by a provider to complete physical examinations. This room
was clean, well-lighted, properly equipped, and maintained.
Intake screening includes a medical history, tuberculosis symptom screen, height and weight,
vital signs, visual acuity, and planting a tuberculin skin test (TST). According to a recent nursing
schedule provided to the Court Appointed Expert, about half the time this responsibility is
5
6

Lippert Report Menard pp. 8-9.
Data provided in advance of the site visit to Menard for the time period April 2017 through April 2018.

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assigned to an LPN and half the time it is assigned to an RN.7 Nurses consistently contacted a
provider to obtain telephone or verbal orders in order to continue medications inmates reported
taking or those which were listed on the transfer summary from jail. Medication was provided as
ordered the next time medications were due.8 Patients were not always followed up to have the
tuberculin skin test read, and in one case, the skin test was not administered.9 These omissions
were identified a few days later by the nurse completing the review of record prior to the physical
exam; the test was administered again, and results obtained timely.
Lab tests performed as part of intake screening at MCC routinely include serum chemistry,
syphilis, and opt-out HIV testing. Although HIV is supposed to be opt-out, the administrative
directive (AD) requires that consent be obtained before drawing blood for HIV.10,11 Opt-out
testing is recommended by the Centers for Disease Control because it supports early
identification and treatment. The AD should be revised to eliminate explicit written consent to
be consistent with an opt-out policy.12 Data reported to the CQI committee shows that on
average only half the incoming inmates are tested for HIV, which is consistent with an opt-in
rather than opt-out testing policy.
A medical history and physical examination are to be completed within seven working days of
intake.13 The medical history and physical examination by a physician, nurse practitioner, or
physician’s assistant took place within the first seven working days after admission in only 60%
of the charts reviewed. Untimely physical exams were between nine to as many as 18 days after
admission. As noted in the previous Court Expert report, the recognition and work up of abnormal
findings was sometimes problematic. Providers did not consistently elaborate on positive
findings noted by the nurse, and the history and physical examination were cursory and lacking
in quality.14 Enrollment of patients in the chronic care program has improved since the previous
Court Expert’s review. Inmates with chronic diseases were usually seen for their first chronic care
appointment at the time of the intake physical exam. This initial visit includes a review of relevant
lab results, amplification of the disease history, assessment of disease control, and initiation of a
treatment plan.
There are no mechanisms in place to monitor timeliness of the intake process or to evaluate the
quality of intake screening, the health history, or physical examination. There were no CQI studies
provided that indicate intake screening is monitored for quality or timeliness. This is a high
Nursing schedule 4-16-2018 through 4-28-2018.
Medical Reception Patients #5, 6, 10, 11, 13.
9 Medical Reception Patients #3 & 4.
10 Opt-out testing means that testing will be performed unless the patient refuses the test. Opt-in testing means that the
patient is offered testing and is performed only upon patient consent.
11 Administrative Directive 04.03.11 Section5 II. F. 5. d.
12
Centers for Disease Control and Prevention. HIV Testing Implementation Guidance for Correctional Settings. 2009: p. 8.
7
8

cdc-hiv-correctional
-settings-guidelines.p
13
14

Administrative Directive 04.03.101, Section II. G. 2. a.
Medical Reception Patients #12, 13 & 14.

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volume, high-risk area of health care delivery in the correctional setting and should be regularly
reviewed as part of the CQI program.15
We found errors in tuberculosis screening, and the intake physical examinations are not timely
or sufficiently thorough to ensure continuity of care. The procedural direction to obtain consent
or HIV testing in IDOC Administrative Directive 04.03.11 conflicts with the policy of opt-out HIV
testing and needs to be corrected.

Nursing Sick Call
Methodology: Nursing sick call was evaluated by:
• Reviewing Menard Institutional Directive 04.03.103 Offender Health Care Services, Health
Services Policy and Procedure-Health Care Screening (Sick Call), and IDOC Treatment
Protocols.
• Interviewing nursing and supervisory staff.
• Observing the boxes in each building where inmates put their health care requests.
• Inspecting the rooms used for sick call in each of the buildings, except MSU.
• Reviewing tracking logs, which were used to select records for chart review.
• Reviewing documentation of 15 sick call encounters. These were selected from Sick Call
Logs from February 25, 2018 through May 9, 2018, with complaints of potentially serious
conditions (chest pain, acute infection, shortness of breath, seizures etc.) and their charts
reviewed.
• Reviewing the triage of 16 sick call requests that were picked up Thursday morning May
24, 2018 from the sick call box in North 1.
First Court Expert Findings
The previous Court Expert described the sick call system as one that relies on the inmate to
submit a written request. These requests are picked up each morning and triaged by nursing
staff. Each inmate was scheduled to be seen either that day if the problem was urgent or within
the next 24 to 72 hours if the problem was routine. Inmates were seen by either LPNs or RNs who
had been trained initially by a physician. Each month the charting of nursing sick call was
reviewed by the facility Medical Director and the results discussed with individual nurses. The
chart review results were also reported in the monthly CQI meeting. Most of the rooms used to
conduct nursing sick call were inadequate, lacking privacy and appropriate equipment. Notable
exceptions were North 2 and the renovations in East Cell House. The medical record was available
to nursing staff conducting sick call, but the original requests were discarded after the sick call
encounter had taken place. Chart review indicated that there were omissions in data collected
during the assessment (incomplete vital signs, failure to indicate duration of the complaint, not
documenting the precise location of injury).16
Current Findings
15
16

National Commission on Correctional Health Care. 2014. Standards for Health Services in Prisons pp. 13-14.
Lippert Report Menard pp. 10-11.

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Our review found that some of the problems with sick call described in the previous Court
Expert’s report have been resolved. Most notably, the rooms used by nursing staff to conduct
sick call are uniformly equipped with accurate weight scales, an otoscope, blood pressure cuff
and stethoscope, peak flow monitor, pulse oximeter, and exam table with paper. Most have sinks
to wash hands and those that do not had hand sanitizer available (in two rooms the hand sanitizer
was empty). Each exam room had a flyer mounted on the wall reminding nurses to change paper
between patients. Wall mounted oto-ophthalmoscopes did not work in most rooms but there
were hand-held ophthalmoscopes in all the rooms. Many of the rooms have a plexiglass door
which ensures auditory privacy during the sick call encounter.
Sick call requests may be written on any piece of paper and put into the designated sick call boxes
in each building. Inmates may also give their request directly to nursing staff whenever they are
on the gallery. The nurse then triages each request and determines whether the inmate needs
to be seen at all, and if so, whether they should be seen that day because it is a problem of urgent
nature or should be scheduled and seen the following day. Documentation of timeliness in
responding to sick call requests was evident from review of the sick call logs. Of 15 medical sick
call requests, all were triaged within 24 hours and all were seen within 48 hours of receipt. Eight
urgent requests were seen the same day the request was received.17 We also interviewed several
inmates in the North and South buildings about access to care. They consistently reported that
they were seen for sick call within two days after putting in a written request and saw a provider
in about a week, if referred by the nurse. The Health Care Unit studied timeliness in responding
to sick call requests, which demonstrated compliance with the Administrative Directive in 2016.
There have been no more recent studies of timeliness in responding to sick call requests.
Timeliness of nursing sick call should be monitored at least annually.18
We interviewed an LPN who had picked up 16 sick call requests from inmates in the North 1
building Thursday morning May 24, 2018. Of these, 15 were requests to refill keep-on-person
(KOP) medications. There was one request for attention to a problem of blood in the urine with
clots. The nurse was not familiar with the inmate and had not reviewed the inmate’s medical file.
The nurse’s triage decision was that the complaint was not urgent, and he would be scheduled
to be seen the next day. We disagree with the nurse’s triage decision and would have seen the
inmate that day.
IDOC Nursing Treatment Protocols guide the nurse’s assessment of inmates’ sick call complaints.
Nurses appropriately assessed and examined the inmate in 12 of 15 sick call encounters reviewed
(80%).19 In one encounter, the nurse did not follow up on an inmate’s elevated blood pressure
and did not complete an opiate withdrawal screening (COWS).20 In another encounter, the
inmate complained of diverticulitis and gave a recent history of treatment for this disease. The
nurse did not use the nursing treatment protocol for abdominal pain, choosing instead to use the

Sick Call Patients #1-8.
National Commission on Correctional Health Care. 2014. Standards for Health Services in Prisons. P. 14.
19 Sick Call Patients #3, 6-11, 13-15.
20 Sick Call Patient #12.
17
18

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one for non-specific complaints.21 In another encounter, there is no nursing assessment of the
patient’s urgent complaint, but only an outbound note that he was sent to the ED.22
LPNs are assigned to perform triage and sick call approximately half of the time.23 Sick call is
conducted in the housing unit and thus each sick call nurse acts independently and autonomously
from any other health care staff. This assignment is outside the Illinois scope of practice for LPNs.
LPNs are to practice “under the guidance of a registered professional nurse, or an advanced
practice registered nurse, or as directed by a physician assistant, physician…to include conducting
a focused nursing assessment and contributing to the ongoing assessment of the patient
performed by the registered professional nurse.” 24 The Illinois nurse practice act does not permit
LPN’s to perform assessments independent of a registered professional nurse or higher level
professional, as is currently being done at MCC. Neither does the scope of practice permit LPNs
to perform independent assessments according to protocols. We agree with the First Court
Expert’s finding that LPNs do not have the educational preparation or scope of practice to
examine patients, make an assessment, and formulate a treatment plan.25 Thus, some patients
at MCC do not receive evaluations by health care staff licensed to perform independent
assessments. This increases the risk of harm to patients.
Nursing sick call documentation is monitored by the facility Medical Director monthly. The results
of these reviews are documented in the CQI minutes. The April 2018 CQI minutes include a table
with results of these chart reviews for 11 months. This internal review appears to monitor
important aspects of nursing sick call (complete vital signs taken, documentation of subjective
complaint, observation of signs and symptoms, appropriateness and thoroughness of the
assessment, appropriateness of referral, etc.). The results suggest that issues are seldom
identified, especially the observation of signs and symptoms or appropriateness and
thoroughness of the assessment. These findings differ from our chart review and suggest that
the internal review is not objective or self-critical. This is an audit function that would be more
appropriately done by expert clinical nurses employed by IDOC.
Two nurses, responsible for completing nursing sick call in the housing units, were interviewed.
Neither reported having the patient’s medical record with them when seeing patients. One said
that it would be too cumbersome to carry the records to the nursing sick call room. However,
there were several examples among the charts reviewed where the patient’s previous medical
history was relevant to the current sick call complaint.26 The IDOC Nursing Treatment Protocols
state that “sick call evaluation using these protocols should be performed with a medical
record.”27 MCC’s Health Services Policy and Procedure also states that the patient’s medical
record will be pulled the day prior and taken to medical area in the unit to document the findings
Sick Call Patient #3.
Sick Call Patient #4.
23 Scheduled nursing assignments 4/16/2018 – 4/28/2018.
24 Illinois LPN Scope of Practice. Section 55-30.
25 Lippert Report Menard p. 43.
26 Sick Call Patients #3, 4, 8, 12, 13.
27 IDOC Nursing Treatment Protocols p. 6; emphasis added.
21
22

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and treatment provided during the sick call encounter.28 Practices at MCC do not comply with
IDOC guidelines or their own policy and procedure for sick call. We discussed with the HCUA
various ways it would be possible for nurses to have the record when seeing the patient.
An improvement since the First Court Appointed Expert’s report is that the sick call request
written by the inmate is filed chronologically in the Miscellaneous section of the Medical Record.
Apparently other HCUAs have complained about this practice but the HCUA at MCC has persisted.
The previous Court Expert recommended that the inmate’s written request be filed in the health
care record and we agree. The practice at MCC should be adopted at all the IDOC facility health
care units.
Inmates who were referred from nurse sick call were not seen timely by providers. Referrals to
providers were appropriately generated for each of the 15 sick call encounters reviewed, but only
three were seen within 48 hours.29 One patient was referred after being seen for smoke
inhalation; he was not seen by a provider for 11 days.30 Another was seen by the nurse for
epigastric pain. The provider was called and ordered medication and follow up in the chronic care
clinic. His next chronic care appointment was five months in the future.31 Another patient was
seen by a nurse after having a seizure. The nurse practitioner was contacted and directed that
the patient be seen the next day. The expected appointment did not take place and was never
re-scheduled.32 One patient complained of a possible ankle fracture. The nurse contacted a
provider by telephone, who ordered x-rays of the ankle, a splint, and a lay-in. The patient had a
severe sprain and was not seen by a provider for two weeks.33 Patients such as these are at risk
of deterioration when medical attention is untimely, and the result can cause harm.
In summary, some of the problems with sick call identified in the previous Court Expert’s reports
have been corrected. Problems with sick call currently include:
• LPNs are assigned responsibility to perform sick call, which is outside the scope of practice
in Illinois.
• Nursing assessments and examinations are inadequate.
• Nurses do not use the patient’s medical record during the sick call encounter.
• Patients referred to providers from sick call are not seen timely.

Chronic Disease Management
Methodology: The HCUA was interviewed about the chronic care scheduling processes. The
current chronic care schedule, the chronic care patient lists, and the chronic illness medication
lists were reviewed. The telemedicine nurse manager, the Wexford hepatitis C physician
coordinator, and the UIC Telehealth (HIV and hepatitis) lead physician were interviewed. A
V3-9 Health Care Screening (Sick Call).
Sick Call Patients #5, 13, 14.
30 Sick Call Patient #2.
31 Sick Call Patient #3.
32 Sick Call Patient #6.
33 Sick Call Patient #7.
28
29

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chronic care provider was briefly interviewed. The records of 17 patients with chronic care
illnesses were reviewed. The Office of Health Services Chronic Illness Treatment Guidelines dated
March 2016 and the IDOC Hepatitis C Guidelines December 2015 and 2017 were reviewed as
needed.
First Court Expert Findings
The First Court Expert noted that there wasn’t a scheduling backlog of chronic care patients.
Combination clinics had been started in which all conditions can be addressed at the same visit.
One of the two current providers assigned to the chronic care clinics was providing a high quality
of care although overall care was not good. The report stated that the providers were not
consistently assessing the degree of control accurately. Thirty-four percent of the 66 patients in
the hypertension clinic who were not in good control had no change in their plan of care. Only
59% of 70 patients in less than adequate diabetes control had a change in their plan of care.
Regardless of the type of insulin patients used as civilians they were all changed to NPH and
regular insulin upon arriving at Menard which was described as inappropriate. Three of four
patients on anticoagulation had therapeutic anticoagulation levels. Even though 15% of patients
in pulmonary clinic had persistent symptoms, all were noted to be in good control which is
contradictory as persistent symptoms is inconsistent with good asthma control. Five records of
patients in asthma clinic had a degree of control that was overestimated or medications were
not adjusted appropriately. Of six patients in seizure clinic who reported seizures since the last
clinic only two had a change in therapy. There were delays in care of four of six seizure cases
reviewed. Four of eight patients on latent tuberculosis treatment had converted their
tuberculosis skin test while at Menard.34 The HCUA presumed that this was a result of inaccurate
tuberculosis skin testing and not conversions. This is inappropriate infection control. It was also
noted that MCC was using a database that could be used to generate a variety of reports.
Current Findings
We had similar findings to the First Court Expert’s findings. However, we identified current and
additional findings as follows:
• Patients assigned to chronic care clinics are regularly seen in these clinics.
• MCC continues to utilize combination chronic care clinics, which allows some but not all
chronic illnesses to be managed in a single clinic session.
• Problem lists occasionally are incomplete or inaccurate.
• Some providers’ chronic care notes were illegible or partially legible; these difficult-tointerpret notes created barriers to the delivery of continuous, comprehensive care.
• Providers at MCC inconsistently document the rationale for clinical decisions and
diagnoses in the chronic care progress notes.
• The MCC chronic care providers and nurses do not have access to current, comprehensive
electronic medical references, such as UpToDate, in all clinical exam rooms. A few

This implies that the patients acquired the disease while at Menard and that there was someone at Menard with active
tuberculosis or that the skin tests were inappropriately done. While it may be true that the skin tests were inappropriately
done, an tuberculosis outbreak investigation should have been done.

34

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•
•
•

•
•

•

•

•
•
•
•
•

administrative offices distant from the chronic care clinical locations have access to the
internet.
Uncontrolled chronic illnesses with problems that appear to be beyond the expertise of
the MCC providers are not referred for specialty consultation.
There was no documentation that the providers reviewed the MARs at the time of chronic
care visits for important data about medication compliance and capillary blood glucoses
(CBG).
A hospitalized patient returned with a prescription for a direct factor Xa inhibitor anticoagulation medication; the MCC providers immediately stopped this medication and
started warfarin. MCC providers were unable to obtain therapeutic anticoagulation in
patients we reviewed. This places patients at risk of harm. Newer direct factor Xa inhibitor
drugs should be used.
The practice of treating diabetics on 70/30 insulin (70% long acting and 30% short acting
insulin) concomitantly with a sliding scale administration of another short acting insulin
puts patients at risk for hypoglycemia.
The MAR is still completed manually by the nursing staff. Blank months for KOP
medication delivery were noted on some patients’ MARs. The lack of accuracy of the
MARs is a barrier to verifying a patient’s compliance with medications and determining
the efficacy of the treatment.
MCC did not screen patients over 50 years of age or individuals with certain high risk
clinical conditions for colon cancer as is recommended by all national guidelines. Not one
of the 14 MCC patients 50 years of age or older whose records were reviewed had been
screened for colon cancer.
MCC did not calculate 10-year cardiovascular risks for adult patients as directed by the
ACC/AHA and IDOC treatment guidelines. Patients with high risk for cardiovascular events
were not administered the statin medications and dosages recommended by IDOC
Treatment Guidelines and by the American College of Cardiology.
MCC did not administer age-based and disease-based pneumococcal 13 and 23 and
meningococcal adult preventive vaccinations as recommended by the CDC.
Two (14.3%) of 14 at-risk patients had received pneumococcal 23 vaccination, zero (0%)
of the eight at-risk patients had received pneumococcal 13 vaccination, and zero (0%) of
the two patients had been administered meningococcal vaccination.
None (0%) of the five diabetic charts reviewed had documentation that optometry
screening for diabetic retinopathy had been performed within the previous year.
The process to determine eligibility for hepatitis C treatment is excessively lengthy and a
barrier to the initiation of treatment. It is not consistent with processes in other
correctional facilities and public health systems.
Only 1 (0.7%) of the 134 patients at MCC with hepatitis C has been treated.

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MCC has 1,037 individual patients, or 34% of the prison’s population, enrolled in chronic care
clinics.35 Forty-one percent of patients at MCC are seen in chronic illness clinics for a single
disease. However, wherever possible, multiple chronic illnesses are combined into a single
session at the next available chronic care clinic. The MCC Clinic Count report dated May 21, 2018,
indicated that 59% of patients with chronic diseases have at least some of their visits in
combination clinics. The chronic conditions of a number of patients continue to be managed in
single disease chronic care sessions. As discussed in other reports, we find single disease chronic
clinic visits inefficient, wasteful, and potentially harmful. This is also consistent with the opinion
of the First Court Expert. Patients are seen based on an inflexible schedule as opposed to the
degree of control of their illness and do not have their various diseases coordinated into a unified
therapeutic plan.
During the week of the experts’ visit, the MCC census was 3,036, including 440 patients housed
in the nearby Medium Security Unit. The May 2018 Chronic Care roster was as follows:
Chronic Care Clinic
Asthma
Cardiac/Hypertension
Diabetes
General Medicine
Hepatitis C
High Risk/HIV
Seizure
Total non-unique patients

Patients
275
431
136
403
134
22
68
1,333

Prevalence in ADC (3,036)
9.1%
14.3%
4.5%
13.3%
4.4%
0.7%
2.2%

During the time of the First Court Expert’s visit, the chronic care clinics were primarily conducted
in the exam rooms on the first floor of the health care building. With the creation of airconditioned satellite clinics in all of the cell houses, all of the chronic care clinics have been
relocated to the cell houses. The only exception are three telehealth specialty clinics: UIC
High/Risk, UIC Liver Clinic, and Renal Clinic that continue to be held in the telemedicine exam
room on the first floor of the health care building. Chronic care patients in the satellite clinics are
seen intermixed with provider sick call and walk-in patients.
Two nurse practitioners and two providers (one is part-time) staff chronic care clinics. The charts
of chronic care patients indicate that patients with chronic illnesses are seen regularly at MCC.
None of the clinical areas at MCC have access to electronic medical references, although it was
reported that a few of the administrative offices in the distant health care building have internet
access. When one provider was asked which current electronic medical references he could
access, he could not list a single online medical reference that he utilized. This partially explains

35

MCC’s chronic care clinic schedule was listed as follows: asthma (January and July), seizure (February and August), cardiac 1
(A-L) (March and September), cardiac 2 (M-Z) ( April and October), diabetes/combo (April, August, and December), general
medicine (May and November), and hepatitis C (June and December).

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some of the clinical decisions and medications prescribed that were not in accord with current
national and community standards of care.
The chronic care nurse maintains spread sheets on patients being followed in each of the chronic
care clinics, listing the last clinic date and the most recent laboratory test date. The spread sheets
also rate the clinic status of each condition as good, fair, poor, and stable. This method of rating
degree of control is very limited; it would be more useful if objective criteria were used.
Onsite specialty consultation is limited. Optometry examinations are provided in the health care
building for 20 hours per week. UIC HIV infection, UIC liver (hepatitis B and C), and renal
consultation and management are provided to MCC patients via the telehealth program. All other
specialty consultations are provided at outside private practices and medical centers in southern
Illinois and a few in St. Louis, Missouri.
A dedicated nurse manager is assigned to assist and coordinate the telehealth clinics. This nurse
is present in the exam rooms during all the UIC High Risk/HIV clinic, UIC telemedicine liver clinic,
and the renal telehealth clinic appointments. She coordinates the appointments for these three
specialty clinics, manages the completion of hepatitis C pre-treatment database, and tracks the
clinical status and lab results of the referrals to UIC liver clinic. This telehealth nurse manager
maintains clinically useful spread sheets on patients being followed in the High Risk/HIV clinic
that tracks the status of the preliminary workup and approval process for hepatitis C patients.
We examined care of hepatitis C patients at MCC. Patients with hepatitis C are followed in a
hepatitis C chronic clinic. When a patient tests positive for hepatitis C, they are followed by facility
providers and tested every six months for an APRI level.36 When treatment of hepatitis C is
deferred and when there is active virus present, there is a risk of ongoing harm to the patient
and ongoing monitoring of liver disease is recommended.37 Yet, except for continuing to obtain
an APRI level, providers in hepatitis C clinic do not monitor for cirrhosis or its complications or
other possible complications of hepatitis C infection. When patients develop cirrhosis, it is
recommended that they receive a baseline EGD to screen for varices and every-six-month
ultrasound or CT scan screening to evaluate for hepatocellular cirrhosis. This is seldom done,
even when patients have significantly elevated APRI levels. We note that in four death reviews
of patients at various facilities who died of complications of hepatitis C, the patients were not
monitored with EGD, ultrasound or for their ascites.38 One example at MCC was a patient who
had APRI levels indicative of cirrhosis as early as 2012, but the patient failed to receive endoscopy
until August of 2015.39 The patient did not have screening for hepatocellular carcinoma until May
of 2015. At that time, a liver mass was found on a CT scan but was not timely worked up. Edema
36 An APRI test is the AST to Platelet Ratio Index. The AST is a liver enzyme and platelets are a blood element that are decreased
in advanced liver disease. The ratio between the AST and platelets yield a number that correlates with the degree of liver
fibrosis. When the APRI reaches > 0.7 there is a greater than 70% chance that there is significant fibrosis.
37 HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C; Last Updated May 24, 2018, American
Association for the Study of Liver Diseases and Infectious Diseases Society of America as found at
https://www.hcvguidelines.org/sites/default/files/full-guidance-pdf/HCVGuidance_May_24_2018a.pdf.
38 Patients #6, 12, 23, and 28 in Mortality Reviews.
39 Patient #23 Mortality Reviews.

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and ascites are complications of cirrhosis. The patient had edema as early as 2012 and ascites
was noted on the CT scan in May of 2015, yet the patient was not treated with a diuretic until he
had massive ascites over a year later, in June of 2016. The patient ultimately died of complications
of his cirrhosis (hepatocellular carcinoma) without ever having a diagnosis of the liver mass
known for over a year and without being appropriately treated for the complications of his
cirrhosis. It does not appear that physicians knew how to monitor for ongoing liver disease and
the hepatitis C clinic does not include monitoring for ongoing liver damage. The purpose of this
clinic appears to be to monitor the APRI until the provider refers the patient for treatment. This
is inconsistent with IDOC hepatitis C guidelines and places patients at risk of harm, and has
resulted in preventable or possibly preventable deaths.
The IDOC hepatitis C guideline states that workup of all hepatitis C positive patients, including
the decision to refer to the UIC Liver Telemedicine Clinic, will be the sole responsibility of the
IDOC providers at each individual IDOC facility.40 This does not occur, as Wexford has inserted
an additional utilization barrier into this process. When the APRI is elevated above 1.0 or above
0.7 with low platelet counts or albumin, facility physicians are to refer patients to a Wexford
corporate internist who makes the decision on whether to refer the patient to UIC.
After the facility physician refers the patient to the Wexford corporate hepatitis C internist, a preapproval packet is also forwarded to the Wexford corporate internist, who reviews the database
and orders pre-treatment tests. This Wexford corporate hepatitis C internist must approve all
requests for diagnostic workups including EGD, ultrasound, fibroscan, additional lab tests, and
the referral to the UIC Telemedicine Liver Clinic.41 This physician stated that she only is involved
with patients who are referred to her for approval to start the process for hepatitis C treatment;
she does not track or receive any data on patients at MCC with hepatitis C who have not been
referred to her office.
Based on mortality records and on case reviews we performed, it appears that referral to the
Wexford corporate hepatitis C internist is significantly delayed. Because these referrals are not
tracked through the normal utilization process and because facility providers do not always
document when they are referring to the Wexford corporate hepatitis C internist, it is not clear
when patients are referred based on the medical record. Because the Wexford corporate
hepatitis C internist does not write notes to the medical record, it is also unclear what her
therapeutic plan is for the patient. At MCC, a chronic care nurse maintains a spreadsheet tracking
patients who have hepatitis C, including those with referrals to the Wexford corporate hepatitis
C internist. Review of three hepatitis C referrals indicated that once the referral was received by
the Wexford corporate hepatitis C internist, the required diagnostic testing was quickly
approved. The Wexford corporate hepatitis C internist did state that she was aware that the
current IDOC policy does not prioritize patients co-infected with hepatitis C and HIV for expedited
treatment. She also stated that she was aware that co-infected patients in the community who
Hepatitis C Guidelines, December 2017.
The Wexford corporate hepatitis C internist does not have to go through the Wexford collegial process to obtain approval but
is authorized to approve these tests directly.

40

41

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have F2 fibroscans are advanced to treatment as opposed to IDOC’s practice of treating only
those with F3 and F4.
In April 2018, 134 men were on the Hepatitis Report maintained by the chronic care nurse. Only
one (0.7%) had completed hepatitis C treatment. This is consistent with statewide data that
shows that approximately 2.9 patients are treated per facility per year.42 Another 12 (9.0%) were
in the process of being worked up. Even though IDOC guidelines43 mandate testing of HCV viral
load on all patients, 17 (12%) of the 134 hepatitis C patients have not yet had their HCV RNA viral
load tested. 87.3% of the hepatitis C patients have not yet had a fibroscan performed, even
though the IDOC Hepatitis C Guidelines mandate that all patients have fibroscans done as part of
their initial evaluation. IDOC restricts HCV treatment to patients with APRI score greater than or
equal to 1.0 or with APRI scores between 0.7 and 0.99 with additional abnormal labs and high
risk conditions, or advanced liver disease. This threshold limits the number of patients who are
eligible for treatment. The process of accessing UIC also has considerable barriers. These barriers
limit the numbers of patients treated and cause unnecessary delays in treatment that harm
patients.
MCC Hepatitis C Report April 2018
Category
Total Hepatitis C Patients
Total HCV Patients with HIV infection
Total HCV Patients currently on treatment
Total Completed HCV treatment
Total with HCV RNA viral load
Total without HCV RNA viral load
Total with a Fibroscan
Total without a Fibroscan
Total with APRI ≥ 1.0
Total with APRI ≥1.0 in workup
Total APRI ≥1.0 with Fibroscans
Total with APRI ≥0.7 and ≤1.0
Total with APRI ≥0.7 and ≤1.0 in workup
Total APRI ≥0.7 and ≤1.0 with Fibroscans
Total in Workup

Number
% of MCC Population
134
4.4%
0
0%
0
0%
1
0.7%
117
87.3%
17
12.7%
24
17.9%
110
82.1%
10
7.5%
7
70% 3 release dates ≤ 12 mos.
5
50%
16
11.9%
3 19% 1 F3 with release date ≤ 12 mos.
8
50%
10
7.5%

A patient with new onset atrial fibrillation was started on a direct factor Xa inhibitor
anticoagulant by the hospital. The MCC providers immediately changed the anticoagulant
medication to warfarin, medication that requires frequent testing and dose modification. There
was no justification written in the provider note about this change. Over the next 150 days, 92%
of the patient’s anticoagulation tests (INR) were either above or below the therapeutic range,
42

Data we received from UIC is that for the three years 2015 through 2017 inclusive, 227 patients were treated for hepatitis C.
This is approximately 2.9 patients per facility per year.
43 Hepatitis C Guidelines December 2017.

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resulting in nine dosage adjustments. At the time of the Experts’ site visit, five patients were
taking direct factor Xa inhibitors and 12 were prescribed warfarin. It was reported that direct
factor Xa inhibitors are non-formulary and require a collegial approval. It is in the best interest of
the patient and the institution that the preferred choice of oral anticoagulation be a medication
in the direct factor Xa inhibitor class, especially in light of the inability of MCC providers to obtain
therapeutic anticoagulation levels.
The clinical care provided to a number of patients at MCC with chronic illnesses had deficiencies
and were not in accord with national standards of care. The providers did not consistently
document the rationale for the selection of medications, changes in the dosages, and types of
medications. The MCC provider progress notes are occasionally illegible; these difficult-tointerpret notes complicate the facility’s ability to provide safe and quality care to its patient
population. There was no documentation in any of the charts audited that the providers had
reviewed the MAR for compliance of the prescribed medications or for the results of capillary
blood glucose testing; clinical decisions were made without this important clinical data. In the
charts of the five diabetics we reviewed, not a single one of these five patients have been
screened by the facility’s optometrist on an annual basis as mandated by the IDOC’s diabetes
treatment guidelines. This is the only one of the five IDOC facilities visited by the experts that
was not meeting this IDOC diabetic retinopathy screening guidelines.
The primary and secondary prevention of arteriosclerotic cardiovascular disease (ASCVD)
provided was not in alignment with current national and IDOC standards. The providers did not
even once calculate patients’ 10-year ASCVD risk score, which would have assisted them in
determining the proper preventive medication and dosage. Patients were prescribed low
intensity HMG-CoA reductase medications (statins) when high-intensity statins at higher dosages
were indicated. Non-statin anti-hyperlipidemia (niacin, gemfibrozil) were prescribed without any
documented clinical justification; these categories of medication have limited impact on the
prevention or progression of cardiovascular disease. The providers concomitantly order 70/30
insulin and sliding scale short acting insulin before meals. The simultaneous use of these two
types of short acting insulin puts diabetic patients at risk for hypoglycemic attacks. Fifty years of
age and older patients are not regularly screened for colon cancer, putting patients at risk for the
development of preventable cancer and delayed identification of potentially treatable colon
cancer. Not one (0%) of 14 patients 50 years and older had been screened for colon cancer. The
providers do not adhere to the CDC’s recommendations for the vaccination of adults. MCC
providers do not order pneumococcal 13 vaccinations for patients 65 years of age or older and
immunocompromised individuals, or meningococcal vaccinations for HIV patients; or
consistently order pneumococcal 23 vaccination for patients with chronic illnesses, patients 65
years of age or older, and those with immunocompromised conditions.
Many of the records of patients with chronic illnesses were found to have concerns about the
clinical care provided. The following patient summaries highlight the concerns and the findings
noted above.

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44
45

•

This patient is 73-year-old male whose diagnoses included hypertension, dyslipidemia,
hepatitis C, and schizophrenia. 44 Due to the system’s failure to order a HCV RNA viral load,
which was found to be negative in 2018, he was erroneously diagnosed with ongoing
hepatitis C infection for many years, resulting in multiple unnecessary lab tests and
provider visits. His hypertension was adequately controlled but he inexplicably was not
seen in the hypertension chronic care clinic for an 11 month period from September 2016
until August 2017. Based on his medication, it is likely that this patient was being treated
for coronary artery disease and angina. He has had four episodes of chest pain in the last
four months and he was prescribed nitroglycerin tabs. However, there was not a single
mention of the etiology of his chest pain in the medical chart nor is angina listed on the
patient’s problem list. The progress notes about the chest pain were brief and did not
adequately assess the clinical characteristics of the chest pain. His 10-year ASCVD risk
score was not calculated by the MCC providers. (The score was determined to be an
extremely high 21%). The providers have failed to prescribe a high-intensity statin as
clearly indicated by his extremely high cardiac risk score and the presumptive diagnosis
of angina. This patient is not receiving the same standard of care as would be received in
the community. This 73-year-old has not been screened for colon cancer and has not been
offered or administered nationally recommended adult immunizations (pneumococcal 13
and 23 vaccines). The failure of the providers to follow national preventive, treatment,
and screening standards puts the health of this patient at risk.

•

This 23-year-old with a history of seizure disorder had not initially provided IDOC
providers with a complete history of his medical problems.45 Once the patient told the
MCC providers that he had previously taken anti-epileptic medications, even though he
had not had a seizure in six to eight months; his seizure medications were restarted.
Although drug levels were in the therapeutic range, the patient reported at the 2/3/18
chronic care visit that he was having one to two unverified seizures per month. This
patient’s history was complicated; additional past clinical history and treatment was
needed to assure that this patient needs to be taking seizure medications and that the
currently prescribed medication is appropriate. The MCC provider did not document that
clinical records of the patient’s care in the community were requested. The provider did
not request consultation with a neurologist. The MARs document that the patient is
taking only 30-50% of his seizure medication; yet the provider did not comment on this
lack of compliance and likely did not even review this important clinical information
during the chronic care clinic visits, nor comment on the presence of therapeutic
carbamazepine drug levels in a non-compliant patient. The failure to monitor this
patient’s compliance with medication and seek neurology consultation jeopardizes the
health of this complex individual.

Chronic Care Patient #1.
Chronic Care Patient #2.

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•

This patient is a 52-year-old male with a history of HIV infection, seizure disorder, and
intravenous drug use.46 HIs problem list also noted hypertension, but he was not on antihypertensive medications and his blood pressures were within acceptable range. MCC
consulted with a neurologist when the patient’s seizures were uncontrolled. The reports
from two return visits to the neurologist in 2017 were not in the medical record. The latest
visit to the clinic suggested the seizures were not fully controlled. The provider should
have, but did not, order immediate drug levels of the anti-seizure medications. The
patient’s HIV was moderately well controlled; however, he has not been administered the
nationally recommended pneumococcal 13 and 23, and meningococcal vaccinations. This
50-year-old patient has not been screened for colon cancer; this is not in accord with
national standards of care. This patient has had lacunar infarcts of his brain, a sign of
arteriosclerotic cerebrovascular disease. He should have been prescribed a high-intensity
statin.

•

This 69-year-old male with hypertension also had a Left Bundle Branch Block (LBBB) that
was not noted on his problem list.47 He had a number of biannual physicals but has never
been screened for colon cancer, had never had his 10-year ASCVD risk calculated (it was
extremely high 21.6%), and he had never been administered pneumococcal vaccinations.
In spite of his elevated cardiac risk and LBBB, he has not been started on a high-intensity
statin. This patient has not received a level of care that approaches that available in the
community.

•

This patient is a 43-year-old male with diabetes type II, hypertension, hyperlipidemia, and
asthma.48 He has been seen regularly in a combined chronic care clinic. His diabetes was
not optimally controlled but the providers have appropriately initiated and increased the
dosage of an additional medication (glipizide). There was no documentation that the
patient’s feet had been examined for sensory neuropathy. This diabetic patient has been
housed at MCC for six months and has not yet been seen by an optometrist. This is an
unacceptable delay for a patient at risk for diabetic retinopathy. Although recommended
by the IDOC Treatment Guidelines, the providers did not calculate this patient’s 10-year
ASCVD risk score (it was determined to be 12.6 %). As recommended for diabetics with a
high 10-year risk of a cardiovascular event, this patient should have been started on a
high-intensity statin. The patient has not been administered the pneumococcal 23
vaccine, which is nationally recommended for all diabetics and asthmatics.

•

This 33-year-old asthmatic who failed to tell IDOC that he had asthma was appropriately
treated until he presented with an acute asthma attack.49 The type of nebulization
administered (two drugs) is generally used for COPD patients. A short burst course of
prednisone and an inhaled corticosteroid inhaler in addition to albuterol should have
been provided to this patient, who was at heightened risk for another exacerbation in the

Chronic Care Patient #3.
Chronic Care Patient #4.
48 Chronic Care Patient #5.
49 Chronic Care Patient #6.
46
47

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near future. Montelukast is not recommended to be used in a patient whose asthma is
not stabilized. The patient was not administered the pneumococcal 23 vaccine that is
nationally recommended for all asthmatics.
•

This 43-year-old patient had diabetes type II and two gunshot wounds (GSW).50 The GSWs
were not noted on his problem list. He had a HbA1C of 6.8% in June of 2015. Patients with
HbA1C ≥6.5% are diagnosed as having diabetes. The providers failed to acknowledge this
abnormal test and did not counsel the patient about lifestyle changes that might impact
on the progression of diabetes, and did not initiate medication to address this newly
diagnosed type II diabetes. Two year later, the HbA1C was repeated, again was found to
elevated, and a diabetic oral agent was prescribed. The two-year delay was unacceptable
and put the patient at risk for diabetic morbidity. The patient had an optometry visit on
6/15/17, but funduscopic exam of the retina for signs of diabetic retinopathy was not
performed. National adult immunization guidelines recommend that all diabetics receive
a pneumococcal 23 vaccine; this has not been done. The patient’s 10-year ASCVD risk
score should have been assessed, but it was not calculated. The 2018 MARs revealed that
the patient was taking only one half of his KOP diabetic medication. The misunderstanding
or non-compliance with this prescribed diabetic medication should have been noted in
the February and April 2018 diabetes clinic. The chronic care providers are not routinely
reviewing the MARs.

•

This patient is a 48-year-old with diabetes and hypertension.51 Diabetic medications were
incrementally increased until an acceptable level of control was reached. However, there
was a period of nine months (3/23/17 to 12/21/17) when his HbA1C’s were 9.2% and
8.3% before the indicated increase in medications was ordered. Control would have been
reached more quickly if medication adjustment had been made more expeditiously.
Diabetics are to be screened annually for the diabetic retinopathy; inexplicably, this
diabetic has not been screened for the last four years. In February 2018, the MAR
indicated that the patient had not received his KOP diabetic and hypertensive
medications; however, there was no comment on this potential lack of compliance or
failure to deliver his medications in the progress notes. The failure to review this
important clinical information in the MAR put the patient’s health at risk. The MCC
providers are not following national recommendations to administer a second
pneumococcal 23 vaccine five years after the first vaccination.52 The providers are not
adhering to IDOC treatment guidelines and national recommendations to calculate the
10-year risk of ASCVD for adult patients with diabetes and, if the risk is greater than or
equal to 7.5%, to initiate a high-intensity statin. His risk was determined to be greater
than 20%, yet a high-intensity statin was not prescribed.53 This patient’s health care is not
being properly protected.

Chronic Care Patient #7.
Chronic Care Patient #8.
52 CDC Recommended immunization Schedule for Adults 2018.
53 IDOC Office of Health Services Treatment Guidelines Hyperlipidemia March 2016.
50
51

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•

This patient is a 60-year-old with insulin-requiring diabetes and coronary artery disease
who had only been at MCC for a few weeks.54 The intake HbBA1C of 6.7% suggests that
the patient’s diabetes had been adequately treated prior to his incarceration. The
decision to add additional short acting regular insulin (on a sliding scale) to this patient
who was already receiving short acting insulin 19.5 units before breakfast and 18 units
before dinner (30% of his 70/30 insulin, 65U/am and 60U pm, is short acting regular
insulin) put the patient at increased risk of hypoglycemic episodes. The providers did not
adhere to IDOC treatment guidelines by failing to prescribe a high-intensity statin in this
diabetic with a documented history of coronary artery disease. They also failed to
calculate his 10-year ASCVD risk (determined to be 19.1%), which should have led them
to prescribe a high-intensity statin.55 The providers missed an opportunity to administer
the pneumococcal 23 vaccine to this diabetic as is recommended by both national adult
immunization guidelines56 and by IDOC treatment guidelines.57

•

This patient is a 59-year-old with hypertension, hyperlipidemia, HIV infection, and a
history of tobacco abuse.58 His hypertension was only moderated controlled, but his
medication had been increased. His HIV infection was well controlled; his medications
have been thoughtfully modified. The patient was not given pneumococcal 13 and 23 and
meningococcal immunizations. This is contrary to national guidelines.59 The MCC
providers did not calculate the patient’s 10-year ASCVD risk score (determined to be
14.4%); this is not in accord with IDOC treatment guidelines.60 There was no documented
justification for the use of gemfibrozil; this patient should have been prescribed a highintensity statin. The patient has received four biannual physicals since he was 50 years
old yet he was not offered screening for colon-rectal cancer. National guidelines
recommend that individuals aged 50 to 75 years should be screened for colon cancer.61

•

This patient is a 57-year-old male with a history of coronary artery disease (CAD) with
stent placements, paroxysmal atrial fibrillation on chronic oral anticoagulation,
degenerative joint disease, fatty liver, and tobacco use.62 The placement of coronary
artery stents, fatty liver, and chronic anticoagulation were not noted on the problem list.
Upon return from the hospital where he been prescribed apixaban anticoagulant on
11/6/17, the Graham providers switched the anticoagulation to warfarin 5mg/day. On
11/21/17, the patient was transferred to MCC. His anticoagulation treatment was poorly
controlled on warfarin: 92% of his 13 INRs over the last five months (11/10/17 to 4/23/18)
were non-therapeutic. On nine occasions, the warfarin medication was stopped or the
dose changed. The providers’ notes did not always document the reason for the dosage

Chronic Care patient #9.
IDOC Office of Health Services Treatment Guidelines Hyperlipidemia March 2016.
56 CDC Recommended immunization Schedule for Adults 2018.
57 IDOC Office of Health Services Treatment Guidelines Diabetes March 2016.
58 Chronic Care Patient #10.
59 CDC Recommended immunization Schedule for Adults 2018.
60 IDOC Office of Health Services Treatment Guidelines Hyperlipidemia March 2016.
61 USPSTF Colorectal Cancer Screening June 2016.
62 Chronic Care Patient #11.
54
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adjustments or why/when anticoagulation was temporarily stopped or held. The lack of
comprehensive progress notes made it extremely difficult to track the care that was being
provided to this patient. It is risky to continue to treat this patient with warfarin. It would
be in the best interest of the patient and the institution if he was prescribed a direct factor
Xa inhibitor that does not require frequent testing and dose adjustment, especially since
providers at MCC were unable to obtain therapeutic control. This patient should have
been administered pneumococcal 23 vaccine63 and should have been screened for colon
cancer;64 neither one of these were performed. The provider notes were rarely
adequately informative and were occasionally illegible. This jeopardizes MCC’s ability to
provide continuity of care to this complex patient. There was no rationale in the progress
notes documenting the clinical reason that this patient was receiving fenofibrate. He was
also prescribed a high-intensity statin, but at a dose that is less than recommended for a
patient with arteriosclerotic coronary health disease.65
•

This is a 54-year-old patient with hypertension, diabetes-type II, hyperlipidemia, and an
EKG suggestive of a previous myocardial infarction. 66 His diabetes and hypertension were
adequately controlled. This was the only patient that we reviewed at five IDOC facilities
that was appropriately administered two pneumococcal 23 vaccines. The MCC staff failed
to calculate the patient’s 10-year ASCVD risk score (determined to be 19.6%) or take into
account his past history of a previous inferior wall MI when they prescribed a moderateintensity rather than a high-intensity statin, as was recommended in the IDOC treatment
guidelines.67 The patient was prescribed niacin, presumably as part of the treatment of
his hyperlipidemia, but there was no justification documented in the chart for the usage
of this medication. The patient did not have an eye exam in the last two and a half years;
diabetics are recommended to have annual exams for diabetic retinopathy.68 This over
50-year-old patient was not screened for colorectal cancer.69

•

This patient is a 55-year-old with a complicated to treat and difficult to control seizure
disorder.70 His medications were changed a number of times, with the phenytoin dose
changing from 400mg/day to 500mg/day to 200mg BID, and his levetiracetam starting at
500mg BID and then increasing to 1000mg BID, then back to 500mg BID. His phenytoin
levels were tested nine separate times; five exceeded the therapeutic range, one was
below the therapeutic level, and three were at the recommended levels. Providers had
difficulty in maintaining the phenytoin level in the therapeutic range. Consultation with a
neurologist was clearly needed but was never requested. The provider and chronic care
progress notes did not document or justify the reason for the medication adjustments.
The lack of comprehensive provider notes made it difficult to understand the course of

CDC Recommended immunization Schedule for Adults 2018.
USPSTF Colorectal Cancer Screening June 2016.
65 IDOC Office of Health Services Treatment Guidelines Hyperlipidemia March 2016.
66 Chronic Care Patient #12.
67 IDOC Office of Health Services Treatment Guidelines Hyperlipidemia March 2016.
68 IDOC Office of Health Services Treatment Guidelines Diabetes March 2016.
69 USPSTF Colorectal Cancer Screening June 2016.
70 Chronic Care Patient #13.
63
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care. A new provider would struggle to comprehend the care being provided to this
patient. The MCC providers must request specialty consultation for patients with
conditions that do not readily respond to initial treatment. National standards
recommend that all patients over 50 years of age be screened for colon cancer using a
validated screening methodology,71 but this patient has never been screened. His 10-year
ASCVD risk score has not been calculated by the MCC providers.72
•

This patient is a 65-year-old with diabetes, hypertension, hyperlipidemia, obesity, and
hypothyroidism.73 His problem list did not note obesity and hypothyroidism. This recently
incarcerated (1/28/18 admission) patient’s diabetes and hypertension were moderately
well controlled. To date, the patient was not evaluated for diabetic retinopathy. His statin
was changed from atorvastatin 10mg/d to simvastatin 10mg/d, a low-intensity statin. The
providers, in violation of the IDOC treatment guidelines, failed to calculate his 10-year
ASCVD risk score (determined to be extremely high, 28.4%).74 If they had done this,
perhaps they would have prescribed a high-intensity statin to minimize his risk of stroke
and heart attack. Contrary to national standards, this patient has not been administered
pneumococcal 13 and 23 immunizations.75 The patient has not been screened for
colorectal cancer; this is not in accord with national guidelines that recommend that
screening begin at 50 years of age.76

•

This patient is a 58-year-old with hepatitis C who was unsuccessfully treated with
interferon and ribavirin in 2009-2010.77 Liver biopsy in 2009 revealed extensive periportal fibrosis and moderate bridging (stage 2). On 9/19/16, the hepatitis C clinic deemed
this patient eligible for treatment; 20 months later, treatment had not yet been initiated.
On 3/29/18, a fibroscan was read as F4 (advanced liver scarring, cirrhosis). Eighteen of
the months of delay appear to have been due to internal delays at MCC. At least two
months of the delay were due to the workup that is required by the UIC Hepatitis C clinic,
which includes psychiatric evaluation and EGD. Psychiatric evaluation and EGD are not
recommended evaluations prior to treatment with the newer anti-hepatitis C
medications.78 The HCV RNA viral load was not located in the medical record but was
eventually located on the Hepatitis Report that is maintained by the telemedicine nurse
manager. The lengthy wait to retreat this patient with advanced hepatitis C is
unacceptable and puts the patient’s health at risk. There is no documentation in the

USPSTF Colorectal Cancer Screening June 2016.
ACC/AHA ASCVD Risk Score.
73 Chronic Care Patient #14.
74 IDOC Office of Health Services Treatment Guidelines Hyperlipidemia March 2016.
75 CDC Recommended immunization Schedule for Adults 2018.
76 USPSTF Colorectal Cancer Screening June 2016.
77 Chronic Care Patient #14.
78
Recommended Assessments Prior to Starting Antiviral Therapy as found in HCV Guidance: Recommendations for Testing,
Managing, and Treating Hepatitis C, last updated May 24, 2018: The American Association for the Study of Liver Diseases and
the Infectious Diseases Society of America as found at: https://www.hcvguidelines.org/sites/default/files/full-guidancepdf/HCVGuidance_May_24_2018a.pdf.
71
72

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medical record that this patient was administered the pneumococcal 23 vaccination.79
The patient was over 50 years old but had not been screened for colon cancer.80
•

This patient is a 66-year-old with hepatitis C infection.81 Sixteen months after having been
deemed eligible for hepatitis C treatment, the patient’s workup was still not completed.
Twelve months of this delay was due to the internal processes at MCC. His liver fibroscan
on 2/19/18 was read as F4 (advanced liver scarring, cirrhosis). The UIC Telemedicine Liver
Clinic requested additional labs, EGD, liver ultrasound, and dermatology consultation,
which also contributed to the long processing time. The EGD and liver US was pending
collegial approval by Wexford, although the experts were informed that Wexford’s
Hepatitis C coordinator could directly approve these tests. Most institutions do not
require such extensive pre-treatment diagnostic testing prior to treatment with the
newer anti-hepatitis C medications. The lengthy wait to initiate treatment for hepatitis C
puts this patient’s health at risk. Colon cancer screening was not provided to this patient,
who is over 50 years old.82

•

This patient is a 50-year-old male with hepatitis C.83 Twelve months after having been
deemed eligible for hepatitis C treatment, the patient’s workup was still not completed.
His liver fibroscan on 3/29/18 was reported as F4 (advanced liver scarring, cirrhosis). The
UIC Telemedicine Liver Clinic’s request for a psychiatric consultation has prolonged the
waiting time. Most institutions do not require such extensive pre-treatment diagnostic
testing including psychiatric consultation prior to treatment with the newer anti-hepatitis
C medications. Colon cancer screening has not been performed on this patient, who is
over 50 years old.84

Urgent/Emergent Care
Methodology: We interviewed the Nursing Supervisor (IDOC), toured the medical clinic, and
assessed the availability and functionality of emergency equipment and supplies. We also
reviewed emergency drills, CQI reports, written directives, and medical records. Medical records
were selected from the list provided by MCC of emergency room visits beginning in January 2017.
This list includes the reason for the ED visit. Records selected for review were those conditions
sensitive to ambulatory care, such as seizure, withdrawal, infection, diabetic complications,
abdominal pain, chest pain, etc. These were used to evaluate nursing response to emergencies.
A total of five records were reviewed. We also reviewed records of five patients who were
hospitalized for ambulatory sensitive conditions to assess whether their pre and post hospital
physician care was adequate.
CDC Recommended immunization Schedule for Adults 2018.
USPSTF Colorectal Cancer Screening June 2016.
81 Chronic Care Patient #16.
82 USPSTF Colorectal Cancer Screening June 2016.
83 Chronic Care Patient #17.
84 USPSTF Colorectal Cancer Screening June 2016.
79
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First Court Expert Findings
The records of nine patients were reviewed, and more than half demonstrated significant
deficiencies in patient care. These deficiencies included absence of important information from
the hospital, inadequate assessments by nursing staff, untimely physician follow up, and failure
to monitor or intervene.85
Current Findings
MCC provides basic CPR and first aid. Emergency response bags are kept in the first aid room in
the main clinic, the armory between north and south buildings, and at the medium security unit.
These bags can be transported by responding nursing staff to the site. This equipment and
supplies are used to conduct an initial triage, provide first aid, and CPR. The first aid room, North
II Medical Clinic, and MSU are equipped to provide space and equipment to treat medical
emergencies. The nursing staff must make a clinical decision to transport a patient in a medical
emergency to the first aid room in the main clinic, which has the most extensive emergency
equipment, or to the use an outlying room.
The emergency bags contain first aid supplies, personal protective equipment, stethoscope,
blood pressure cuff, cervical collar, equipment and supplies to start an IV, and a few medications
(i.e., glucagon, an epi pen, aspirin). The contents of the bags are standardized but not sealed. We
checked the contents of several of these bags and found them to be adequately supplied. We
discussed with the nursing supervisor who accompanied us the advantages of using plastic
numbered locks to indicate a bag that was fully stocked and ready for use. The first aid room has,
in addition to the emergency bags, two transport chairs, an automatic external defibrillator
(AED), crash cart, stretcher with backboard, portable ambu-bag, portable oxygen, EKG machine,
suction, nebulizer, and oto-ophthalmoscopes. A mobile crash cart with AED is also available in
the infirmary and in the MSU clinic. Disaster trunks which contain triage tags and more first aid
supplies are located in the first aid room, the armory between north and south housing units, in
the MSU clinic, and in the North II clinic area.
The presence and functionality of the emergency response equipment is checked each shift and
documented on a daily equipment log. No outdated supplies were found in the emergency bags
we checked, but we did find outdated material in the disaster trunk in the armory. We checked
the AED and other emergency equipment and found all were functional. Menard Health Services
Policy V1-25 lists the contents and location of first aid kits available in housing units, program
areas, and vehicles, but we did not evaluate the accuracy of this information.
The Menard ID #04.03.108 and Menard Health Services Policy and Procedure V1-26 P-112 are
consistent with one another. Both require emergency response drills twice a year on each shift.
In addition, one mass casualty or disaster drill must be conducted annually. Actual practice
appears to conform to these directives. The mass casualty drill for 2017 was reviewed and found
to be thorough, with good multidisciplinary participation and candid critique of strengths and
weaknesses. The results were presented to the CQI committee; however, there was no specific
85

Lippert Report Menard pp. 23-24.

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plan to improve areas that were considered weaknesses. We also reviewed the emergency
response drills for 2017 and 2018. They are sufficient in number and there is some critique,
although not very thorough. These are also presented to the CQI committee. The minutes of the
CQI meetings do not reflect any presentation of trends, discussion, analysis of issues, or plans for
improvement in emergency response.
Emergency responses are documented in a log that includes the date, time, inmate name and
number, location, and diagnosis. Only two emergencies were listed for 2017. When we inquired
about this, the HCUA said that the nurses had stopped documenting in the log. She discovered
this when she asked for the urgent care log in February. Entries since then are much more
numerous than those recorded for 2017. We selected five patient charts to review from the list
provided by MCC of emergency room visits beginning in January 2017.
Incomplete or inadequate nursing assessments were discussed in the earlier section on Nursing
Sick Call. Two of these patients were seen by nurses for urgent complaints. One was seen for
abdominal pain and the nurse assessed the patient using the protocol for non-specific
complaints.86 The assessment of his condition would have been more thorough if the protocol
for abdominal pain were used. This patient had been seen in the ED three days earlier and
diagnosed with diverticulitis. The nurse contacted the provider and was given a verbal order for
a liquid diet. The provider did not see the patient for six days after his return from the ED. The
other patient was seen urgently for priapism and the only documentation is the outbound note
that he was sent to the ED.87 The nurse conducted no assessment and did not even take the
patient’s vital signs.
•

The first patient was seen in nursing sick call on 4/16/2018 for a boil on his buttocks that
had been present for one and a half weeks.88 The nursing assessment was incomplete. He
was referred to see the provider the next day. However, he was not seen for five days, at
which point an antibiotic was ordered. No labs or wound care was ordered. The provider
did order a follow-up appointment in four to five days. The patient was not seen for eight
days and at this encounter was sent to the ED because he was having lower abdominal
pain. There is an outbound note, but it contains minimal information. Upon his return,
the inbound note documents the medications and dressing change recommendations
that were on the patient discharge summary from the ED visit. He did not see a provider
for another two days. The nursing assessment of this patient’s condition was incomplete,
access to definitive care was delayed, and he was treated symptomatically with antibiotics
without a thorough work up. Documentation of the ED visit was not obtained from the
hospital and he was not seen promptly upon his return to MCC. This is a patient whose
condition deteriorated because it was not managed in a timely and clinically appropriate
manner by providers at MCC.

Sick Call Patient #4.
Sick Call Patient #5.
88 Urgent/Emergent Care Patient #1.
86
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•

Another patient whose ED visit could have been avoided on 4/23/2018 had been seen in
the emergency room on 11/1/2017 because of acute urinary retention.89 He was
diagnosed with septicemia resulting from bladder infection. He returned to MCC three
days later with an indwelling catheter and a recommendation to see a urologist in two to
three weeks. The provider tried to remove the catheter twice only to have another one
reinserted because the patient could not urinate. He was discharged to general
population and returned three weeks later because the catheter was not draining and
had clots of blood in the tubing. A new catheter was inserted. He saw the urologist the
next day, or five weeks after it was recommended, rather than two to three weeks later.
The urologist recommended cystography, dilatation, and bladder biopsy for a chronic
urinary tract infection. None of these procedures were completed and he continued with
an indwelling urinary catheter until 1/18/2018, when it was removed at his request. On
4/23/2018, he was unable to urinate and was sent to the ED. He was hospitalized, and a
prostatectomy was done. His discharge diagnosis was sepsis secondary to urinary tract
infection with underlying severe BPH and possible nephritis. A cardiology consult was
recommended four weeks post discharge, but has not been done per direction from the
facility Medical Director. There is no note documenting the rationale for not having a
cardiology consult on the patient. This patient would have benefited from prostate
surgery that was worked up and done as a planned procedure. The delay in scheduling
urology consults and diagnostic procedures resulted in an avoidable emergency and
unplanned surgery. The prolonged reliance on an indwelling catheter to relieve urinary
retention harmed the patient because of the increased risk of infection.90

We also reviewed five patients who were hospitalized, in order to assess whether the
hospitalization might have been prevented and whether follow-up care was appropriate. We,
indeed, found preventable hospitalization and poor care in general. We found problems with all
records reviewed.
•

89
90

One patient had hypertension and elevated cholesterol as early as 2008.91 However, due
to his age (46), his 10-year heart disease risk did not warrant use of a statin in 2008. In
2008, the patient did have EKG findings (T wave abnormalities suggesting lateral
ischemia), but these abnormal findings did not appear to result in follow-up investigation.
On 10/21/17, the patient sustained a myocardial infarction with cardiac arrest, for which
he was hospitalized. He was resuscitated and was found to have stenosis of his left main
coronary artery, for which he received a stent. The patient was discharged on a highintensity statin, Brilinta, a beta blocker, Lisinopril, and aspirin, all of which he received
upon return to the facility. The Brilinta was changed to a formulary medication (Plavix),

Urgent/Emergent Care Patient #5.

Managing Urinary cauti-guidelines.pdf
Retention in Men - Pr
91

Patient #1 Specialty Consultation and Hospitalization.

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which is a reasonable substitution. A cardiologist saw the patient on 11/14/17 after the
hospitalization. The cardiologist recommended follow up in three months, which did not
occur. The specialty care tracking log documented the 11/14/17 visit, but no other
referrals were documented. We could not find any documentation that the patient’s
heart condition was being monitored in chronic care visits. We could not locate the
patient on the chronic illness roster provided to us by IDOC in preparation for our visit. A
doctor did see the patient in follow up of the cardiology visit, but there were no further
provider visits until 3/30/18. On that day, the doctor noted that the patient had a prior
myocardial infarction. The doctor ordered no laboratory tests and did not enroll the
patient in chronic care clinic. His coronary artery disease was not being monitored. We
brought this to the attention of the HCUA, so he could be enrolled.
•

Another inmate had problems listed as diabetes, hypertension, and asthma.92 However,
the patient actually had chronic obstructive lung disease (COPD). Asthma and COPD are
different diseases and not managed in the same manner. The patient was described in
multiple chronic care visits as having various stages of asthma (mild persistent, moderate
persistent, etc.) when he actually had COPD based on radiologic examinations. These
descriptions for asthma were not pertinent to his actual diagnosis. There was no evidence
in the medical record that the patient had a pulmonary function test, the cornerstone of
diagnosis and management for COPD and asthma.
We reviewed the record for this patient for a two-year period. Over those two years the
patient was seen on seven occasions for chronic care. The patient was diagnosed on all
those occasions as having asthma, even though a chest x-ray on 10/26/17 showed
hyperinflation and fibrotic changes consistent with COPD, and even though a CT scan of
the abdomen incidentally showed fibrosis of the lung with emphysema consistent with
COPD. The patient had wheezing on several occasions that were treated with steroids.
Pulmonary function testing should have been ordered to clarify his diagnosis. Also, the
wheezing may have been due to other conditions, including heart failure. Additional
testing was indicated, specifically an echocardiogram. The patient should have been
referred to a pulmonologist for clarification of his diagnosis so appropriate therapy could
be provided, or MCC providers should have ordered a pulmonary function test. The
patient was not on an anti-cholinergic inhaler, never had a pulmonary function test, had
no assessment of exercise capacity, did not have an evaluation for the need for oxygen
therapy (even though having an oxygen saturation of 85% on 1/9/17), and had no
consideration for pulmonary rehabilitation.93 This patient should also have been
considered for evaluation of heart failure.
The patient was 82 years old in 2015. In 2015, he had a 43% 10-year risk of heart disease
and should have been on a moderate or high-intensity statin and aspirin. Additionally, the

Patient #6 Specialty Consultation and Hospitalizations.
persons with a room air oxygen saturation of less than 88% should be started on oxygen therapy. This person should
at least have been tested to determine if oxygen supplementation was necessary. If the facility physicians were untrained in how
to do this, referral to a pulmonologist was indicated.
92

93 Generally,

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patient had an EKG in 2013 that showed T wave abnormalities consistent with possible
ischemia. Despite this, the patient was not on a statin or aspirin until 11/17/17, when he
was started on a low-intensity statin. This placed the patient at risk of harm.
The patient weighed 208 pounds in a chronic clinic visit on 5/5/15. On 12/14/15 in chronic
clinic, the patient weighed 182 pounds. This 26-pound weight loss was unrecognized. On
1/4/16, a doctor documented a 40-pound weight loss. The patient complained of
abdominal pain, loss of appetite, diarrhea, and emesis. The doctor’s only diagnostic
evaluation was to order a blood count and abdominal x-ray. Despite having diabetes, the
doctor did not check blood sugar values. The CBC showed anemia (hemoglobin 12.2) but
no action was taken. GI symptoms with anemia and weight loss need to result in
colonoscopy and other testing to determine if a serious medical condition is present. On
1/21/16, a doctor referred the patient for an abdominal CT scan. A plain abdominal CT
scan is not adequate screening for colorectal cancer, but may be useful for other
purposes. Specialized CT scanning for colorectal screening is called CT colonography.
However, CT colonography was not ordered. This patient’s CT scan showed emphysema,
aortic atherosclerosis, hepatic cysts, renal cysts, infra-renal ectasia (abdominal aortic
aneurysm), bilateral common iliac aneurysms, and compression fracture of the L1
vertebra. None of these problems were added to the problem list or monitored. The
identification of aneurysms was of concern and should be monitored and referred, if
indicated. The identification of aortic atherosclerosis in combination with diabetes,
hypertension, and a greater than 40% risk of cardiovascular events should have prompted
use of a statin drug, but this was not done at this time. There was no follow up of the CT
scan or the problems identified on the CT scan. There was no follow up of the weight loss
or anemia. The patient did not have a follow-up blood count until two years later on
1/19/18, and the hemoglobin was 9.9, a significant deterioration. At that time, the doctor
ordered iron studies and gave the patient cards for fecal occult blood testing.
Colonoscopy was not done.
On 11/4/16, the creatinine was 1.66, indicating chronic kidney disease. This was not
added to the problem list and was not followed as a problem. Specifically, on 12/19/16,
the patient was evaluated in diabetic and hypertension chronic clinics. The blood pressure
was 142/84. For persons with chronic kidney disease and diabetes, the blood pressure
should be controlled to less than 130/80, yet this was not done, and the chronic kidney
disease was unrecognized as a problem. On several other occasions (9/10/15, 12/14/15,
5/3/16, 12/19/16, 11/17/17, 1/8/18), providers saw the patient with either a systolic
pressure above 130 or a diastolic pressure above 80 without intervention or comment on
why intervention was unnecessary.
On 1/9/17, a nurse evaluated the patient for shortness of breath and obtained an oxygen
saturation of 85%, which improved with treatment with a beta agonist inhaler. Because
of the patient’s myriad problems, a physician examination was indicated; instead, a
doctor presumed the etiology was asthma and ordered prednisone by phone. If the
diagnosis was asthma, an oxygen saturation at this level would have been life-threatening
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and the patient should have been admitted to a hospital. Even if COPD was the presumed
diagnosis, an oxygen saturation of 85% should have prompted consideration of
hospitalization for diagnostic evaluation. Treatment over the phone with prednisone
without knowing the diagnosis or reason for the new hypoxemia was inappropriate.
HbA1C levels from 2015 through 2017 indicated good diabetic control. However, capillary
blood glucose checks being done every other week started to show a rise in blood sugar
values. These were not monitored. On 11/14/17, the blood sugar was 256. On 11/22/17,
the blood sugar was 446. On 11/28/17, the blood sugar was 414. On 12/5/17, the blood
sugar was 423. On 12/12/17, the blood sugar was 411. On 12/18/17, the blood sugar was
471. There were no interventions after any of these blood sugars which indicated out of
control diabetes. On 12/19/17, a doctor saw the patient and noted that the most recent
HbA1C value was 6.1, but that a recent blood sugar value was 460. The blood sugar had
been significantly out of control for over a month. The doctor did not adjust medications;
instead, they ordered that the patient be seen in the diabetic clinic in two weeks with an
HbA1C test. On 12/23/17, a nurse practitioner saw the patient and documented that the
patient had vomiting, agitation, and was not feeling well. The nurse practitioner did not
check a blood sugar even though vomiting in an out of control diabetic can be caused by
ketoacidosis. The nurse practitioner ordered a month follow up despite this being an
acute problem. This patient should have had emergent blood testing and evaluation to
determine if an acute medical problem was present. Instead, the patient was not seen
again until the patient was sent to a local emergency room on 1/2/18, presumably for
evaluation for possible diabetic ketoacidosis. There were no progress notes from MCC
before the hospitalization, so it could not be determined why the patient was
hospitalized. There was no hospital report, so it could not be determined what occurred
at the hospital. When the patient returned to the prison, a nurse documented that the
patient was to follow up with a provider in five days. The hospital patient instructions
listed diabetes, vomiting, hyperglycemia, and abdominal aortic aneurysm as problems,
but the patient instruction sheet had little information. If the admission was for diabetes,
it was preventable. Poor management of the patient’s out of control diabetes resulted in
harm (hospitalization) to the patient. The problem of aneurysm was never addressed
despite potentially being life threatening.
The patient was not seen in five days as ordered. On 1/8/18, a nurse saw the patient for
chest pain. The pulse was 110 and blood pressure 140/88. A doctor did not write an
independent note but wrote an annotation to the nursing note stating that the patient
had numbness of his fingers for 10 years and had no chest pain. He documented that the
EKG showed no acute changes. He diagnosed COPD and chronic numbness and took no
action. He did not check a blood sugar or review the hospital record. The EKG showed
non-specific STT changes with V2-6 T wave inversions that can be associated with
ischemia.
On 1/9/18, a nurse notified a doctor about a blood sugar over 500. The doctor ordered
regular insulin and increased metformin to 1-gram BID and ordered blood tests. The
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doctor did not examine the patient. The patient was not evaluated after hospitalization
until 1/13/18, 11 days after hospitalization. The doctor noted that the blood sugar control
was poor but did not review the hospitalization or findings during hospitalization. A
HbA1C on 1/19/18 was 11.4, indicating very poor diabetic control.
On 2/13/18, the patient was seen for his diabetes, hypertension and “asthma.” The doctor
took little history but did note that the patient was short of breath. The patient was
started on an antibiotic without explanation of why. The patient was noted to be on
Lantus insulin, but the recent hospitalization was not discussed. Many of the patient’s
problems were not addressed or even listed as medical problems, including anemia, prior
weight loss, prior abdominal pain with vomiting, recent chest pain, abdominal aortic
aneurysm, chronic kidney disease, renal and hepatic cysts, and atherosclerosis. The
patient’s COPD was still being managed as if it were asthma.
In summary, this patient had multiple chronic medical conditions, many of which were
not being managed at all and some of which were managed inappropriately. It did not
appear that clinicians knew how to manage this patient’s medical problems. He was
hospitalized, and it was not even clear, based on the medical record, that providers
understood why he was hospitalized. Follow up of serious medical conditions (abdominal
aortic aneurysm, anemia, renal and hepatic cysts, chronic kidney disease, atherosclerosis,
and COPD) was non-existent. For most of these problems physicians appeared unaware
that the patient even had the problem. This placed this patient at significant risk of harm.
•

Another patient had a problem list that documented hypertension and asthma.94
However, the patient also had hepatitis C, chronic kidney disease, and first-degree heart
block, which were not being monitored.
Although the patient’s chronic kidney disease was not listed as a problem and was not
being followed in chronic clinic visits, the patient saw a nephrologist for this on 6/1/17.
The specialty care tracking log documented that the patient was again seen in nephrology
clinic on 10/5/17, but there was no report of the 10/5/17 visit or documentation in the
medical record that this appointment occurred, or what occurred at that appointment.
On the 6/1/17 visit, the nephrologist had recommended a vitamin D level, PTH level, urine
protein/creatinine ratio, and a four-month follow up.
Based on a 12/23/17 chronic clinic visit, the patient had a 14% risk of heart disease and
should have been on a moderate to high-intensity statin, but was not. He also should have
been considered for aspirin therapy as primary prevention of cardiovascular disease.
These were not provided to the patient and were not discussed with the patient.
On 12/25/17, the patient was admitted to a local emergency room for fever and diarrhea.
He was diagnosed with acute kidney injury secondary to dehydration and diarrhea. There

94

Patient #7 Specialty Consultation and Hospitalizations.

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was no documentation of a follow up of this hospitalization and it was not entirely clear
what occurred at the hospital, due to a lack of a complete report. The next physician visit
was not until 2/24/18, when the patient was seen in asthma and hypertension chronic
clinics. The blood pressure was documented as 120/18, but this clearly was a data entry
error and was unnoticed and uncorrected.
A doctor saw the patient in chronic clinic on 3/6/18, and noted that the patient was
recently hospitalized, but did not document what occurred at the hospital. The doctor did
note that the patient for hospitalized for fever, dehydration, and chronic kidney injury,
but there was no other history.
Several of this patient’s problems were not even identified or monitored as problems.
The patient did not have reports of a consultation visit and a hospitalization. Doctors did
not acknowledge what had occurred at the hospitalization and at one of the nephrology
visits. Lack of review of consultation and hospital reports meant that the patient’s clinical
status was unknown to medical staff. The patient should have been on a statin and
possibly aspirin, but doctors appeared unaware of this need.
•

Another 28-year-old patient had a medical reception screening at MCC on 8/18/17.95 The
nurse took a history of congenital heart disease, but the specific details were not
documented. The patient’s actual condition was not identified. A doctor did note that the
patient had a venous stasis ulcer on his right leg, but the type of heart disease was not
identified. On the day following medical reception, 8/19/17, a CMT evaluated the patient
for chest pain, shortness of breath, oxygen saturation of 82%, and atrial flutter. The
patient was sent to a local hospital.
The hospitalization log provided to us by Defendants in preparation for our visit showed
that the patient went to Chester Memorial Hospital on 8/19/17, and from there was
transferred to Carbondale Memorial Hospital on 8/22/17. A discharge summary from
Carbondale was not available, but an echocardiogram showed tricuspid atresia with a
possible small clot in the right ventricle. The patient was started on Lovenox, an
anticoagulant. A report from the local hospital noted that the patient had atrial
fibrillation, a stage II stasis ulcer, prior ablation procedures for atrial fibrillation, and had
tricuspid atresia96 with surgical correction at age five. The lack of the hospital record was
significant, as it was not clear from the medical record what the opinion of the cardiologist
was regarding the patient’s serious heart condition.

Patient #8 Specialty Consultations and Hospitalizations.
is a congenital absence of the heart valve between the right atrium and right ventricle, impairing flow of blood
to the lungs and preventing oxygenation of blood. This is typically corrected by a Fontan procedure which diverts blood
appropriately to the lungs from the inferior vena cava. When this procedure is done, patients require lifelong follow-up with a
cardiologist experienced with complex congenital heart disease. Annual evaluation is recommended at a minimum, as additional
interventions may be needed. These patients can acquire a number of complications which require intervention, including venous
stasis ulcers and venous insufficiency, protein losing enteropathy, cirrhosis, thromboembolic events, arrhythmias, heart failure,
and restrictive lung disease.

95

96 Tricuspid atresia

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The patient was sent to Barnes Jewish Hospital in St. Louis the following day on 8/25/17,
but there was no discharge summary and it was not clear what the therapeutic plan was
for the patient, except that the patient was on metoprolol, diltiazem, and Lovenox. Barnes
Jewish Hospital recommended a two to three week follow up.
On return from the hospital, the patient was admitted to the infirmary. The admitting
physician did not document a therapeutic plan or acknowledge what had been
recommended at Barnes Hospital. The doctor noted problems as atrial fibrillation,
tricuspid atresia, and hypoplastic right ventricle. The doctor prescribed metoprolol,
diltiazem, and Lovenox, but it was not clear what the therapeutic plan was.
Between 8/25/17 and 9/27/17, the patient was evaluated by providers six times. On none
of those occasions was an accurate description of the patient’s problems documented.
None of these notes documented a therapeutic plan for the patient’s serious medical
conditions. At several clinic appointments, the only assessment was “cardiac.” When we
asked the physician who wrote this assessment what he meant, he stated that the patient
had some type of cardiac issue. On one note, a doctor ordered a benzodiazepine and
referred to mental health for palpitations, when the patient actually had atrial fibrillation
which was possibly the cause of the palpitations.
According to the hospital log provided to us, the patient was sent to Memorial Hospital
of Carbondale on 9/27/17. It was not clear why the patient was sent to a hospital based
on progress notes before the admission. There was no hospital report, so it was not clear
what occurred. On 9/28/17, the patient developed abdominal pain with an oxygen
saturation of 79%, and the patient was sent to Barnes Jewish Hospital. There was no
hospital report for this admission. On 9/29/17, a nurse practitioner documented that the
patient “apparently had scan of G bladder, CT of chest, labs, EKG, US of abd [with] a note
‘fit for confinement.’” The therapeutic plan was not documented. This uninformed note
failed to document the results of any of these tests.
On 10/4/17, a cardiologist at Barnes Jewish Hospital saw the patient on a consultation
and documented that the patient had pulmonary and tricuspid atresia with atrial septal
defect and had multiple complications of his surgery, including atrial arrhythmia with
prior cardioversion and ablation, iliac vein obstruction with venous stasis ulcers, and atrial
thrombus. The cardiologist recommended stopping Lovenox, starting Eliquis, a liver
ultrasound, and referral to an electrophysiologist for possible ablation therapy.
On return from the cardiologist, the patient was seen twice by a doctor. On both
occasions, the doctor did not document review of the report. The recommendations for
referral for ultrasound and for electrophysiology were not documented as recognized and
do not appear to have occurred.
Progress notes document that the patient went offsite for a medical furlough on 11/4/17,
but the specialty consultation log documents this as occurring on 12/4/17. Progress notes
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do not document what the patient went offsite for. There was no report. On 12/4/17, a
scheduling clerk documented that the patient was discussed in collegial review and
approved for follow up. The clerk did not specify what the referral was for. On 12/15/17,
Wexford utilization approved a six-month follow up with cardiology. Progress notes
document that on 12/22/17 the patient went to Prairie Cardiology, but the reason for this
appointment was not clear. The specialty care tracking log does not have this
appointment in the log. The medical record remarkably did not detail the ongoing care of
the patient.
On 1/10/18, a doctor documented that the patient had been to a cardiologist but did not
document what occurred. The only diagnosis was “cardiac.” There was no therapeutic
plan.
Between 1/10/18 and 5/11/18, the patient was evaluated on three occasions. One of
these was a chronic clinic visit. On none of these visits did physicians document review of
prior consultations. On 2/9/18, a doctor wrote, “He is planned to have a procedure? At
SLUH.” The doctor did not appear to know what the therapeutic plan was or what
procedure the patient was scheduled for. The other notes, including the chronic clinic
visit, do not document understanding of what occurred at consultation visits or what the
therapeutic plan was.
On 5/11/18, the patient went offsite for a medical furlough. There was no report. The
specialty care tracking log did not document a visit for this patient on this date. A nurse
practitioner saw the patient on 5/17/18 and documented that the patient had been
offsite but that there was no report and no action was taken.
Care for this patient was grossly and flagrantly unacceptable as providers at MCC, despite
three consultations, did not identify all of the patient’s conditions, did not document a
therapeutic plan for the patient, and were not monitoring all of the patient’s medical
conditions in chronic care clinics. No one documented what had occurred at the
consultations, including status of the patient or recommendations for further care. One
doctor diagnosed the patient repeatedly as “cardiac,” and did not appear to understand
what the patient’s conditions were. It appeared that at least two recommendations of the
cardiologist (ultrasound of the liver and referral to an electrophysiologist) did not occur.
Two of the consultations had no report and it was not clear what the patient was seen
for. The patient had multiple abnormalities that were not documented as being
monitored including:
o Transformation of the EKG to first degree AV block with left atrial enlargement and
STT wave changes
o Thrombocytopenia of 79,000 and white count of 3.8 on 9/11/17
o Bilirubin 1.3 on 2/5/18
o The venous stasis ulcer

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The tracking log failed to accurately document specialty care appointments. Post
consultation visits failed to include documentation of understanding of what occurred at
the consultation or hospitalization. Three of five hospitalizations did not include a report.
Two offsite consultations did not include a report. It was not possible, reading the medical
record of this patient, to understand what the patient’s status was or what the
therapeutic plan of the cardiologist was. The patient’s serious medical condition was so
poorly managed that he is placed at serious risk of ongoing harm.
•

Another patient was 66 years old with a history of hypertension.97 This patient’s medical
conditions were mismanaged over a two-year period. The patient had wheezing on 10
separate occasions from late 2016 until April of 2018 without a diagnosis being made.
Although presumably treated for asthma, the patient was not diagnosed with asthma and
was not in chronic clinic for this condition. The patient’s wheezing occurred with
cardiomegaly and a chest x-ray showing an enlarged heart. These are consistent with
heart failure, yet when providers referred the patient to a pulmonologist and cardiologist,
the Wexford utilization doctor denied the referrals without recommending an adequate
plan of action. Echocardiogram and pulmonary function tests should have been done. The
referrals to cardiology and pulmonary were appropriate but not permitted. A second
cardiology referral was again denied without an adequate alternative treatment plan. A
nurse practitioner again referred the patient for CT scan and a pulmonary consult, but the
CT scan was denied, and although the pulmonary consult was approved, there was no
evidence it ever occurred.
In early 2018, the patient developed shortness of breath, wheezing, and tachycardia, and
was seen on three occasions (4/21/18 and twice on 4/22/18) by nurses who did not even
refer the patient to a doctor. The patient should have been immediately referred and this
placed the patient at life-threatening risk, as there was no diagnosis yet. When a nurse
practitioner finally saw the patient on 4/23/18, the nurse practitioner treated the patient
for an infection and apparently for asthma, even though this diagnosis had never been
made and was not made at this evaluation. A chest x-ray was ordered and was consistent
with heart failure. But when a nurse practitioner saw the patient on 4/27/18, the chest xray was not documented as being evaluated. On 5/4/18, the patient was admitted to the
hospital for a supraventricular arrhythmia and was diagnosed with atrial fibrillation. An
echocardiogram was consistent with heart failure. When the patient returned to the
facility on 5/8/18, the patient did not receive two ordered medications (Lopressor and
diltiazem) for two days. The patient was never documented as having heart failure and
his wheezing remained undiagnosed, although it appears he was treated as having
asthma.
Also, we noted that this patient had elevated alkaline phosphatase as high as 217 on
12/15/17 and had an elevation of this test dating from 12/18/15, yet it was never
evaluated. He may have undiagnosed serious liver or bone disease. Also, the patient had

97

Patient #9 Specialty Consultations and Hospitalization.

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an elevated 10-year risk of heart disease dating from at least 2/24/16, yet was not treated
with a moderate or high-intensity statin, which is recommended; or considered for aspirin
treatment, which is also recommended, but was not done. The care placed the patient at
continual risk of ongoing harm. The care of this patient was grossly and flagrantly
unacceptable, particularly the denial for cardiology and pulmonary referral when the
patient had undiagnosed symptoms of pulmonary disease or heart failure that were not
diagnosed or monitored.
In summary, the deficiencies in Urgent/Emergent Care were similar in frequency and type to
those reported by the First Court Appointed Expert. These include absence of important
information from the hospital, inadequate assessments by nursing staff, untimely physician
follow up, and failure to monitor or intervene. We found many additional deficiencies, including
inappropriate denials of care by the Wexford utilization physician, failure to review or complete
recommendations of consultants, ignorance of the status or therapeutic plan recommended by
consultants, and failure to follow up on abnormal test results. Several episodes of care were
grossly and flagrantly unacceptable, sufficient to typically result in peer review of the clinician
caring for the patient. We agree with the First Court Appointed Expert’s recommendations and
make additional recommendations found at the end of this report.

Specialty Consultations
Methodology: We reviewed 12 specialty consultations in four patients and reviewed other
records. We spoke with the clerk who schedules specialty care. We reviewed the specialty care
log and other documents.
First Court Expert Findings
Providers do not explain alternate treatment plans to patients. Follow up was inconsistent and
problematic. Consultant reports were frequently unavailable, making follow up difficult.
Current Findings
We found that all of the First Court Expert’s findings were still present. There was no
documentation of a discussion by the primary care provider with the patient following
consultation visits of the consultant’s recommendations or after an alternative treatment plan
was initiated. We found that the alternative treatment plans were occasionally described by the
scheduling clerk in progress notes. However, alternative treatment plans were not being
documented by the primary care provider. According to the scheduling clerk, consultation
reports are present for only about half of the consultations. We also found that follow up of
recommendations was inconsistent.
The process of obtaining specialty care was similar to all other facilities. The expectation is that
there is to be a written referral for specialty care, an approval of the referral in a collegial
conference call, a scheduled appointment, and a follow up of the appointment with the primary
care provider. All of these events are to be documented in the medical record.

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Specialty care referrals at MCC are not tracked on a log in a manner that accurately documents
all steps of the referral process. Three hundred ninety-nine (44%) of 892 referrals in 2017 did not
have a referral date documented in the specialty clinic tracking log. Of the 892 appointments,
877 (98%) had an approval date documented on the log, but only 469 (53%) had the date of the
completed appointment documented on the log.
It was not possible, using the specialty care tracking log, to determine whether patients were
timely receiving care. In chart reviews, the referral, approval, appointment, and follow up were
not consistently documented in the medical record. This made it impossible to verify the
timeliness or completeness of specialty care benchmarks using either the tracking log or the
medical record. As with other facilities, the approval date was the most frequently documented
item on the specialty care log, making it appear that approval of care is the most important
tracked item.
There were a low number of referrals for specialty care and an extraordinary number of denials
of care at MCC. The 2018 annual CQI report lists 994 referrals for care in fiscal year 2018.98 This
is the second lowest number of referrals per 1000 population of all five sites we have visited.99
Despite having a very low rate of referrals, MCC also has the highest number and rate of denials
of care of the five facilities we have visited.100 The CQI report documents 237 (24%) denials of
care. The five facilities we visited averaged 9.5% denials of referred cases. The CQI report did not
analyze the reason for the high number of denials. We were told that the Medical Director was
asked by patients for certain services which the Medical Director did not feel comfortable telling
the patients were unnecessary. So, the Medical Director would refer the patient for a service
knowing that the utilization physician would deny it. If this is accurate, this is a cynical misuse of
a referral process, disrespectful of patients, and violates effective communication of the treating
physician and the patient. We were told that this practice is no longer occurring. This practice
does not explain the very low rate of referral. We were told that the Medical Director is also now
taking referrals more seriously and preparing a rationale prior to the collegial reviews so that a
greater number of referrals are approved. It is our opinion that, based on record reviews in this
report, many persons who need specialty services are not referred. The lack of primary care
physicians and the Wexford utilization process itself are likely the cause of this phenomena.
The program had a concern about the number of denials and initiated a CQI study on denials. The
title of this study was Re-education in Amount of Medical Specialty Service Denials. The plan of
the study was to decrease denials of specialty care by 30%. The hypothesis of the CQI study was
that if a doctor reviewed documents being sent to the utilization physician prior to the collegial
review conference call to ensure that all treatments and steps that should have been taken
before referral were done and that all clinical information was available to the utilization
physician, that the number of denials would decrease. The CQI study compared the usual referral
process to a process with additional Medical Director preparation of referral documents. The
The fiscal year in Illinois is July 1 through June 30.
NRC was the lowest, at 144 referrals per 1000 population. MCC had 994 referrals a year or 328 referrals per 1000 inmates.
100 We include a table of referrals and denials in the Specialty Care section of our Summary Report. Please refer to that section
to review these data.
98
99

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number of referrals for consultations was 578 in a six-month period prior to the Medical Director
review of referral documentation material and 189 over a three-month period of study when the
Medical Director reviewed documents in advance. There were 153 denials over the six-month
period prior to the study and 55 denials in the three-month study period. This revised practice
resulted in a decrease in both referrals and in denials.
Although the intention was to reduce denials, the most important result, in our opinion, was to
reduce referral. Given that MCC has one of the lowest rates of referral for specialty care, we were
concerned that this process will place inmates at greater risk of harm by further reduction of
necessary referral.101 Based on record reviews, including mortality reviews, we found that far
fewer patients were referred for consultations than should have been. It is our opinion that under
referral is a more important problem than over referral. It is also our opinion that if the collegial
review process worked as designed, unnecessary denials should be eliminated in the collegial
discussion. What can the Medical Director prepare the day in advance that could not be discussed
the day of the “collegial” review discussion? We view the collegial review process as a barrier to
specialty care and believe it should be eliminated as it currently exists.
The program does not track whether clinical staff document benchmark events of specialty care
(referral, collegial review, appointment date, and five-day follow up) in the medical record. The
tracking log is so poorly maintained that it was not possible to use it for this purpose. As discussed
above, 44% of referrals and 53% of appointments listed on the log did not have a date associated
with them. Based on record review, we found that these specialty care benchmarks are not
consistently documented in the medical record. There was therefore no means to verify whether
care was timely or was being followed up.
The attorney for Wexford communicated by email to us that we would need to review individual
records to obtain the alternative treatment plan information, as it was not centrally maintained.
On chart reviews we performed we were unable to locate alternative treatment plans for all
denials. The scheduling clerk, but not the doctor, would sometimes document the alternate
treatment plan, based presumably on information obtained on the collegial review calls.
For specialty consultations that were completed, we noted multiple problems. These included:
• Delayed specialty care due to the collegial process
• Lack of follow up of recommendations of the consultant
• Failure to timely schedule follow-up appointments
• Failure to obtain reports of consultation care
• Failure to appreciate the status of the patient as reported by the consultant
• Failure to monitor the clinical care of the patient as recommended by the consultant and
• Failure to refer patients for specialty care when it was clinically indicated.

101 Referrals per 1000 inmates was 328 at MCC

,which was the second lowest number of the five sites we visited. This information
is available in a table in the Summary Report section of the overall report.

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We reviewed four records of patients who had multiple specialty visits. All four had significant
problems. The following record reviews illustrate these problems.
•

The first patient had hypertension, epilepsy, and asthma.102 On three occasions in 2016,
EKGs had T wave tracings consistent with possible ischemia. In April of 2016, he had over
a 10% risk of heart disease but was not on a statin or on aspirin, both of which the patient
should have been on. Eventually, in August of 2016 the patient was hospitalized for chest
pain, and a cardiac catheterization showed 60% stenosis of the circumflex coronary artery
and 15-20% stenosis of the left main coronary artery. It was recommended that he be
aggressively medically managed, including with a high-intensity statin, and Brilinta, an
anticoagulant.
On return to the facility from the hospital, medication was started as recommended. In
November of 2017, the patient experienced chest pain and was again hospitalized. He
had a myocardial infarction. A stent was inserted. The patient was documented as
receiving two doses of medication at MCC during the times when he was hospitalized,
indicating problems with documentation and medication administration. When
discharged from the hospital, a cardiology consultation was recommended. This
appointment occurred in December of 2017. The cardiologist recommended a follow-up
cardiology consultation, but that referral never took place and there was no explanation
in the record as to why the patient was not sent back to the cardiologist. The patient was
on Brilinta, likely because of the myocardial infarction and because he had a stent. Some
stents require use of a medication like Brilinta to prevent clotting in the stent. Yet in
February of 2018, a doctor at MCC stopped the Brilinta without explanation and without
substitution with a similar drug. This placed the patient at significant risk of stent clotting
and further myocardial infarction. Based on documentation, it did not appear that the
physician evaluating the patient reviewed the cardiology consult or understood the
reason for being on Brilinta.
Problems with this patient’s care included not being started on a statin drug or aspirin
early in his disease, which placed the patient at higher risk for myocardial infarction. The
patient was documented as receiving medication at MCC when he was hospitalized,
which is a problem with documentation of medication administration. A recommended
follow-up cardiology appointment never occurred and there was no explanation why. The
post-cardiology physician visit at MCC was two months after the consultation and the
doctor did not review the cardiology consultation report. Effectively, there was no followup medical appointment to determine the status of the patient’s condition after the
cardiology consultation. The doctor stopped the anticoagulant despite the patient having
had a cardiac event and a recent stent. There was no explanation given for
discontinuation of the medication. This placed the patient at significant risk of stent
clotting and myocardial infarction.

102

Patient #2 Specialty Consultations and Hospitalization.

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•

Another patient initially complained to a nurse of neck pain in March of 2016, and the
nurse did not refer to a provider, but gave the patient ibuprofen by protocol.103 In
December of 2016, the patient again complained of a sore throat and swelling on the left
side of his neck. The nurse evaluating the patient used an upper respiratory protocol,
which was not an appropriate protocol to use. The nurse noted an enlarged lymph node
on the left which was tender. No referral was made. This was inappropriate; the nurse
should have referred to a provider.
A CMT evaluated the patient again for sore throat on 1/6/17. The CMT noted an “enlarged
lymph node” and gave the patient acetaminophen by protocol. A nurse practitioner saw
the patient on 1/11/17 and noted that the left neck was swollen and “hard.” The nurse
practitioner diagnosed pharyngitis and ordered an x-ray and an antibiotic. No follow up
was ordered. A hard neck swelling is not consistent with pharyngitis. Other work up (CT
scan and lab tests) were indicated but not done.
An LPN evaluated the patient on 2/7/17 for neck pain, which the patient described as
having since December. The LPN noted a “large swollen lump under L side jaw.”
Presumably, the LPN referred the patient to a physician. On 2/15/17, a clerk documented
that a doctor presented the patient at collegial review for a CT scan, which was denied by
a Wexford utilization physician. The CT scan was appropriate and should have been
approved, in our opinion.
On 3/3/17, a CMT evaluated the patient again for neck pain and noted a large lump on
the left side of the neck. The CMT described the lump as getting bigger and harder. On
3/8/17, a doctor again referred the patient for a CT scan, which was discussed in collegial
review on 3/8/17 and again denied. The Wexford UM physician recommended a neck
ultrasound as an alternative plan. Ultrasounds are useful tests to evaluate thyroid
conditions, but hard neck masses are best evaluated with CT scan. Getting an ultrasound
would only serve to delay the diagnostic effort.
An ultrasound was done on 4/4/17 and showed a mass. The radiologist recommended a
CT scan. The doctor at MCC referred the patient for CT scan on 4/12/17 and it was
approved on 4/17/17. The CT scan was not done until 5/22/17 and showed a complex
mass suspicious for malignancy.
On 6/8/17, a doctor referred the patient to a general surgeon for biopsy, but in collegial
review on 6/22/17, the Wexford utilization physician changed the referral to an Ear Nose
and Throat (ENT) surgeon. The consultation with the ENT occurred on 7/31/17 and the
surgeon recommended a biopsy. The biopsy was approved on 8/4/17 and done on
8/18/17. The biopsy showed squamous cell carcinoma of the tongue. This significant delay
(eight months) in diagnosis of a head and neck cancer appeared to be caused by the
collegial review process and inability of primary care doctors to timely evaluate a hard
neck mass.

103

Patient #3 Specialty Consultations and Hospitalization.

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On 9/13/17, a doctor at MCC saw the patient but there was no report yet of the biopsy.
A doctor saw the patient again on 9/27/17 and again there was no report. Apparently,
the ENT surgeon working through the scheduler had multiple pre-operative appointments
made at Barnes Jewish Hospital in St. Louis. The patient ultimately had surgery on 10/4/17
to remove an advanced disease tumor with metastases to lymph nodes. The patient was
discharged with recommendation for speech therapy, a swallow study, and ENT and
oncology follow up.
On 10/17/17, the patient went for an offsite appointment, but it was not clear what the
patient was seen for. On 10/18/17, a doctor at MCC documented that the patient had a
swallow study, but did not document what the therapeutic plan was for the patient
regarding eating or follow up. A report of the swallow study noted that the patient could
start eating with nutritional supplements and could upgrade the diet. Swallowing
exercises were recommended during radiation therapy. These recommendations were
not documented by MCC physicians as incorporated into the patient’s therapeutic plan
and it was not clear that they occurred. On 10/26/17, the patient was discharged from
the infirmary without a documented therapeutic plan except that the patient was to start
radiation therapy. Documentation was poor, and it was not clear whether the patient
kept the ENT, oncology, or initial radiation therapy appointments.
Problems with this patient’s care included a delay of eight months from the time the
patient complained of a lump in his neck until the squamous cell carcinoma was
definitively diagnosed and an additional two months until resection of the tumor
occurred. The patient had advanced cancer and the delay may have contributed to its
spread. The Wexford utilization physician made an improper decision in twice denying a
CT scan for a hard neck mass. Consultant reports after surgery were not available in the
medical record and doctors did not document understanding of the therapeutic plan
except that the patient was to receive radiation therapy. There is no evidence in the
records that some of the recommendations for follow up with consultants occurred or
whether a recommendation for swallowing exercises was discussed with the patient.
Also, there was no evidence we could find of a comprehensive dental examination,
including of the oral cavity, that may have identified the oral cancer earlier. This speaks
to the lack of comprehensive dental evaluations.
•

104

Another patient had long standing hip pain.104 On 8/22/08, an x-ray showed marked
reduction of the left hip joint with sclerosis of the joint. The impression was severe
osteoarthritis with no change since the last study. X-rays were taken again in 2009, 2011,
2013, and 2014, all showing continued deterioration. A 2015 x-ray showed “near
obliteration of the joint space with prominent juxta-articular bone spurs and subcondylar
cysts.” Indications for hip replacement are failure of conservative management,
debilitating pain, and significant decrease in activities of daily living. This patient appeared
to have indications for hip replacement surgery as early as 2008.

Patient #4 Specialty Consultations and Hospitalization.

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On 3/8/16, a nurse saw the patient. Indications for hip replacement were present. The
nurse documented that a physician requested a collegial review because the hip “comes
out of joint when walking. Painful movements noted, appearance of possible foot drop.”
We could not find the collegial review for this patient around March of 2016 in the record.
So, it is not clear if the collegial review happened or if it was denied or just not
documented.
On 6/5/16, a nurse saw the patient and noted pain in the hip, unsteady gait, and difficulty
in standing up, and requested a low bunk for that reason. There were a lack of physician
evaluations documenting a thorough history and physical examination during this time
period. However, the nurse sent the patient to a nurse practitioner, who saw the patient
on 6/8/16 and referred the patient to the Medical Director for a consultation referral for
the hip.
On 6/10/16, a doctor referred the patient to an orthopedic surgeon. On 6/15/16, a clerk
documented that the patient was discussed in collegial review, but a final decision was
pending. On 6/29/16, a clerk documented that the referral was denied. The clerk did not
document the alternative treatment plan. There were no physician notes documenting
the plan of care for the patient. However, it appears that the alternate treatment plan
was to refer to a physical therapist.
On 7/22/16, the patient went to a physical therapist in Carbondale. The therapist noted
that the patient had a hard time walking and was unstable when standing and had
crepitance of the left hip. The therapist gave the patient exercises but noted that the
patient probably needed hip replacement.
No action was taken based on the 7/22/16 therapy consultation until 11/11/16, when an
MCC physician referred the patient to an orthopedic surgeon again. This referral was an
appeal of the prior decision. Because it was an appeal, the IDOC was involved. The referral
was approved on 11/22/16.
An orthopedic consultant saw the patient on 12/20/16. The consultant noted that the
patient could not put weight on the joint and struggled to walk, and pain medication was
no longer effective in relieving pain. The consultant recommended total hip replacement.
The patient was now on tramadol for pain relief. Tramadol is an opioid pain medication.
The MCC doctor referred the patient for total hip replacement on 12/23/16. The
procedure was approved by Wexford on 1/6/17. Despite the approval for hip
replacement, the pre-operative evaluation was not approved until 2/20/17. The hip
replacement was not performed until 3/20/17. The hospital’s procedure for hip
replacement was to start an anticoagulant and perform a Doppler study of the legs to rule
out DVT in four weeks. During the entire post-operative period when the patient was on
anticoagulation, the INR was not checked once even though it is standard practice to do
so.
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On 4/4/17, an orthopedic surgeon saw the patient and again recommended obtaining a
venous Doppler study and, if negative, to stop the anticoagulation. However, when a
doctor at MCC saw the patient on 4/13/17, about nine days after the consultation, the
doctor ignored the recommendation for a Doppler study and just stopped the
anticoagulant. The doctor did not document review of the orthopedic consultant note.
The patient was not referred for physical therapy until July 2017.
Problems with this patient’s care included a significant delay in hip replacement surgery.
There was x-ray evidence of severe degeneration of the joint since 2008. Physician notes
failed to document a thorough history or physical examination in any notes of the current
volume. However, a nurse noted that the patient could not walk due to the joint problem.
Even after a doctor referred the patient to an orthopedic consultant, it was initially
denied. Referral to a physical therapist resulted in an opinion that hip replacement was
needed. The patient ultimately went to an orthopedic consultant. But after a
recommendation for hip replacement, the surgery was delayed for another three months.
A recommendation by the orthopedic consultant to obtain a Doppler study to assess for
thrombosis was ignored by MCC staff. It was not even clear that they reviewed the
consultant report. Physical therapy was not initiated for four months after the surgery.
While hip replacement is an elective procedure, the surgery was delayed apparently for
years, resulting in pain and disability endured by the patient for an extended period of
time.
•

Another patient did not have appropriate management of his goiter or appropriate follow
up of his rheumatoid arthritis.105 On 10/23/15, a dentist told a CMT to refer the patient
to a doctor for a goiter first noticed by the dentist. The goiter had been unrecognized
previously by medical staff. The dentist ordered a thyroid panel and an antinuclear
antibody test. The antinuclear antibody test is a test for autoimmune disease and is not a
test typically ordered to evaluate a goiter. A doctor, not a dentist, should have been
initiating care for the patient. A doctor did not initially evaluate the patient’s goiter by
taking a history or performing a physical examination of the goiter. Goiters should be
evaluated to assess whether they are so large that they are obstructive and impinge on
the trachea. The reason for the goiter should also be determined; some multi-nodular
goiters are cancerous. The TSH ordered by the dentist was reviewed by a doctor and was
elevated, indicating hypothyroidism. A doctor ordered Synthroid but did not document a
discussion of this medication with the patient, did not perform an evaluation of the
etiology of the goiter, did not evaluate for obstruction, and did not appear to see the
patient.
About two months after the dentist referred the patient, a doctor apparently saw the
patient on 12/15/15. The doctor did not take a history of the patient’s condition or
perform a physical examination, so it was not clear from the note whether the doctor
evaluated the patient in person. Goiters may be caused by a variety of conditions or may

105

Patient #5 Specialty Consultations and Hospitalization.

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be large and cause obstruction of the trachea. The doctor failed to evaluate for the cause
of the goiter, did not evaluate for obstruction, and merely noted that the patient was not
taking the Synthroid. The doctor did not document a discussion with the patient about
why the Synthroid was necessary. The doctor did not document a diagnosis. The doctor
was treating the elevated TSH without establishing a diagnosis. The doctor was a surgeon
and may not have understood how to properly evaluate a goiter. The patient, therefore,
should have been referred to an endocrinologist.
The TSH remained elevated. On 1/21/16, a physician saw the patient. Again, there was no
history or physical examination. The doctor noted that the rheumatoid factor test was
elevated (348) and that the Synthroid was recently increased. No action was taken with
respect to the elevated rheumatoid factor. A year earlier the patient had complained to
a nurse about multiple joint pains, but this had not resulted in a physician evaluation of
the joint pains. Also, no evaluation was initiated to evaluate the cause of the goiter. It
appeared that the doctor did not know how to evaluate the patient’s conditions and the
patient should have been referred to someone who knew how to manage these
problems.
Two months later, on 3/15/16, without explanation, the doctor referred the patient for
an ultrasound of the thyroid gland. This test was an appropriate test for the goiter but
should have been ordered four months earlier, when the goiter was first identified. The
doctor’s only history was that the patient still had polyarticular pain. The doctor, knowing
that the rheumatoid factor was significantly elevated, took no other history of the joint
pains and performed no examination of the patient’s joints. The doctor took no history of
symptoms of obstruction of the trachea and performed no examination of the goiter. The
only actions taken were to refer for an ultrasound, to order a TSH, and to increase the
Synthroid. The doctor did not appear to know how to manage this patient’s polyarticular
arthritis or goiter.
On 5/20/16, an ultrasound of the goiter showed an enlarged thyroid gland with multiple
nodules. Multinodular goiter can be caused by multiple different conditions, which had
yet to be determined.
On 5/25/16, a doctor saw the patient for joint pains and ordered x-rays of the elbows and
wrists. Another rheumatoid factor test was ordered and was again elevated.
On 6/13/16, a different doctor noted the positive rheumatoid factor and that the patient
had an enlarged thyroid gland with multiple nodules. This doctor, who was an internist,
referred the patient back to the primary doctor, who was a surgeon, to consider referral
for a thyroid nuclear scan. A thyroid nuclear scan would be indicated if the patient was
hyperthyroid, but this patient was hypothyroid. A thyroid scan would not typically be
recommended. What was necessary was to determine the cause of the multinodular
goiter and to determine if the goiter was causing obstruction.

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On 6/16/16, a doctor saw the patient and noted painful wrists, but did not document a
thorough examination of the joints.
On 7/7/16, a doctor saw the patient and noted that the patient had multinodular goiter
and that the TSH was still elevated, and increased the Synthroid. The doctor initiated no
further evaluation to determine the cause of the multinodular goiter. The doctor did not
evaluate the size of the goiter and did not determine if it was causing obstructive
symptoms. The doctor did finally refer the patient to a rheumatologist.
A rheumatologist saw the patient on 12/16/16. The rheumatologist diagnosed likely
rheumatoid arthritis and recommended a tapering steroid dose. He requested hepatitis
tests and, if negative, would start methotrexate. A six to eight week follow up was
recommended.
A nurse practitioner saw the patient on 12/16/16, the day of the rheumatology
consultation. The patient had not been evaluated at MCC for his arthritis or goiter since
July. Apparently, he was not enrolled in chronic clinics for these conditions. The nurse
practitioner noted that the rheumatologist had recommended a tapering steroid dose for
the arthritis and that a surgery consultation was also recommended. The reason for the
surgery consultation was not stated. The nurse practitioner did not document review of
the rheumatology note; apparently this had not yet been provided. A doctor saw the
patient post-rheumatology visit on 12/22/16, but did not document review of the
consultation except to note that the patient was on a tapering steroid dose. The doctor
took no history, performed no physical examination, and did not make any assessment of
any of the patient’s conditions.
Although the rheumatologist recommended a six to eight week follow up, the patient did
not return to the rheumatologist until 3/28/17, over three months later. A report of this
visit was in the medical record. The rheumatologist diagnosed seropositive erosive
rheumatoid arthritis and recommended methotrexate titrated up to a dose of 20 mg
weekly. He recommended monthly CBC and CMP to monitor for methotrexate toxicity
and a six to eight week follow up.
There was no follow up by an MCC physician after the rheumatology visit. Rheumatoid
arthritis was not added as a problem and was not being followed in chronic illness clinic.
A CBC and CMP were done on 4/6/17, but monthly follow-up tests were not documented
as reviewed by physicians.
The follow up with the rheumatologist occurred in about three months, on 6/16/17, later
than recommended. The rheumatologist noted that the requested CBC and CMP tests
were unavailable and that requested x-rays of the hands and a TB skin test result were
also not sent as requested. The rheumatologist tried to contact the MCC Medical Director
but could not contact him. The rheumatologist added sulfasalazine and was considering
adding hydroxychloroquine for the arthritis, but wanted an ophthalmology evaluation
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before adding hydroxychloroquine. The consultant recommended a CBC, CMP every 30
days along with ESR and CRP tests, an ophthalmology evaluation, and return in six to eight
weeks.
The patient was not evaluated by a physician post-rheumatology consultation. On
8/24/17, more than two months after the rheumatology visit, a doctor documented that
the patient was recently seen by a rheumatologist and that the patient was on
methotrexate and folate. There was no history, physical examination, or update on the
patient’s status. The doctor did not document review of the rheumatology note and
appeared unaware that the rheumatologist had recommended sulfasalazine. There was
no evidence in the medical record or on the specialty tracking log that an ophthalmology
referral was made. The doctor did not document review of the CBC and CMP for
methotrexate toxicity.
On 9/22/17, a doctor documented that the patient had seen a rheumatologist but that
there was no report. The tracking log documented that the patient was seen by a
rheumatologist on 9/22/17, but there was no report in the medical record and no
evidence in the medical record that an appointment had occurred. The doctor at MCC did
document prescribing sulfasalazine on 9/22/17. There was no history, physical
examination, or updates on the status of the patient’s conditions. The multinodular goiter
was not addressed. The patient was not monitored with CBC or CMP for methotrexate
toxicity and neither the multinodular goiter nor rheumatoid arthritis were not being
followed in chronic clinics. Since there was no report, it was not clear if a follow up
rheumatology consultation was recommended.
The patient was not seen again for these problems by a physician until 12/30/17, when a
coverage doctor saw the patient. There was no history or physical examination. The
rheumatology note was still not present. The doctor wrote, “Pt wants [treatment] for
Crohn’s prescribed by consultant.” The doctor prescribed sulfasalazine. The sulfasalazine
had expired without notice. Also, the doctor presumed that the patient was taking the
sulfasalazine for Crohn’s disease, when he was taking it for rheumatoid arthritis. The
doctor took no history, performed no physical examination, did not review the
rheumatology report, did not monitor the patient for methotrexate toxicity, did not
document or understand the therapeutic plan for the patient, and did not even know
what conditions the patient had. There was a complete absence of management or
monitoring of this patient’s serious medical conditions.
There were multiple problems with the care of this patient. The goiter was not
appropriately evaluated, and a diagnosis was not made as to the etiology of the goiter.
There was no evidence of a history or physical examination determining whether or not
there were obstructive symptoms. Physicians did not document whether the ultrasound
indicated that a biopsy was needed. Because the physicians appeared unable to
appropriately evaluate this condition, the patient should have been referred to an
endocrinologist. Also, the patient had long-standing pain in multiple joints. The patient
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never had an adequate evaluation for this condition at MCC over two years. The patient
was sent to a rheumatologist but return appointments were late. Recommended testing
was not done or not provided to the rheumatologist. A recommendation by the
rheumatologist for ophthalmology evaluation was unnoticed or ignored by MCC
physicians. Consulting reports were not all available, and doctors and MCC did not
document knowledge of the status of the patient’s condition. Recommended medication
was not timely prescribed. One doctor appeared unaware of the patient’s actual
diagnosis. Doctors appeared unaware of the treatment plan of the rheumatologist and
were not monitoring the patient as recommended. The patient’s rheumatoid arthritis and
goiter were not identified as problems and were not being monitored in chronic illness
clinic. The doctors at MCC did not appear to know how to manage the rheumatoid
arthritis. Even though the patient was sent to a rheumatologist, the follow up was nonexistent and placed the patient at risk of harm.
•

Another patient was incarcerated on 3/3/17 at MCC.106 The patient had a history of
hepatitis C. The platelets were not initially done, but by 7/18/17 the platelets were 147
and AST was 141, which yielded an APRI score of 2.4, indicating likely cirrhosis. The patient
was released on parole and re-incarcerated on 5/4/18. Despite having likely cirrhosis on
APRI in March of 2017, the patient did not have an evaluation for cirrhosis, did not receive
an upper endoscopy to screen for varices, and did not receive semi-annual ultrasound
tests to screen for hepatocellular carcinoma. Patients in IDOC are not typically screened
for cirrhosis, do not typically receive endoscopy when they have likely cirrhosis, and do
not consistently receive screening for hepatocellular carcinoma. We have seen this
repeatedly in IDOC. We note that the IDOC hepatitis C guidelines require a fibroscan for
patients with an elevated APRI. This was not done for this patient. A fibroscan would have
provided additional information as to whether the patient had cirrhosis.

•

Another patient had an APRI score of 1.14 from at least 5/1/17, yet a year later, as of
5/16/18, the patient was still not referred to UIC for treatment of his hepatitis C.107 The
patient was evaluated in hepatitis C clinic twice. Yet when seen in this clinic, there was no
evaluation for cirrhosis, no endoscopy to screen for varices, and no ultrasound to screen
for hepatocellular carcinoma. This is significant underutilization that places the patient at
risk of harm. We discuss deficiencies in hepatitis C care in the Chronic Care section of this
report.

Infirmary Care
Methodology: The clinic space and equipment in the infirmary was inspected, nursing staff were
questioned, clinical charts audited, nurse logs reviewed, porters questioned, and patient-inmates
interviewed. The infirmary physician was not interviewed.

106
107

Patient #11 Specialty Consultations and Hospitalizations.
Patient #10 Specialty Consultations and Hospitalizations.

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First Court Expert Findings
The First Court Expert noted that the infirmary was staffed 24 hours a day and seven days per
week with RN’s. The infirmary patient rooms were padlocked and did not have nurse call devices.
He commented that padlocked rooms created a serious barrier to the expedited evacuation of
patient-inmates in the case of fire or other emergencies. The First Court Expert reported that the
porters had not been trained about blood borne pathogens, infectious and communicable
diseases, body fluid cleanups, the proper sanitation of the patient-inmate areas, and the
confidentiality of patient information. Only four of the 26 infirmary beds were hospital beds and
only one of these four hospital beds had functional safety rails. The infirmary bed linen was torn
and ragged. The First Court Expert also noted that the infirmary linens were being cleaned in a
residential level washing machine that did not achieve the temperature required to sanitize
contaminated linen.
Current Findings
With the exception of the finding that the porters now had received documented training and
the linens were generally good condition, we agree with the findings of the First Court Expert and
we identified the following additional findings:
• Nearly half of the patient-inmates were permanently assigned to the infirmary.
• Two of the patients primarily require skilled nursing care that the infirmary is neither
staffed nor equipped to provide.
• Provider admission and progress notes met the frequency and timeliness standards
established by the IDOC.
• Admission RN notes are written in accord with the established timelines. Nurse notes are
written daily and provide useful information on the clinical status of a patient.
• The quality of provider notes was inconsistent and failed to reflect key components of the
patients’ histories, physical findings, and the treatment plan.
• Provider admission and progress notes were brief and contained limited clinical
information or rationale for treatment plans.
• The infirmary provider does not write intermittent comprehensive progress notes that
summarize and update the patient’s current condition and treatment plan.
• Only three of the 26 infirmary beds were hospital beds with adjustable heights and head
and leg sections. In spite of the high level of physical and mental impairment of the
patients housed on the infirmary, there were an insufficient number of adjustable
hospital beds in the infirmary. The low level fixed metal beds make it difficult to examine
and transfer patients. This is a barrier to the delivery of needed care and put the staff at
risk for injuries.
• There is no exam room in the infirmary.
• None of the infirmary patient rooms have nurse call devices.
• The padlocked patient room doors are an obvious barrier to the infirmary’s ability to
safely evacuate patient-inmates in emergency situations.
• The level of nursing staffing, the type and quality of the beds, and the diligence of the
infirmary provider are not adequate to provide the level of care needed by patients who
require skilled nursing services and monitoring of complicated conditions.

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The infirmary is located on the third floor of the health care unit. The infirmary has 26 beds; the
census was six on the day of the inspection. The physical plant and layout is unchanged since the
First Court Expert’s report. Nurses reported that the provider generally makes rounds once a
week and that most patients have a weekly provider note. A review of the charts revealed that
nurse admission notes and vital signs were recorded on the day of admission. This is in accord
with IDOC policy 04.03.120.108 In-depth review of four infirmary records verified that all four had
provider admission notes written within 48 hours of admission and, with one exception, there
were at least weekly provider progress notes. Nursing notes were consistently entered no less
than daily and commonly on every shift.
It was reported that an RN is assigned to the infirmary on all shifts seven days a week and that
there are generally two nursing personnel on each shift. Patients who need additional assistance
with activities of daily living (ADL) may have an inmate assistant who is assigned to a bed in the
same room as the patient. At the time of the inspection, one of the six patients had a live-in
inmate assistant. Three porters also live in a separate room in infirmary.
Three of the individuals in the infirmary were designated or soon to be designated as requiring
assistance with some activities of daily living. Included in this non-independent group were two
individuals with metastatic cancer, one of whom refused all further treatment and had signed a
Do Not Resuscitate form (DNR). Another individual has severe spinal arthritis; the risk for fall was
so high that his mattress was placed on the floor. This individual should have been assigned to
the hospital bed that had functional safety railings.
None of the infirmary rooms had nurse call devices. The HCUA is aware of this problem and is
working to purchase the same type of nurse call device that has been installed at LCC. None of
the patient rooms at MCC’s infirmary was in the direct line of sight from the nurse station or the
correctional officer desk. Since the infirmary rooms are padlocked, patients stated that they
would have to bang on their padlocked door and yell if they had an urgent condition. The
condition of at least two of the patients precludes their capability to stand up, walk to the door,
and bang for assistance. As noted during the First Court Expert’s report, the patient rooms
continue to be padlocked at all hours; this creates a significant safety risk if the floor needs to be
evacuated during a fire.
A number of concerns and deficiencies in the care provided to infirmary patients was noted. We
describe these concerns and deficiencies below.
•

A 63-year-old patient’s problem list failed to note that this patient had a stroke, deep vein
thrombosis on chronic anti-coagulation medication, an inferior vena cava filter, and
urinary incontinence.109 This creates a barrier to the delivery of continuous care to this
very complicated patient. The infirmary provider notes were generally extremely brief,

108
109

Reference Offender Infirmary Services.
Infirmary Patient #1.

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with “no change” being the entire note. Providers did not write an intermittent
comprehensive provider note that addressed all of the patient’s clinical conditions with
the current treatment plan. There were no formal consultant reports from the
interventional radiologist in the medical record. There was a seven-month period of time
during which the patient’s anticoagulation level was subtherapeutic on five of seven
(71%) lab tests before the provider finally increased the dosage of warfarin. The patient
had an expressive aphasia that interfered with his ability to communicate, yet there was
no documentation in the chart that he had ever received speech therapy or if the aphasia
had worsened or improved. This patient with documented stroke and hypertension was
at risk for a recurrent cerebrovascular accident (stroke) and a myocardial infarction, yet
had not been prescribed a high-intensity statin. This is not in accord with national and
IDOC guidelines.110 The patient had a ASCVD risk of >15% which warranted therapy.
•

Prior to his recent return from the hospital and admission to the infirmary, another
patient, a 58-year-old with hyperlipidemia on a moderate intensity statin, was seen three
times in nurse sick calls during the month of March 2018 for mid-abdominal and chest
pain and pressure, neck and shoulder pain with vomiting, and for EKG review.111 An EKG
with new ST elevation was inaccurately interpreted as having no changes from an EKG in
2017. There is no documentation that the provider compared these two EKGs. The only
notes were written by nurses. The patient saw the provider on 3/30/18 with exerciserelated shortness of breath and chest discomfort; he was sent to the hospital, where he
underwent a coronary artery bypass after being diagnosed with a heart attack. He was
returned to MCC with a LifeVest due to increased risk of ventricular arrhythmia resulting
from decreased LVEF (24%) and ischemic cardiomyopathy. Based on his symptoms and
his abnormal EKG, he should have hospitalized at least 12-24 days prior to his heart attack.
His pre-heart attack ASCVD risk score was elevated (>7.5%) but the MCC clinical team did
not calculate this risk and did not prescribe a high-intensity statin. He was seen twice by
the infirmary provider during the first week, but then was not seen for next 21 days. This
high-risk patient (post-op, congestive heart failure, high-risk for ventricular arrhythmia)
should be followed and monitored more closely by the infirmary provider. To date, MCC
providers have failed to screen this over 50-year-old patient for colon cancer112 and to
vaccinate this patient against pneumococcal 23 as indicated by national adult
immunization standards.113

•

A 48-year-old patient with an abdominal cancer that has progressed while on treatment
is being followed by medical oncology, radiation oncology, and urology specialists.114 He
had been in the infirmary for over a year. Although the chart had weekly provider notes,
these notes are extremely brief and contain very little clinical information about the

Office of Health Services, Treatment Guidelines, Hyperlipidemia, March 2016, and ACC/AHA Arteriosclerosis Cardiovascular
Risk Estimator.
111 Infirmary Patient #2.
112 USPSTF Colon Cancer Screening 2016.
113 CDC 2018 Vaccines for Adults.
114 Infirmary Patient #3.
110

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patient’s status and treatment. There were no intermittent comprehensive progress
notes that summarize the current status and treatment plan for this complicated patient.
Reading only the provider notes, it was difficult to follow the care that is being provided
to this complicated cancer patient. If another provider had to assume responsibility for
the care of the infirmary patients, it would extremely difficult to comprehend the status
of this patient’s cancer and the plan of treatment. This puts the health of the patient at
risk for errors. There is also no documentation that the patient has received
pneumococcal 13 and 23 vaccinations.115
•

The next patient is a 79-year-old with metastatic prostate cancer on heavy analgesia who
was intermittently confused and had difficulty ambulating, who suffered a torn urethral
meatus that was reported to have occurred when the patient (or another person) stepped
on the tubing of the catheter that was dangling and laid on the floor.116 This could have
been prevented with proper nursing management of the tube and bag. This patient is
dying; there is no documentation that he has been considered for compassionate release
from the IDOC. There is no documentation that this patient had ever been previously
screened for colon cancer117 during times prior to his metastatic cancer or administered
the age recommended pneumococcal vaccines.118 The patient has never been treated for
hepatitis C, but based on his current condition, he is not a candidate for treatment.

With the exception of the previous recommendations that have been addressed, we agree with
the recommendations of the First Court Expert and have additional recommendations that are
found at the end of the report.

Pharmacy/Medication Administration
Methodology: We reviewed medication services by touring the medication room with the
Nursing Supervisor (IDOC) and interviewed four of five nurses preparing medication for delivery
the afternoon of Wednesday, May 23, 2018. They were documenting medication as having been
given as it was prepared and put into envelopes or pill cups to be administered later. We
observed the count of controlled substances in the trauma area between shifts on Monday May
21, 2018. We also observed a nurse count out controlled substances to administer that evening.
We also toured the medication storage area and interviewed one of the pharmacy assistants.
Medication administration was not observed. We reviewed medication administration records
and corresponding medical records of 11 patients selected from lists of patients on medications
that cannot be missed.
First Court Expert Findings
The system used, and policies and practices described in the previous Court Expert’s report, are
mostly unchanged today. Medications are provided by BosWell, a subcontractor to Wexford,
CDC 2018 Vaccines for Adults.
Infirmary Patient #4.
117 USPSTF Colon Cancer Screening 2016.
118 CDC 2018 Vaccines for Adults.
115
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using a “fax and fill” system. Pharmacy assistants are responsible for sending orders and
requisitions for stock medication to be dispensed by BosWell. These same personnel receive
shipments and verify medications received against those ordered. Once this is completed, the
medications are moved to the medication room where they are prepared by nurses for
administration. Medications are administered by nursing staff at the cell door. Documentation of
medication administered, refused, or not available is done on a paper Medication Administration
Record (MAR) that is kept in binders in the medication room for the current month and filed in
the medical record the month after.119
Current Findings
Medication administration at MCC is problematic and relies on outdated practices that are no
longer considered safe from patient harm. These problem areas include:
• Handwritten orders and transcription of orders to the MAR
• Late transcription of orders
• Pre-pouring medication, including medications that are crushed and floated
• Use of unsanitary envelopes to administer medications
• Not having the MAR available during medication administration
• Not documenting administration of medication at the time it is given.
Chronic disease patients are not monitored to ensure continuity in treatment nor is their
compliance with prescribed treatment assessed. Prescription end dates do not coincide with
chronic clinic appointments and require patients to request renewals via sick call.120
In addition, we found that medication errors are not identified and/or not reported. One of the
charts reviewed was a patient who had been hospitalized for several days and yet the MAR
documents that nurses at MCC administered medication to him.121 This is a significant
documentation error that was not recognized or reported. Also, there is no accountability for the
medications that were prepared but not administered to this patient.
In 23 months of CQI minutes provided for review, medication errors were reported only in four
of those months.122 Only once was there an attempt to categorize the types of errors reported.
Pharmacy inspection reports are also not discussed at CQI meetings. There was no discussion or
analysis to determine root causes of medication errors or trending to identify problems with the
system to provide medications, or improve patient safety. Persistent problems with medication
practices are not subject to corrective action or systematic quality improvement.
Medication errors have long been recognized as a substantial area of focus in improving the
safety of patient care.123 Handwritten orders and transcription have been eliminated in many
correctional health care programs because of error and inefficiency. An obvious solution is to
Lippert Report Menard pp. 21-22.
Pharmacy/Medication Administration Patients #8-11.
121 Patient #2 Specialty Consultation and Hospitalization
122 MCC CQI agenda and minutes June 2016 – April 2018.
123 Institute of Medicine (2000), To Err is Human: Building a Safer Health System. Washington DC: The Academies Press.
119
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install computerized provider order entry (CPOE). This eliminates transcription by hand. Labels
generated from the computerized order after it has been reviewed by a pharmacist are affixed
to the MAR.124 Automated dispensing cabinets are also being used more often now to record the
withdrawal of controlled substances and eliminate manual inventory control systems like that
implemented at DCC because of non-compliance on the audit at DCC. Upgrading pharmacy
services in this way requires capital expenditure and would only likely happen as a statewide
decision made by IDOC. But if these pervasive problems are not identified, discussed, studied, or
reported at the facility level, IDOC is without notice that there is a systemic issue that must be
addressed statewide.
Orders and Delivery of Medication
Medications are obtained from BosWell Pharmacy Services, via subcontract with Wexford.
Prescriptions are faxed to BosWell and filled in 30-day “blister packs,” and then delivered to MCC.
A pharmacy assistant receives and inventories the medications in the medication storage area
and then puts them into the room nurses use to prepare medication to give to patients. The
pharmacy assistant we interviewed reported that prescriptions faxed to BosWell generally are
received the next day. Delays in receiving medications were because the order needed
clarification, a drug-drug interaction had to be addressed, or they required higher level approval
(nonformulary). If medications are urgently needed, they can be obtained from a local pharmacy.
The pharmacy technician stated that there is communication with the hospital before patients
are discharged and if they are on medications that are not on formulary or will require time to
obtain, the Medical Director will ask the hospital to keep the patient until the medication can be
obtained from BosWell. Rarely is the back-up community pharmacy used.
We toured the medication storage room where the pharmacy assistants send and receive
medication supply and the medication room where the nurses prepare medication for
administration. These rooms were clean, uncluttered, well lighted, and kept secure. There is a
refrigerator with a thermometer and temperature log that was up to date. All other refrigerators
used to store medications had thermometers and documentation of daily temperature checks.
Of the logs inspected, temperatures were within the correct range. No outdated medication was
found in the medication storage or preparation rooms. On Monday May 21, 2018, we observed
the count of controlled substances and instruments between day and evening shift, and verified
that it was accurate.
Medication orders in the charts reviewed were complete and there was an accompanying
progress note that indicated the reason for the order. Transcription of the order by a nurse to
the MAR was delayed in two of the charts reviewed (82%); therefore, the delivery of either
antiviral or anticoagulation medication to the patient was delayed. We also noted that one of the
charts reviewed for sick call had an order that was not transcribed for five days after the patient
was seen by the provider for constipation.125 We also found an instance of a nurse who wrote
Patient Safety Network. (2017) Medication Errors, Agency for Healthcare Research and Quality available at
https://psnet.ahrq.gov/primers/primer/23/medication-errors.
125 Pharmacy/Medication Administration Patient #1, 4 and Sick Call Patient #14.
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the date of the new order over the old order, rather than writing the new order on a new line on
the MAR.126 This is an alteration of the record and should be prohibited.
When the medication arrives from BosWell, a pharmacy assistant verifies the medication
received against the order, which serves to identify dispensing errors. Once verified, the
medication is put in the nurses’ medication work room into boxes designated by the housing
location of the inmate.
Medication Administration
The morning medication pass is scheduled to take place between 3:00 a.m. and 5:00 a.m. and
the evening medications are administered between 6:00 p.m. and 8:00 p.m.127 Nurses pre-pour
all medications administered to patients at MCC. We observed the preparation of medications,
which is done in a large room in the health care unit that contains shelves with boxes for patients
in each housing unit and three ring binders of MARs for the current month. Pre-pouring entails
looking at the MAR, selecting the right medication for the patient, popping the pill out of the
blister pack, and putting it into an envelope labeled with the patient’s name and medication. The
envelopes are re-used for the same patient.
We also observed a nurse prepare controlled substances for administration. Controlled
substances are stored in a double locked cabinet in the trauma room. A list of inmates with orders
for controlled substances is used to guide the nurse in removing individual doses for each inmate
on the list. Once removed from the blister card and signed out on the controlled substances log,
the medication is put into a collective cup. The nurse takes the cup to the medication room. The
nurse then selects the correct medication for each patient from the collective medications in the
cup and puts it into the envelope for the individual patient.
Once all the medications the patient is scheduled to receive are in the envelope, it is placed in a
tray and into a bag that the nurse transports to the housing unit. If it is a medication that must
be crushed, the nurse will crush it in advance as part of the pre-pour. We also observed a nurse
prepare a medication that was crushed and then floated in liquid. This is kept in a medicine cup
with a lid until it is delivered to the patient sometime in the next several hours.
We interviewed a nurse preparing medications in the medication room. She requests that the
patient provide identification only when she does not recognize or know the inmate. We also
asked what happened when a pill fell onto the floor when being given to a patient. She said that
the patient can choose to pick it up and take it or give it to her and she will waste it. She did not
offer to obtain another pill to replace the one that was wasted. This is consistent with what one
of the chronic care patients complained about during our visit.128

Pharmacy/Medication Administration Patient #3.
Email communication dated May 17, 2018 from Nicholas Staley, AAG to Michael Puisis.
128 Pharmacy/Medication Administration Patient #11.
126
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Documentation that medication was given takes place at the time it is prepared rather than at
the time it is given to the patient. If a patient refuses the medication or is not on the unit, the
nurse will circle their initial on the MAR to indicate that the medication was not given after
returning to the medication room in the clinic. Only 9% of the MARs selected for review were
complete.129 Documentation of doses given, refused, or not available was missing from 10 of 11
charts reviewed. This is extremely poor performance and calls into question the accuracy of the
MARs.
Contemporaneous charting on the MAR at the time of administration is considered the nursing
standard of practice. MCC does not meet this standard of professional practice.
None of the MARs reviewed contained the signatures and initials of nurses who administered
medication. This practice violates MCC’s own policy and procedure and demonstrates lack of
supervision and oversight failure.130 We asked the HCUA if a signature sheet was maintained and
were told that at one time a signature sheet was kept but that it was not up to date. Therefore,
it was not possible to identify any of the nurses who administered medication in the health record
of a patient.
Problems with medication administration practices at MCC are:
• Pre-pouring defeats the purpose of patient specific packaging. As soon as the medication
is taken out of the blister pack, verification that it is the correct medication, for the right
patient, at the right time and the right dose is not possible. This is a patient safety risk and
unnecessarily exposes the patient to errors in administration (receiving the wrong drug).
It is also a wasteful use of the cost of blister packaging.
• Reuse of individual envelopes to hold medication is unsanitary.
• Use of a list rather than the MAR to select controlled substances for administration
increases risk of medication error.
• Combining controlled substances for multiple patients into a single container and then
selecting the right medication, in the right dose for the right patient by sight is an
extremely risky practice and exposes patients to unnecessary harm from medication
error.
• Crushing and floating medication in advance of administration is time consuming, but also
dangerous because it changes the nature of the drug and can cause problems with
absorption or irritation of the GI tract. The medication should instead be provided in
another form (liquid or injectable).
• Two-part identification is not used to identify inmates before administration, greatly
increasing the risk of giving the wrong medication to the wrong patient.
• When medication is dropped during administration, patients are not given replacement
medication. It is cruel for nurses to make a patient choose between missing a dose or
ingesting medication that has been dropped and unsanitary.

129
130

The only MAR that was complete was Pharmacy/Medication Administration Patient #3.
V4-1. Pharmacy Services p. 5.

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•
•

Nurses do not have a way to verify medication that is not taken. Visual identification of
medication remaining after administration is not accurate.
Medication is not documented at the time it is given. This practice is a source of errors
and numerous omissions in documentation of patient care.

Renewal of Chronic Disease Medications
Chronic disease medications are provided to patients monthly either as “Keep on Person” (KOP)
or each dose is administered by a nurse. The scheduled appointments for chronic disease clinic
do not coincide with the end date on medications ordered for chronic disease.131 Providers often
order medications for patients with chronic conditions without seeing the patient.132
MCC’s policy on provider visits is that the MAR is available with the medical record at the time of
a provider visit.133 We saw no evidence that current MARs were available at the time a patient
saw a provider. If filing is up to date, the MAR from the previous month will be in the chart for
the provider to review. However, MCC’s policy and procedure on care of patients with chronic
conditions makes no suggestion that the MAR be reviewed to evaluate patient adherence to
prescribed treatment.134 Further, MCC’s policy is that if an inmate refuses medication twice in
two days they are referred to a provider for evaluation and possible change in treatment.135
There were multiple examples of patients not taking medication as prescribed in the charts we
reviewed which were not referred for provider evaluation. The record review also identified
several patients prescribed medication that required continuity who had lapses in their care.136
Chronic disease patients are not monitored to ensure continuity in treatment nor is their
compliance with prescribed treatment assessed.
In summary, medication services at MCC do not meet the standard of practice, they employ
outdated methods that compromise patient safety, and are not reviewed and analyzed to make
improvements that prevent human error and harm to patients.

Infection Control
Methodology: We interviewed the nursing supervisor responsible for infection control, reviewed
the infection control procedures, CQI Minutes, tracking logs, and other documents related to
communicable diseases and infection control. Infirmary porter training agenda and training
materials were reviewed. We also reviewed the charts of patients treated for tuberculosis
infection (two), HIV disease (three), and skin infection (two).
First Court Expert Findings

Pharmacy/Medication Administration Patients #1,9.
Pharmacy/ Medication Administration Patients #9, Sick Call Patients #1, 3, 8, 12.
133 V3-11 Assisting Physician Call Lines page 1.
134 V3-12 Medical Management of Offenders with Chronic Conditions.
135 V4-1. Pharmacy Services p. 5.
136 Pharmacy/Medication Administration Patients #6, #9; Sick Call Patient #1.
131
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The First Court Appointed Expert Report found that MCC had a named infection control nurse
(IC-RN). This individual was responsible for reporting infection to the Illinois Department of Public
Health. The facility also had an aggressive program to monitor and treat skin infections. Monthly
safety and sanitation infections were conducted by the IC-RN, as well as food handler screening,
tuberculosis monitoring, and hepatitis vaccination for staff and inmate workers. The IC-RN also
supervised the inmate peer education program.
Tours of the health care areas at the prison verified the availability of personal protective
equipment (PPE). Puncture proof containers were available for disposal of needles, syringes, and
other sharps in all areas where patient care took place. Problems identified with the infection
control program were that there were no alarms on the negative air pressure rooms to indicate
loss of pressure, porters had received no training and the water temperature used in the washing
machine in the infirmary was too low to sanitize soiled linens, impervious vinyl on exam stools,
tables and infirmary mattresses was torn or cracked, a paper barrier was not used between
patients on the exam table, and there was no policy to clean the table between patients. Finally,
one of the sick call rooms did not have a sink for handwashing.137
Current Findings
MCC continues to dedicate one FTE to infection control. One of the Nursing Supervisors is
responsible for infection control. Her responsibilities include all those described by the First Court
Appointed Expert. In addition, she manages the HIV and HCV clinics. She was very knowledgeable
of the facility’s policies and procedures for infection control.
The IC-RN also tabulates the monthly infection control report that is reviewed at the CQI meeting.
This report lists the number of patients placed in isolation, status of the negative pressure room,
occupational exposures to blood borne pathogens, cases reportable to Public Health, skin
infections treated, patients screened for, monitored, and treated for HIV and HCV, and results of
tuberculosis skin testing. Review of CQI minutes from June 2016 through April 2018 reflect
minimal analysis of the data reported. We also found an instance of incorrect data reporting on
the monthly infection control report. This was a patient we reviewed who was positive on the
annual tuberculin skin test (PPD) given in October 2017.138 He should have been reported as a
converter, since there were three prior PPDs that were documented as 0 millimeters, which is
considered negative.139 Neither the October 2017 or November 2017 infection control reports
identify any TB converters.
The IDOC Infection Control Manual was reviewed. It was last updated in 2012. While the material
in the manual is thoughtful and many resources are provided, some of them are out of date. The
manual should be updated at least every two years. The IDOC Nursing Treatment Protocols,
revised March 2017, were reviewed and provide guidance to nurses in the care of common
Lippert Report Menard pp. 28-29.
Infection Control Patient #4.
139
Persons who have a previous negative skin test that becomes positive are labeled TB convertors. These are red-flag type
infection control issues as they mean that the incarcerated person has acquired TB within the prison. These need to be tracked
and investigated.
137
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infectious diseases and infections such as scabies, urinary infection, rash, pediculosis, chicken
pox, and skin infections. In addition, the Menard Health Services Policies and Procedures provide
detailed instructions for infection control, sanitation, and patient education material for several
common communicable diseases (syphilis, herpes, HIV, tuberculosis infection, etc.). The Health
Services Policies and Procedures were last reviewed in 2015 and need to be brought up to date.
Puncture proof containers were available for disposal of needles, syringes, and other sharps in
all areas where patient care took place. Menard Health Services Policies and Procedures include
detailed instructions for sanitation in the health care areas.140 Paper was present on all the exam
tables and there were sinks in all but one exam room. Hand sanitizer containers were in all patient
care areas, but two were empty.141 Two of the infirmary porters were interviewed and the
records of these two and one other infirmary porter were reviewed.142 The porters were
knowledgeable about their duties and stated that they had received formal training about their
duties. Their records revealed that all three had received training in 2017 or 2018. All three had
completed or initiated hepatitis B (and A for two) vaccination series. The infection control nurse
manager provided copies of their training curriculum.
As noted by the First Court Expert, the infirmary washing machine does not attain a high enough
temperature to adequately sanitize body fluid-contaminated linens. The infirmary has attempted
to address this deficiency by directing the porters to place bleach in all loads of linens being
washed and having a practice to separately bag and send obviously contaminated patient linen
to the facility’s industrial level laundry. This does not fully address the sanitation level required
to fully sanitize all patient linen for this high-risk patient population, who have bladder catheters
and issues with fecal and urine continence. We did not find among the Menard Health Services
any policy and procedure for laundering patient linens in the infirmary. There are policies and
procedures to clean, but nothing was found on laundry. We recommended to the HCUA that
testing the water temperature be done periodically and that a booster on the hot water inlet
could be used to increase temperature.
The IC-RN conducts Safety and Sanitation rounds monthly. The results of these inspections are
reported to the CQI committee monthly. We reviewed these reports and note that action taken
to correct identified problems is slow.143 We suggested revisions to the items looked for during
Safety and Sanitation rounds to incorporate items we were looking for during our site visit (vents,
chipped paint, paper posted on walls, torn upholstery, working examination equipment,
availability of hand wash, etc.).

V4-64 through V4-69.
North 1 Lower, South Lower.
142 Infirmary patients #5, 6, 7.
140
141
143

Menard Safety and
Sanitation Inspection

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Tuberculosis screening is completed annually. We did not evaluate actual performance of TB
screening. We reviewed the charts of two patients who completed prophylaxis.
•

In one case, at intake at NRC on 3/25/2018, the patient had a PPD of 10 millimeters, which
is considered positive for tuberculosis infection.144 The chest radiograph done on
3/26/2018 was normal. The health appraisal done at NRC on 4/6/2018 does not comment
or elaborate on the patient’s tuberculosis screening results and it is not noted on transfer
screening. The screening results should have been documented on both the health
appraisal and transfer summary. When the patient was received at MCC on 4/11/2018,
tuberculosis screening was done again with a 12-millimeter induration and a second chest
radiograph was done. He was seen promptly by the IC-RN and started on prophylaxis. He
was also screened for HIV and syphilis. He had baseline labs done and has received
medication as ordered. The secondary screening done when he transferred to MCC was
unnecessary and could have been avoided if the results of screening at NRC had been
apparent at the time of transfer.

•

The other chart reviewed was the patient who was a tuberculosis test converter which
was discussed earlier.145 We suggested that the IC-RN consider calculating the rate of new
conversions at MCC to assess risk on an annual or biannual basis per the CDC
recommendations for prevention and control of tuberculosis in correctional facilities.146

Inmates may request HIV testing at any time and it is also offered to inmates just before release
from incarceration. See the comments and suggestion regarding HIV opt-out testing made in the
earlier section of this report on Medical Reception and Intrasystem Transfer. Inmates who are
infected with HIV are managed by UIC. Three charts of patients seen by the UIC HIV clinic were
reviewed. In all three records reviewed, medication was initiated timely and each patient was
seen at scheduled intervals with labs done in advance. One patient did not receive medication
daily as prescribed and there is no documentation on the MAR as to the reason.147 See comments
about incomplete charting of medication administration in the section of this report on Pharmacy
and Medication Administration.
•

Another patient was seen in the HIV clinic on 11/17/2017 and the specialist
recommended that his dose of Metformin be reduced below 500 mg. because of an
interaction with one of the HIV medications.148 His primary care providers at MCC did not
act on this recommendation. When the patient was next seen by the HIV specialist on
4/10/2018, he was still on the same dose of Metformin. This time the HIV provider noted
the drug interaction and wrote the order to reduce the dose of Metformin. The patient
went for five months taking Metformin at a dose that was contraindicated. The HIV
specialist reduced the dose when his primary care provider failed to act on the

Infection Control Patient #5.
Infection Control Patient #4.
146 https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5509a1.htm.
147 Infection Control Patient #1.
148 Infection Control Patient #3.
144
145

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recommendation. This is an example of uncoordinated and contradictory care of a patient
with multiple chronic conditions.
We also reviewed the charts of two patients with skin infection.
•

The first was seen in nurse sick call for a complaint of having a boil for about a week.149
The nursing documentation does not indicate what the nurse’s action were to treat the
complaint, but there is documentation by a nurse practitioner later that day. The nurse
practitioner ordered an antibiotic (Bactrim) for 10 days. He saw the nurse practitioner 15
days later, who documented that the patient did not take the Bactrim because he did not
know what it was. This patient’s treatment was delayed because he misunderstood the
treatment plan and none of the nurse’s explained it to him.

•

The second patient had surgery to repair a hernia on 4/4/2018.150 Upon his return, he was
cleared for general population, with a follow up with a provider in five days. On
4/10/2018, the provider saw the patient for follow up. He ordered daily dressing changes
and an antibiotic (Levaquin) for 10 days. There is no documentation about the surgical
site and whether it is infected. We suggested to the IC-RN that a review of post-surgical
infections might result in a suggestion to use infirmary placement for a day or two after
return to the institution to ensure the patient was capable of their own wound care.

Hepatitis C (HCV) disease is also managed via the chronic care clinic, with the work up and
treatment of these patients directed by UIC.
The infection control program at MCC is managed by a dedicated nursing supervisor. Important
improvements have been made in the sanitation and safety of health care delivery at MCC since
the report of the First Court Appointed Expert. However, there are still areas that need attention,
including the analysis of clinical information to prevent infection and improve patient care,
updating of written directives, and the repair and maintenance of patient care areas and
equipment. We also found examples of patient care that were delayed, unneeded repetition of
screening and testing, and incomplete documentation that are consistent with systemic
problems in the delivery of health care at MCC that are discussed earlier in this report.

Dental Program
Dental: Staffing and Credentialing

Methodology: Reviewed staffing documents, interviewed dental and other staff, reviewed the
Dental Sick Call Log and other documents.
First Court Expert Findings

149
150

Infection Control Patient #6.
Infection Control Patient #7.

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•

•

MCC has a dental staff of three full-time dentists, one dental hygienist, and three full-time
dental assistants. All are Wexford employees except one of the dentists. In addition, one
PRN dentist and three PRN assistants are available if needed. This meets the
Administrative Directive staffing guidelines and is adequate for MCC’s 3700 inmates.
All providers have current credentials on file and all the staff are current with their CPR
certification.

Current Findings
While we agree with the First Court Expert that the number of authorized dental personnel
positions is adequate, staffing has deteriorated materially since the First Expert’s Report. When
all positions are filled, the clinic is staffed by three dentists, three dental assistants, one dental
hygienist, and one clerk. Currently, two dentist positions are unfilled151 and wait times for routine
care are approximately 15 months (see Figure 1 infra).
State positions are filled by a dental hygienist, a dental assistant, and a dental office associate.
Per the HCUA, the state dentist position had been open for more than two years. It had been
advertised several times, and there were applicants; however, the position expired (and had to
be reposted). Due to the inability of IDOC to fill the position, it asked Wexford to fill it.

Dental: Facility and Equipment

Methodology: Toured the dental clinic to assess cleanliness, infection control procedures, and
equipment functionality. Observed intake screening and evaluated the quality of x-rays taken at
intake. Reviewed compliance with radiologic health regulations.
First Court Expert Findings
• There are three clinics: a single chair clinic at North 2 that serves the segregation inmates
and a general population housed in that unit. A single chair unit is in the Receiving and
Classification clinic and is used for reception screening examinations. It contains a
Panorex x-ray and developer. The third is a four-chair clinic located in the HSU and serves
the rest of the institution. There is a 400-bed medium security satellite institution that
does not have a dental clinic. This population is served by the clinic in the Health Service
Unit. Both North 2 and R&C clinics have old and worn equipment.
• The chairs/units in the HSU clinic are only two years old and in excellent repair. There is a
single x-ray unit for this entire clinic and it is very old, faded, and worn. There is a Panorex
unit on the second floor of this building, above the dental clinic. The metal cabinetry is
old, rusting, and has several areas of chipping paint. Proper disinfection is difficult.
• The x-ray developers in the North 2 clinic and the R & C clinic do not work and radiographs
must be brought to the HSU clinic for developing. This is unacceptable, in that x-rays are
often needed immediately, especially as a diagnostic tool in urgent care situations.
• The four chairs/units in the HSU are in small individual spaces. This space is barely
adequate. The single chair clinics at North 2 and R&C are small but adequate. The lab and
151

A Wexford dentist recently retired, leaving a vacancy.

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sterilization area are large. The existing facility is adequate to meet the needs of the
institution. The x-ray developers need to be replaced or repaired immediately.
Current Findings
We concur with the First Court Expert’s findings with respect to the inadequacy of the dental
facilities and equipment. Moreover, they have not improved materially. We identified current
and additional findings as follows.
The panoramic x-ray unit in the R&C clinic does not have shielding between the unit and the door.
Before an x-ray is taken, people in the corridor are asked to move away from the door. There is
no x-ray processor in the North clinic because an inoperative unit was not replaced. Exposed film
is processed in the radiology clinic. There is an area in the MSU health clinic designated for a
dental clinic.

Dental: Sanitation, Safety, and Sterilization

Methodology: Reviewed Administrative Directive 04.03.102. Toured the dental clinics and
observed dental treatment room disinfection. Interviewed dental staff and observed patient
treatment.
First Court Expert Findings
• Surface disinfection was performed between each patient and was thorough and
adequate, and protective covers were utilized on most unit surfaces. Instruments were
properly bagged and sterilized. All handpieces were sterilized and in bags.
• The sterilization procedures themselves at the Health Service Unit clinic were improper.
Flow did not proceed from dirty to clean. The ultrasonic was on the wrong side of the sink,
and a dental lathe and protective covers were situated between the sink and the
autoclave.
• The R&C clinic used disposable instruments.
• The clinic at North 2 had a proper flow of sterilization from dirty to clean. Surface
disinfection was adequate. Protective covers were used appropriately. No biohazard
warning signs were posted in the sterilization areas. 152
• Safety glasses were not always worn by patients. Eye protection is always necessary, for
patient and provider. No warning signs were posted where x-rays were taken to warn of
radiation hazard.
Current Findings
Sanitation, safety, and sterilization have deteriorated since the First Court Expert’s Report. We
concur with the findings and we observed inadequate hand sanitation by the dentist between
initial examination patients (see Initial Examination section infra). We observed initial exams at
the R&C clinic, and treatment at the North 2 and HSU clinics. Surfaces were disinfected
152 CFR

1901.145(e)(4). “The biological hazard warning shall be used to signify the actual or potential presence of a biohazard and
to identify equipment, containers, rooms, materials, experimental animals, or combinations thereof, which contain, or are
contaminated with, viable hazardous agents.”)

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appropriately between patients and instruments were disinfected, bagged, and stored
appropriately. The HSU and North 2 clinics have protective glasses for patients; however, we did
not see them worn when we observed treatment at the HSU clinic153.

Dental: Review Autoclave Log

Methodology: Reviewed the last two years of entries in autoclave log, interviewed dental staff,
and toured the sterilization area.
First Court Expert Findings
• Spore testing of the steam autoclaves was being accomplished only once a month. This is
highly irregular and violates OSHA guidelines calling for weekly spore testing of
autoclaves. The dry heat sterilizer is tested on an irregular, somewhat quarterly basis.
These are egregious deficiencies that should be corrected immediately. Steam autoclaves
and dry heat sterilizers should be tested weekly.
Current Findings
Autoclave log management has improved since the First Court Expert’s Report and is adequate.
We identified current and additional findings as follows.
The dry heat sterilizer in the HSU clinic has not been used for two years and is not subject to
spore tests. Weekly spore tests for the steam sterilizers were documented, and the deficiencies
noted by the First Experts have been remedied.

Dental: Comprehensive Care

Comprehensive, or routine care154 is non-urgent treatment that should be based on a health
history, a thorough intraoral and extraoral examination, a periodontal examination, and a visual
and radiographic examination.155 A sequenced plan (treatment plan) should be generated that
maps out the patient’s treatment.
Methodology: Interviewed dental staff, reviewed dental charts of an inmates who received nonurgent care that were randomly selected from the Daily Dental Reports. Reviewed Daily and
Monthly Dental Reports.
First Court Expert Findings
• A review of 10 records revealed that a comprehensive examination was not performed,
and sequenced treatment plans were not developed. Examination of soft tissues for oral
cancer was rarely documented and periodontal assessments employing probing was not
part of the treatment process.
Why We Take Infection Control Seriously. UIC College of Dentistry. Viewed at https://dentistry.uic.edu/patients/dentalinfection-control, viewed February 2, 2018. “We use personal protective equipment […] as well as provide eye protection to
patients for all dental procedures.”. Emphasis added.
154 Category III as defined in Administrative Directive 04.03.102.
155 Stefanac SJ. Information Gathering and Diagnosis Development. In Treatment Planning in Dentistry [electronic resource].
Stefanac SJ and Nesbit SP, eds. Edinburgh; Elsevier Mosby, 2nd Ed. 2007, pp. 12-15, passim.
153

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•
•

Hygiene care and prophylaxis were never part of comprehensive care. Restorations were,
in five of the charts, provided without appropriate diagnostic x-rays for caries. No hygiene
treatment was part of any of the routine care provided.
Oral hygiene instructions were never documented in the dental record as part of
treatment.

Current Findings
We concur with the First Court Expert’s finding that comprehensive care is inadequate.
Moreover, it has not improved materially. We identified current and additional findings as
follows.
Routine care is provided without adequate x-rays and periodontal assessment. Rather than
relying on intraoral x-rays, the accepted professional standard, the dentist bases his charting for
caries on the panoramic x-ray in conjunction with a visual exam.156 Not only is this insufficient to
diagnose interproximal (between the teeth) decay but it ignores periodontal disease. In fact, even
when periodontal disease is occasionally categorized per Administrative Directive 04.03.102
(Dental Care for Offenders), there is no documented periodontal probing157,158 and the location
of the disease is not noted.159 Dr. Assemeier stated that he occasionally does periodontal probing
but does not record PSR; however, none of the records reviewed had documented probing. He
said that he routinely did PSR on his military patients when he was in private practice and
occasionally on his other patients, but not at MCC.160
Of 16 inmates who received comprehensive (routine) care, none had documented periodontal
probing or a sequenced treatment plan. While 10 (56%) had a recent Treatment Needed form

156 Dental

Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure. American Dental
Association and U.S. Food and Drug Administration, 2012. Table 1, pp. 5-6. (Dentate or partially dentate adults who are new
patients receive an “[i]ndividualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior
bitewings and selected periapical images. ” Furthermore, recall patients [i.e., biennial exam patients] should receive posterior
bite wing x-rays every 12 to 36 months based on individualized risk for dental caries. With respect to periodontal disease,
“[i]maging may consist of, but is not limited to, selected bitewing and/or periapical images of areas where periodontal disease
(other than nonspecific gingivitis) can be demonstrated clinically.”)
157 Stefanac SJ. Information Gathering and Diagnosis Development. In Treatment Planning in Dentistry [electronic resource].
Stefanac SJ and Nesbit SP, eds. Edinburgh; Elsevier Mosby, 2nd Ed. 2007. A panoramic radiograph has insufficient resolution for
diagnosing caries and periodontal disease. Intraoral radiographs (e.g., bite wings) and periodontal probing are necessary (p. 17).
Also, Periodontal Screening and Recording (PSR), an early detection system for periodontal disease, advocated by the American
Dental Association and the American Academy of Periodontology since 1992, is an accepted professional standard. Id., pp. 1214. See American Dental Hygiene Association. Standards for Clinical Dental Hygiene Practice Revised 2016. Periodontal probing
is also a standard of practice for dental hygiene.
158 Makrides, N. S., Costa, J. N., Hickey, D. J., Woods, P. D., & Bajuscak, R. (2006). Correctional dental services. In M. Puisis (Ed.),
Clinical Practice in Correctional Medicine (2nd ed., pp. 556-564). Philadelphia, PA: Mosby Elsevier, p.560 (Early diagnosis of
periodontal disease is important since the disease is often painless and the prevalence of moderate to severe periodontal disease
in correctional populations is high and often not associated with pain).
159 The only categories related to specifically periodontal disease are Ib “(acute periodontal abscess”), Ic (“acute periodontitis”),
Ie (“acute gingivitis”), IIIb (“localized gingival involvement”), and Vb (“lack of visible gingival irritation”). Id. Attachment A.
160 None of the dental charts reviewed at MCC documented periodontal probing.

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completed,161 five (31%) had the Treatment Needed assessment informed by bite wing x-rays,162
and (38%)163 had a cleaning (prophy or oral prophylaxis) that preceded treatment.164
Biennial exams are scanty and of minimal clinical value. Of eight patients who received biennial
exams, none of the exams were informed by bite wing x-rays or documented periodontal
probing, none had a sequenced treatment plan, and two had no documented oral cancer
screening.165
While the dental examinations performed by the dentist did not document a periodontal
assessment, the dental hygienist documented a periodontal assessment when she saw a patient.
However, she did not document periodontal probing, a standard of care for dentistry and dental
hygiene.
Absent a sequenced treatment plan informed by intraoral x-rays and periodontal probing, the
dentist does not have enough information to make an informed decision. In the community, what
is called a biennial exam is analogous to a periodic exam.166, To summarize, what is called a
biennial exam is cursory, and not substantially different from the inadequate “complete”
examination performed at intake.
Not only is periodontal disease underdiagnosed but it is undertreated. In none of the MCC dental
charts reviewed was there a treatment plan that identified specific non-surgical periodontal
procedures such as scaling and root planing. Moreover, the Daily Treatment Report that lists the
treatment provided to each patient has no section for periodontal treatment.167 Both the dentist
and dental hygienist stated that they were in private practice and were familiar with the standard
procedure codes which are required for billing third parties and are industry standard. However,
there is no column for SRP and no way of knowing if it is performed.168, 169 The hygienist said that
the she classifies SRP as “periodontal;” however, she does not record the number of quadrants,
nor are there details of the treatment (e.g., that a SRP procedure was performed, and which

Comprehensive Care Patients #2, 6, 8, 9, 10, 11, 12, 13, 14, and 16.
Comprehensive Care Patients #7, 10, 12, 14, and 15.
163 Comprehensive Care Patient #1, 4, 11, 12, 14, and 16.
164 Dr. Assemeier said that while he does not do a sequenced treatment plan, he often includes a treatment plan in his clinical
progress notes.
165 Biennial Exam Patients #1 and 8.
166 The profession standard code for a periodic exam is D0120. It is defined as “[a]n evaluation performed on a patient of record
to determine any changes dental and medical health status since a previous comprehensive or periodic examination. This includes
an oral cancer evaluation, and periodontal screening where indicated, […]].” Dental Procedure Codes. American Dental
Association, 2015.
167 The categories on the form are “scale and prophylaxis,” “gingivitis”, and “periodontal.” While the procedure “scale and
prophylaxis” corresponds to American Dental Association treatment code D1110 that has a profession-wide definition and
treatment, “gingivitis” and “periodontal” do not have a standard treatment. ADA Treatment Codes, 2015.
168 The ‘uniform record system’ sponsored by the American Dental Association is the Code on Dental Procedures and
Nomenclature. “In August 2000 the CDT Code was designated by the federal government as the national terminology for
reporting dental services on claims submitted to third-party payers.” American Dental Association Dental Procedure Codes, 2015,
p. 1.
169 ADA Treatment Codes D4341 and D4342.
161
162

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teeth were treated). The hygienist also said that she does not document PSR, although she did
so in some of the private practices where she worked.

Dental: Intake (Initial) Examination170

Methodology: Observed intake examination process. Reviewed dental records of inmates that
have been examined recently. Reviewed Administrative Directive 04.03.102.
First Court Expert Findings
• All records reviewed revealed that the exam was performed timely, a panoramic x-ray
was taken, and the APHA categorization was completed.
• Screening was not observed; however, based on its description, it appeared to be
procedurally adequate.
• Four panoramic x-rays were processed improperly and presented as an opaque negative.
These radiographs are not acceptable for diagnostic use. This problem did not occur in
later record reviews. I was told the developer in the reception clinic was not functioning
properly. The radiographs were being developed in the main clinic.
Current Findings
The “Initial Examination” is governed by Administrative Directive 04.03.102 (¶II F 2), which states
(inter alia) that
Within ten working days after admission to a reception and classification center
or to a facility designated by the Director to accept offenders with disabilities for
a reception and classification center, each offender shall receive a complete
dental examination by a dentist.171
The initial examination process has not changed materially since the First Court Expert’s Report
and remains inadequate. While we agree that the initial examination was performed timely and
the APHA categorization was completed, we find it to be inadequate nonetheless. We cannot
compare our findings to those of the First Court Expert since the First Court Expert did not
observe the exam.
MCC receives approximately 100 prisoners each month. The dentist (standing) examined a
patient seated in a dental chair with a dental light. He performed a cursory oral exam using a
mouth mirror, which lasted approximately five minutes, with a dental assistant acting as
recorder. He used a mouth mirror to illuminate the lateral border, and the tongue and floor of
the mouth. The dentist wore gloves and changed them between patients; however, he did not
wash his hands (or disinfect them using alcohol wipes) between donning new gloves. This is a
breach of infection control protocol.
170 The First Expert Report describes

the examination performed at intake as a “Screening Examination;” however, Administrative
Directive 04.03.102 describes it as a “complete dental examination.” We use the terminology of the Administrative Directive and
refer to the intake or initial dental examination as a complete dental examination.
171 Administrative Directive 04.03.102 (¶II F 2). Emphasis added. Furthermore, the exam should include, “[c]harting of the oral
cavity and categorization of status or treatment needs in accordance with the American Public Health Association's priorities
delineated in Attachment A. Id. at (¶II F 2a). Emphasis added.

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In addition to the charting of existing and needed dental treatment, the record noted that OHI
(oral hygiene instruction) was provided, and that an oral cancer screening (OCS) was performed
and the results were negative or WNL (within normal limits). The “OHI” consisted of saying,
“make sure you brush and floss” – and took no more than a minute.172 This is not adequate oral
hygiene instruction. Furthermore, while spooled dental floss is deemed contraband at MCC, he
did not mention the existence of (not to mention how to use) floss alternatives.
Of 10 charts of inmates who had recent intake examinations, nine (90%) panoramic x-rays were
clinically adequate. Since the panoramic x-rays are not available to inform the charting, the
dentist completes the charting when the x-ray is available. Oral cancer screening was
documented in all charts; however, no chart documented periodontal probing.

Dental: Extractions

Methodology: Interviewed dental personnel and reviewed 11 dental records of patients who had
teeth extracted selected from the Daily Dental Report and 14 charts of patients who were
scheduled to have extractions.
First Court Expert Findings
• A review of 10 records of inmates who had dental extractions revealed that nine of the
10 were in full compliance with the aspects reviewed. The radiograph was over three
years old in one of the records and the reason for extraction was not included in another.
This does not rise to a level of concern. A quick scan of several other records of inmates
who had teeth extracted did not reveal a repeat of these issues.
• In two of the records, non-restorable was provided as a diagnosis for pain. This problem
was seen in other records reviewed in other areas.
Current Findings
Our findings diverge from those of the First Court Expert and suggest that the treatment of dental
extractions has deteriorated since the First Court Expert Report. While the First Court Expert
found documentation to be generally adequate, we found that while of 11 patients who had
extractions, all were informed by adequate preoperative x-rays and were accompanied by signed
consent forms, nine (82%) forms173 listed the tooth number but not the reason the tooth was to
be extracted, and nine (82%)174 did not document an updated health history.
Of 12 patients who were scheduled for extractions, the wait time ranged from seven to 41 days,
with a median of 26 days (see Figure 2 infra).175 Of the 11 who were prescribed antibiotics, all
but one (91%) waited more than 10 days.176 This is problematic, since the tooth should be
Oral Hygiene Instructions (D1330) “may include instructions for home care. Examples include tooth brushing technique,
flossing, and the use of special oral hygiene aids.” American Dental Association Codes extract.
173 Extractions Patients #1, 2, 4, 6, 7, 8, 9, 10, and 11.
174 Extractions Patients #1, 2, 3, 4, 5, 8, 9, 10, and 11.
175 The patient was seen with a complaint of pain, palliated, and scheduled for an extraction appointment. Scheduled Extractions
Patients #1, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14, and 15.
176 Scheduled Extractions Patients #1, 2, 3, 6, 8, 9, 10, 11, 12, 13, 14, and 15.
172

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extracted within the therapeutic window of the antibiotic,177 which for these patients was 10
days.178

Dental: Removable Prosthetics

Methodology. Reviewed four charts of patients who received partial dentures (selected from the
Prosthetics List) in the past year and interviewed dental staff.
First Court Expert Findings
• Removable partial denture prosthetics should proceed only after all other treatment
recorded on the treatment plan is completed. The periodontal, operative, and oral
surgery needs all should be addressed first. In none of the records reviewed was a
comprehensive examination and treatment plan developed prior to impressions for
removable partial dentures.
• In none were oral hygiene care or oral hygiene instructions provided.
• Periodontal assessment and treatment were not provided in any of the records.
• Because there was no comprehensive examination, nor any treatment plans developed,
it was impossible to ascertain if all necessary care, including operative and/or oral surgery
treatment, was completed prior to fabrication of removable partial dentures.
Current Findings
We concur with the First Court Expert that removable prosthetics treatment is inadequate.
Moreover, it has deteriorated since the First Court Expert’s Report, as wait times have increased
(see Figure 1 infra). As with most of the other patients who received comprehensive care, none
had a sequenced treatment plan or a periodontal assessment that included documented probing.
Three (75%) had no documented oral hygiene instruction.

Dental: Sick Call/Treatment Provision

Methodology: Interviewed dental staff, reviewed Dental Sick Call Logs, Daily Dental Reports, and
reviewed records of 12 inmates who were seen on sick call.
First Court Expert Findings
• Sick call is accessed via the inmate request form or from staff referral if the perceived
need is immediate. It takes five to 10 days for urgent care complaints to be seen. This is
unacceptable; they should be seen within 24-48 hours.
• In all 10 records reviewed the SOAP format was used and the patient’s complaint was
addressed.

Shulman JD, Sauter DT. Treatment of odontogenic pain in a correctional setting. Journal of Correctional Health Care (2012)
18:1, 58 – 69; p. 68.
178 Makrides et al.(“[d]elayed dental treatment of the original focus of the [tooth-related] infection may turn a minor problem
into a serious condition. Although infection is usually self-limiting, and spatially-confined, it may spread because of a highly
virulent organism. Complications could include Ludwig’s angina, mediastinitis, cerebral abscess, maxillary sinusitis, chronic
fistulous tracts, and infective endocarditis.” (p. 559).
177

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•
•

•
•

•

•

The sick call appointment was not used for routine care. Treatment proceeded with a
diagnosis in only two cases and an improper diagnosis in another. This lack of a proper
diagnosis was seen in records reviewed in other areas that included sick call entries.
An inadequate triage system is in place that prioritizes treatment needs. Inmate request
forms are evaluated by the dental program by the following day and their treatment
needs, based upon the request form, are prioritized. Urgent care needs are identified
from the request form and seen ASAP, often taking five to 10 days. Others are scheduled
accordingly or placed on the hygiene list if requested. All request forms are seen within
14 days.
Inmates seek urgent care via the inmate request form or, if they feel they need to be seen
immediately, by contacting staff, who can then call the dental clinic with the inmate’s
complaint. These inmates are seen at the dentists’ discretion.
Inmates with urgent care complaints (pain or swelling) from the request form often take
five to 10 days to be seen. They should be seen with 24-48 hours from the date of the
request. Mid-level practitioners at the units do not routinely see the inmate face-to-face
to evaluate urgent care needs as indicated on the request form. If an inmate complains
of a toothache, swelling, or pain to the nurse making rounds, the nurse can call the dental
clinic with this information. They can provide over-the-counter pain medication.
Some inmates are seen immediately if correctional staff can get the inmate to the dental
clinic. There is no system in place to provide a face-to-face evaluation with medical/dental
staff or inmates that complain of pain or swelling. This should be provided within 24-48
hours from the date of the request.
Request forms from inmates seeking routine care are evaluated the next working day and
the inmate given an appointment to be evaluated within 14 days. Inmates requesting to
have their teeth cleaned are placed on a waiting list. Inmates for routine care are placed
on a waiting list in sequential order. This list is approximately nine months long.

Current Findings
Dental sick call has deteriorated since the First Court Expert’s Report. We concur with the findings
of First Court Expert that dental sick call for urgent care issues is often untimely and the sick call
triage system for dental problems is inadequate. We also identified current and additional
findings as follows.
Sick Call
Prisoners access sick call by placing written requests (kites) in boxes in the cellhouses or by signing
up for nurse sick call. Of five patients who submitted kites for dental sick call, the wait time ranged
from five to 14 days, with a median of nine days. All progress notes were in the SOAP format.
Of seven entries in the nurse sick call log that suggested dental pain, all were referred to the
dental service and five (71%) received face-to-face assessments by nursing. All those assessed
received analgesics. Of six patients whose records document treatment, wait time to see a

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dentist ranged from five to 14 days, with a median of six days.179 Patients who signed up for nurse
sick call were generally seen by nursing staff the next day.
Timeliness of Care
Figure 1 is a summary of patient wait times based on monthly dental reports from May 2017 to
April 2018. The wait time for fillings is more than 60 weeks (15 months),180 higher than it has
been since May 2017. Moreover, with only one dentist available, the backlog will continue to
grow. According to the April dental report, 45 extractions and 18 fillings were performed; a 2.5:1
ratio, which suggests that MCC has insufficient dentist staffing to provide needed routine care
and instead must focus on urgent care needs.
Wait time for dentures seems to have stabilized at around 15 months as well. However, since the
standard of care is to complete the needed fillings and periodontal treatment before the denture
impressions are done, there may be an additional delay of several years before denture
fabrication can begin.
Figure 1. Wait Time for Filling and Denture Appointments

Wait Time (Weeks)
90
80
70
60
50
40
30
20
10
-

Fillings

Dentures

The kite log from January through April 2018 comprises 413 entries, listed by service
requested.181 Before a prisoner may have a filling appointment, he must first have a “filling
evaluation,” to determine if a filling is an appropriate treatment. If a filling is deemed to be the

Nurse Sick Call Patient #6 has no documented treatment for this episode.
The First Court Expert reported that the routine care wait list was approximately nine months long (see supra), which shows
that the MCC dental program has deteriorated markedly since then.
181 Per memo from Colleen Runge to Gail Walls, HCUA, dated 5/21/18, the Dental Codes are O1 (written request), O2S (filling
evaluation), O3S (filling evaluation), O4S (denture adjustment), O1x1 (extraction), O2x1 (filling), O3x1 (impressions), O6 (oral
prophylaxis), O6x1 (dentist-referred prophylaxis), and O6D (Dilantin prophylaxis).
179
180

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appropriate treatment, the patient is placed on the filling list.182 Of the 39 entries for fillings on
the kite log, 28 were for filling evaluations and 11 were for fillings.
The Wexford contract specifies that “[v]endor shall provide dental checkups to offenders every
two years, or more often if clinically indicated, and evaluations must be provided within 14 days
after the offender's request for routine care treatment.”183 However, it is mute on the more
critical issue, the maximum waiting time for treatment.184 So, under current dentist staffing, a
prisoner who needs (for example) three fillings that require three appointments may wait more
than three years for the last tooth to be filled. It is more likely than not that the teeth awaiting
filling will become more difficult to fill and cause preventable pain.
While Wexford does not report periodontal treatment backlogs, dental hygienist caseload is
reported in the in the monthly CQI minutes. The April CQI minutes (based on March data)
reported a dental hygienist caseload of 1018 patients and the March 2018 Dental Report noted
that the hygienist performed 61 cleanings/prophylaxes. This equates to a more than 16-month
backlog. While a cleaning or prophy is not a periodontal procedure,185 it is often a precursor to
periodontal treatment (if periodontal treatment has been prescribed by a dentist on the
treatment plan).186 A wait of more than a year before periodontal treatment can begin, even if it
is diagnosed, is unreasonable and a such a treatment delay can result in preventable disease
progression with concomitant bone loss.
Figure 2 shows that while the wait time for extractions has decreased from its high of 12 weeks
in August 2017, it is currently at an unacceptable level for reasons explained in the extraction
section, supra.

X-rays may be taken then, rather than at the biennial or initial exam. However, by delaying taking x-rays until the filling
evaluation, valuable time may be wasted, and undiagnosed decay may progress to a point where the tooth becomes more difficult
(or impossible) to fill.
183 HFS# 2010-05-008, ¶ 2.2.6.1
184 If the filling evaluations occur within 14 days, Wexford is deemed to be complying with the contract even if the queue for
fillings is infinite. Similarly, if prisoners receive timely biennial examinations, Wexford is deemed to be in compliance even if the
exams are incomplete and below accepted professional standards.
185 The American Dental Association Classifies it as a preventive procedure (Code D1110).
186 Treatment plans rarely prescribe periodontal treatment.
182

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Figure 2. Wait Time for an Extraction187

Wait Time (Weeks)
14
12
10
8
6
4
2
0

Dental: Orientation Handbook

Methodology: Reviewed orientation manual and related documents.
First Court Expert Findings
The orientation manual is minimally but adequately developed for dental services and addresses
types of care, access to care, and how treatment is scheduled.
Current Findings
We were not provided with an inmate orientation manual.

Dental: Policies and Procedures

Methodology: Reviewed Administrative Directives that deal with the dental program.
Interviewed dental staff. Reviewed dental charts. Toured dental clinical areas. Reviewed DCC
organizational chart.
First Court Expert Findings
The Dental Director was not aware of a policy and procedures manual. A review of the MCC Policy
and Procedures Manual revealed a large section devoted to the policies and procedures for
dental care. It was dated 1995, with no indication that it has been updated since then. This is not
an adequate document from which to run the dental program.
Current Findings

187

Wait time was not reported for February 2018.

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The First Court Expert found that MCC dental policies and procedures were outdated and should
be rewritten. This was done in 2015. However, the intake examination is still not consistent with
the plain text of Administrative Directive 04.03.102.
The dental program is governed by Administrative Directive 04.03.102, amended 1/1/2012. It
specifies that within 10 working days after admission to a reception and classification center,
offenders shall receive “a complete dental examination by a dentist” (¶F2; emphasis added).
The initial examination done at intake was not a complete examination by any reckoning and was
in violation of IDOC policy.188
We reviewed three MCC policies that relate to dental care: V1-15 (dental reporting and statistics),
V1-16 (dental radiography), and V1-17 (handling instruments). All were revised January 2015.
The policies suffer from several problems. First, the versions we were provided were unsigned.
Second, the previous Medical Director’s signature block is present and there is no evidence that
the current Medical Director is aware of (and approves of) these policies. Finally, there is no
signature block for the Dental Director – the individual directly responsible for implementing the
policies.

Dental: Failed Appointments

Methodology: Reviewed dental sick call log. Interviewed dental staff. Reviewed daily dental
reports.
First Court Expert Findings
• The failed appointment rate of about 40% is very high. Reasons included refusals,
lockdowns, and “other.” When asked, the dentists related that “other” usually meant
security precedence and unavailability of escort staff.
• The percentage was very high for the month of April, when 362 appointments were
missed because of a lockdown.
• When only failed appointments (inmate chose not to come to appointment) are included,
the percentage drops to about 12%. In an older high security institution with multiple
missions and security concerns such MCC, movement of inmates is a challenge. That does
not excuse the problem. Every effort should be made to work with administrative and
correctional staff to correct this issue.
Current Findings
We concur with the findings of First Court Expert that failed appointments are a problem, despite
apparent improvement. However, the April 2018 failed appointment rate (15.2%) is the lowest it
has been this year.189 On the other hand, there were 31 refusals, almost a yearly high.

Dental: Medically Compromised Patients
188
189

See section on Comprehensive Care, supra.
Source: Monthly Dental Reports.

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Methodology: Reviewed health history form and randomly selected records of eight patients
who were on Chronic Care Lists with diabetes or on anticoagulant therapy and had a dental
encounter within the past two years.
First Court Expert Findings
• A review of the dental records of the four inmates on anticoagulant therapy revealed that
two records made no mention of this in the health history section of the dental chart. It
was indicated but not “red flagged” in the other two. No treatment was provided to any
of these inmates.
• When asked, the clinicians indicated that they do not routinely take blood pressures on
patients with a history of hypertension.
Current Findings
Documentation of the health record of medically compromised prisoners has not improved
materially since the First Court Expert Report and we concur that documentation of the health
record of medically compromised patients is inadequate. However, we identified current and
additional findings as follows.
Of eight charts reviewed, five (63 %) did not document an updated health history at the last
encounter.190 There was no documented periodontal assessment and request for follow-up for
the diabetics,191 which is particularly problematic given the relationship between periodontal
disease and diabetes.192

Dental: Specialists

Methodology: Interviewed dental staff, reviewed CQI documents, and reviewed dental charts of
inmates who were seen by an oral surgeon.
First Court Expert Findings
• A local oral surgeon, Dr. Jay Swanson, is available and used for dental conditions such as
trauma, removal of difficult wisdom teeth, and evaluation and removal of oral pathology.
He has offices in Effingham and Mt. Vernon, Illinois. General anesthesia cases use the
Effingham office.
• All records reviewed revealed proper case selection and good patient management, and
good record documentation.

Medically Compromised Patients #2 (anticoagulant therapy), #3 (diabetes), #5 (diabetes), #6 (anticoagulant therapy), and #7
(anticoagulant therapy).
191 Medically Compromised Patients #3 (generalized bone loss noted but periodontal probing was not documented, and
treatment plan was not revised to include non-surgical treatment), and #5 (dental hygienist performed a prophylaxis; however,
periodontal probing was not documented).
192 See, for example, Herring ME and Shah SK. Periodontal Disease and Control of Diabetes Mellitus. J Am Osteopath Assoc. 2006;
106:416–421; Patel MH, Kumar JV, Moss ME. Diabetes and Tooth Loss. JADA 2013;144(5);478-485 (adults with diabetes are at
higher risk of experiencing tooth loss and edentulism than are adults without diabetes); and Teeuw WJ, Gerdes VE, and Loos BG.
Effect of Periodontal Treatment on Glycemic Control of Diabetic Patients. Diabetes Care 3 3 :421-427, 2010 (periodontal
treatment leads to an improvement of glycemic control in type 2 diabetic patients).
190

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Current Findings
Oral surgery consultations have not changed materially since the First Court Expert’s Report and
remain adequate and we concur with the First Court Expert’s findings. Of five dental charts of
patients sent to an offsite oral surgeon, all patients appear to have received appropriate
treatment.

Dental: CQI

Methodology: Reviewed CQI minutes and reports. Interviewed dental staff.
First Court Expert Findings
• The dental program contributes monthly statistics to the CQI committee. The dental
program conducted two studies, one in 2013 and another in 2014. One involved the
effects of the medications Dilantin and Norvasc on the incidence of gingival hyperplasia.
The other was a study of grievances as related to the different cellhouses within the
institution. The results of each was presented and steps taken to address the findings.
• No studies were in place to address program weaknesses and problem areas.
Current Findings
The dental CQI program, has improved since the First Court Expert’s Report and is adequate. We
were provided with a summary of two studies.193 We concur with the First Court Expert’s findings
that there is an ongoing dental CQI program. Moreover, current and additional findings follow.
A study of 50 patients who were on the restoration (filling) list May 2015 to December 2015, with
treatment dates ranging from August 2016 until September 2016, found that 94% had successful
restorations without need of extraction. However, the actual study was not provided – just a fiveline summary, so its validity cannot be assessed.
Another study summary, “Effects of lockdowns and dental coverage on filling numbers and
backlog numbers” had no analysis – just a recitation of findings.

Internal Monitoring and Quality Improvement Activities
Methodology: We reviewed annual and monthly CQI meeting minutes. We interviewed the CQI
coordinator. We reviewed multiple death summaries and death records.
First Court Expert Findings
There was no relationship between CQI activity and improvements in the quality of services
provided.
Current Findings
We agree with the First Court Expert’s finding. We were told in interviews that a medical records
technologist is the CQI Coordinator. She has no training in CQI. Although she told us that she
193

Since we were not provided with the actual studies, we have no basis to assess their validity.

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spends half of her working hours on CQI work, this work is mostly paperwork and organizing data
collection and combining that into the CQI report. There is no one at the facility with any
expertise or training in CQI. No one with CQI experience or knowledge of CQI methodology is
involved in developing the CQI studies.
Three of six persons on the CQI Governing Body are custody-trained personnel (The Warden,
Assistant Warden of Programs and the Wexford Regional Manager who is an ex-warden). Our
opinion is that a Governing Body for a medical CQI program should not be directed by custody
personnel. The medical CQI program should have a majority of medical personnel. The three
persons on the Governing Body who are health personnel are the Agency Medical Director, the
HCUA who is a nurse, and the Wexford site Medical Director.
The CQI plan is a generic plan that is not specific to issues at MCC. The CQI plan lists administrative
directive requirements of the CQI program but does not indicate what the specific plan for CQI is
at MCC.
There were 10 CQI medical studies. There were six outcome studies and four process studies. The
six outcome studies were:
• Whether medication renewal for chronic illness was renewed prior to expiration.
• Whether a viral load was performed for persons with a positive hepatitis C antibody test.
• The percent of x-ray appointments which actually were completed when scheduled.
• The percent of inmates referred to the health unit for injuries who needed to be sent to
a higher level of care.
• Whether inmates were seen within five days of discharge from the infirmary.
• Whether inmates with diabetes had medications renewed prior to expiration.
None of these were outcome studies. Two of these studies were poorly defined and we did not
understand what the study was meant to measure. One was a study of viral load testing for
hepatitis C. The study purpose was not defined. Another outcome study consisted of measuring
the number of persons requiring treatment outside of the facility after being evaluated for injury.
We could not figure out the purpose of this study or what clinical outcome it was meant to
measure. The remaining four studies were performance measures, not outcome studies. As with
other sites, none of these outcome studies included a clinical outcome. While some of these
performance measurement were useful, none appeared to be amongst the most serious clinical
problems at this facility.
We have comments on two of the process studies. One study had a declared intention of reducing
denials by 30%. The study did not study variables of the referral process with an intention of
improving the quality of referrals, but there was an intervention. The study resulted in a
reduction of 389 referrals and a reduction of 98 denials. The intervention resulted in a reduction
of referrals of 33 per month and a reduction of denials of 18 per month. Our concern is that it
appears that patients who need referral are not receiving it. The study did not evaluate whether
the reduced referrals were necessary or not. It’s only intent was to reduce denials. Improvement

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of quality was not the intent of the study. Reduction of referrals and denials only improves quality
if the referrals and denials are unnecessary, which was not evaluated.
One study reviewed 1637 inmates with chronic illness with an intent apparently of studying
whether their chronic illness appointment was timely. This study identified every staffing
deficiency or lockdown situation with the resulting backlog in chronic illness clinic appointments.
However, the study did not map the process and did not draw conclusions, so it was not clear
what was learned or what actions could be taken to improve chronic illness appointments.
The HCUA identified staffing, scheduling appointments, and utilization management as the top
three problems at the institution. There was only one study reasonably related to these three
highest priority problems. This was a study of specialty care denials. This study was described in
the specialty care section of this report. The study was initiated as an attempt to reduce denials
without an analysis of whether denials were appropriate. The outcome of the study intervention
was a greater reduction in referrals than a reduction of denials. In our opinion, the major
problems related to specialty care referral are the lack of qualified primary care physicians who
understand when to refer patients for consultation care, and the specialty care process itself,
which we view as a barrier to care. The collegial review process and the impact of primary care
training on referrals was not evaluated. Our opinion is that patients are not referred for necessary
specialty care, but the CQI process had no mechanism to evaluate that question.
Deaths were listed in the CQI 2018 Annual Report. Death summaries were included in the report,
but the death summaries had no critical analysis of the deaths. There was no mortality review
and no problems were identified in the death summaries. Performing critical mortality review is
a way to identify systemic problems so that future deaths can be prevented. This is not currently
done. We reviewed seven deaths from MCC. Of those seven deaths, two were preventable and
two were possibly preventable. This is an extraordinary large number of preventable deaths. We
identified problems on all of the death reviews we performed. Summaries of these death reviews
are present in the mortality review appendix of this report.

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Recommendations
Leadership, Staffing, and Custody Functions
First Court Expert Recommendations
1. Place a priority on filling the Director of Nursing and Supervising Nurse positions. We
agree with this but believe that a priority should be placed on all supervisory positions and
include physician and dental positions.
Additional Recommendations
2. All budgeted positions should be filled.
3. A staffing plan should be developed that ensures sufficient staff to adequately provide
care and to ensure administrative directives are adequately accomplished. This plan
should include appropriate relief factors and include budgeted staff for infection control
and CQI activities.
4. Vendor regional leadership positions should be filled with persons trained in a health care
field.
5. IDOC Regional Coordinator positions should be filled by full-time persons without other
IDOC responsibilities.

Clinical Space
First Court Expert Recommendations
1. Renovations in all the cell house sick call areas be completed.
2. All sick call areas be appropriately equipped.
We agree with these recommendations.
Additional Recommendations
3. Repairs (cracked walls, chipped and peeling paint, clogged vents, missing electrical outlet
plates, etc.) and ongoing maintenance of the exam rooms in the cell houses and the
medical building must be done to allow effective cleaning and create a safe patient care
and professional environment.
4. Exam rooms and exam tables are not be used as storage spaces.
5. Replace all the non-adjustable infirmary beds with hospital beds with safety railings that
have the capability to adjust the height, the head section, and the lower extremity
sections. One of these beds should be an electrically adjustable bed.
6. Nurse call devices must be installed next to all infirmary beds.
7. Showers in the infirmary and geriatric housing units must be repaired and maintained to
minimize the risk of falls.
8. Each cell house and the medical building must have an automated external defibrillator.
9. All clinical devices must have documented annual electric safety inspections.

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Sanitation
First Court Expert Recommendations
1. Critically monitor cell house sick call areas for cleanliness and the use of paper barrier
between patients on examination tables, or assure that table tops are sanitized between
patients and appropriate hand washing/sanitizing is occurring between patients. We
agree with this recommendation.
Additional Recommendations
2. Expand environmental rounds and the monthly Medical Safety and Sanitation Report to
include the condition of the infirmary beds and exam tables, the functionality of the
infirmary’s negative pressure rooms, the compliance with annual inspection of medical
devices, and other clinical space and equipment findings. The findings should be
presented to the Quality Improvement Committee.

Radiology Services
First Court Expert Recommendations
The First Court Expert did not have any recommendations regarding radiology services.
Current Recommendations
1. IDOC needs to contact the Illinois Emergency Management Agency (IEMA) and
Occupational Safety and Health Administration (OSHA) to review the reported decision
that IDOC x-ray technicians do not need to wear radiation exposure devices (dosimeter
badges) while working in IDOC radiology suites as outlined in Illinois Administrative Code
32-340 510 and 520. This current practice is not in alignment with the radiation safety
practices in the community.
2. Contract with a radiation safety expert to assess the safety of the panorex (mandible
films) unit’s current location in an unleaded exam room in the MCC Reception and
Classification building without a shielded area for the technician to stand when panorex
films are being taken.

Medical Records
First Court Expert Recommendations
There were no recommendations of the First Court Expert for Medical Records.
Current Recommendations
1. An electronic medical record should be initiated statewide. This record should include
electronic medication administration capability.
2. When charts are thinned, carry forward documents should include critical consultation
reports, hospital reports, and specialized test reports that have significant impact on
patient care.

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3. Only medical records staff should file documents in medical records and only medical
records staff should refile medical records.
4. Sick call requests by inmates should be filed in the medical record, as they are medical
record documents.

Medical Reception and Intrasystem Transfer
First Court Expert Recommendation
1. The quality improvement program must utilize a clinician to review the records of patients
who have recently gone through the reception process and for whom abnormalities have
been identified in order to ensure that appropriate follow up occurs. This should be an
ongoing part of the quality improvement program.194 We agree with this
recommendation.
Additional Recommendations
2. We recommend that the steps in the intake screening and reception process be
monitored by adding data fields to the intake logs that indicate the timeliness of each
step, including the physical examination, tuberculosis screening, etc.
3. The IDOC Administrative Directive 04.03.101 should be revised to eliminate obtaining
written consent for HIV testing given the opt-out policy that has been established. HIV
testing should be opt-out testing.

Nursing Sick Call
First Court Expert Recommendation
1. Transition to an all Registered Nurse triage and sick call system. Licensed Practical Nursing
(LPN) staff is triaging sick call requests and may or may not perform an examination, make
an assessment and then formulate a plan, which could be no treatment or treatment from
approved treatment protocols or to refer to a provider. All of these actions are beyond
the educational preparation and scope of practice for an LPN.195 We agree with this
recommendation.
Additional Recommendations
2. Timeliness of nursing sick call should be monitored by CQI at least annually.196
3. The quality of nursing assessments and the plan of care should be monitored by nursing
service as part of the peer review or quality improvement. This should replace Medical
Director review.
4. Medical records must be taken to sick call and used by nurses when seeing patients. This
is one example of the benefit of having an electronic health record.

Lippert Report Menard p. 43.
Lippert Report Menard p. 43.
196 National Commission on Correctional Health Care. 2014. Standards for Health Services in Prisons. P. 14.
194
195

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5. Providers should see patients timely according to the urgency of the referral.197

Chronic Disease Management
First Court Expert Recommendation
1. Physicians should be trained and certified in a primary care field. Only primary care
trained providers should be managing chronic illnesses.
2. The chronic disease database should be used as a tool to identify areas in which the
program is underperforming so that interventions can be targeted to improve.
3. Providers should be implementing a change to the care plan when patients have
suboptimal control of their disease.
4. All providers need access to electronic references at the point of care.
5. There were issues with the accuracy of evaluating the degree of disease control for
patients enrolled in the pulmonary clinic. This is partly due to the language of the policy,
which should be revised to be more consistent with the NHLBI guidelines.
6. Providers should be familiar with alternative methods of TB testing, i.e., the interferon
gamma assays and their appropriate use. Efforts should be made to confirm patient’s
reports of previous treatment for LTBI prior to committing them to treatment.
7. The cell block clinics should be adequately equipped and present a professional clinical
environment. Safety concerns among the providers need to be addressed.
We agree with these recommendations.
Additional Recommendations
8. Update problem lists so that they include all current and significant past clinical conditions
and procedures. Failure to develop a complete and accurate problem list puts patients’
continuity of care at significant risk.
9. Monitor the providers’ documentation in the chronic care progress notes for the rationale
for clinical decisions, diagnoses, and treatments.
10. Expand the existing telehealth and/or establish an e-consult specialty program to include
additional medical specialists to assist primary care providers with the management of
complex and common medical conditions including diabetes, hypertension, cardiology,
dermatology, neurology, and infectious diseases.
11. Perform hepatitis C RNA viral loads and fibroscans on all patients with hepatitis C as
required by IDOC policy.
12. Revise the hepatitis C Guidelines to increase the number of the patients who are eligible
to receive treatment. It is the best interest of the patient-population, the institution, and
the non-incarcerated community to treat all patients with hepatitis C. It is impossible to
clinically and legally justify waiting for patients to develop cirrhosis before initiating
treatment.

Emergent referrals should be seen immediately, urgent referrals should be seen the same day and routine referrals seen
within 72 hours.
197

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13. Streamline the prerequisite testing required prior to initiating hepatitis C treatment to
match the processes utilized in the community. The current lengthy pre-treatment testing
and evaluation contributes to the unacceptably prolonged delays in hepatitis C treatment.
14. Implement and utilize current United States Preventive Services Task Force (USPSTF)
guidelines for screening adults for cancer and other conditions (abdominal aortic
aneurysm, etc.).
15. Implement and utilize CDC age-based and disease-based standards for the administration
of adult immunizations.
16. Calculate and document the 10-year cardiovascular risk score on all appropriate adults to
assist with the decision, timing, and medication selection for the prevention of
cardiovascular disease.
17. Consult with endocrinologists/diabetologists to provide a comprehensive review and
recommendations concerning the medical management and the frequency of CBG testing
of type 1 and type 2 insulin-prescribed diabetics at MCC and in the IDOC system.
18. Develop a plan to change anticoagulation treatment from Vitamin K antagonists
(warfarin) to newer types of anticoagulants that do not require frequent ongoing lab
testing to determine the adequacy of anticoagulation. This should especially be
considered when physicians are unable to obtain a therapeutic anti-coagulation level.
19. Provide all chronic care providers and nurses with access to current, comprehensive
electronic medical reference services such as “UpToDate” in all clinical areas and clinical
offices.

Urgent/Emergent Care
First Court Expert Recommendations
1. Nursing staff must be retrained with regard to an appropriate assessment for a patient
who has been sent to the hospital and returned to the infirmary. Specifically, the training
should include what subjective and objective information to collect in relationship to the
problems that were addressed at the hospital. We agree with this recommendation.
2. A clinically trained person should insure that all of the relevant offsite service reports for
unscheduled offsite services are available within a few days, including discharge
summaries, emergency room reports, operative reports, and catheterization reports, so
that they can be discussed by the primary care clinician with the patient and a plan can
also be discussed. We agree with this recommendation.
3. When a procedure or a visit is interrupted due to a lockdown, the Medical Director should
be notified and must determine whether, despite the lockdown, it must occur or can wait
and occur the following day198. We agree with this recommendation. There were no
instances of a procedure or visit being interrupted because of a lockdown among the
charts we reviewed.
Additional Recommendations

198

Lippert Report Menard p. 44.

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4. Each of the openings in the emergency response bag should be sealed with a numbered

5.
6.
7.

8.

plastic tag. The integrity of the seal should be checked and documented on the emergency
equipment log at the beginning of each shift.
A corrective action or improvement plan should be developed based upon the critique of
the annual mass casualty drill. Implementation of the plan should be monitored by the QI
program.
The critique of emergency responses should be reviewed by CQI for trends and areas
identified for correction or improvement.
All emergency room visits should be reviewed with regard to timeliness, appropriateness
of preceding care, accuracy of information in the health record, and continuity of care
upon release back to the facility. This should be done by clinical leadership and the QI
program.
IDOC medical supervisors should conduct reviews of sentinel events, including
preventable hospitalizations. These reviews need to identify deficiencies and develop
corrective actions. Providers who commit grossly and flagrantly egregious infractions
should be referred to peer review and these actions should be reviewed with respect to
their privilege renewal.

Specialty Consultations
First Court Expert Recommendations
1. A clinically trained staff person should be responsible for ensuring that all relevant offsite
service reports are available for the clinician to review with the patient within a week of
the offsite service having been provided. We agree with this recommendation but add
that the responsibility for this rests on the vendor that establishes the contract with the
consultant and hospital. They must be held accountable for this deficiency. A clinically
trained staff at the facility can be responsible for getting reports but responsibility for the
process resides with the vendor.
2. When the scheduled offsite service reports are available, the physician must document a
visit with the patient in which the findings and a plan are discussed. We agree with this
recommendation but add that the physician must review the offsite service report and key
findings and recommendations, and discuss all of these with the patient in an effective
manner so that the patient understands the therapeutic plan resulting from the
consultation. A rationale for not accepting recommendations needs to be documented and
discussed with the patient. This must be done timely. A week timeframe is acceptable.
3. Services that cannot be scheduled for more than a month must be addressed by the
Medical Director with the State Medical Director. We agree with this recommendation.
Additional Recommendations
4. The collegial review process should be abandoned because it is, in our opinion, a patient
safety hazard.
5. Referral for hepatitis C to UIC should not be required to go through Wexford utilization
review. IDOC physician should refer patients directly.

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6. Referral to the Wexford infectious disease doctor for approval for ultrasound and EGD for
persons with cirrhosis should be abandoned on the basis of patient safety. If a Wexford
doctor is not primary care trained (board certified or board eligible in a primary care field),
then all patients with APRI > 0.7 should be used as a benchmark to begin diagnostic
screening for cirrhosis (upper endoscopy for varices and biannual ultrasounds to screen
for hepatocellular carcinoma). Primary care trained doctors should document cirrhosis as
a problem when it is identified and begin appropriate screening as recommended for
cirrhosis (screening EGD as baseline and ultrasounds biannually for hepatocellular
carcinoma).
7. Tracking specialty care should be standardized and under control of IDOC, not Wexford.
IDOC should track whether hospital reports and all types of specialty care reports are
received within five working days of the service date. Summary statistics on reports
received later than five days after the service date need to be reported in CQI monthly
and annual reports. This should be included in the contract as a monitored item
associated with penalties for poor performance (e.g., <95% of reports available within five
days).

Infirmary Care
First Court Expert’s Recommendations
1. Address life/safety concerns with infirmary patients padlocked in their rooms.
2. Train inmate health care unit porters in blood borne pathogens; infectious and
communicable diseases; bodily fluid clean-up; the proper cleaning and sanitation of
infirmary beds, furniture, and linens; and confidentiality of medical information.
3. Replace torn and ragged linens. Maintain an adequate supply of bedding and linens.
4. Sanitize infirmary bedding and linens through appropriate laundering methods.
5. Properly document in the patient medical record a medical acuity level, i.e., acute,
chronic, housing, administrative placement.
6. Properly document in the patient medical record a medical assessment rather than a
housing designation in the “assessment” portion of an infirmary patient SOAP notes.
The First Court Expert’s recommendations to train the infirmary porters and to maintain an
adequate supply of linens have been addressed. We concur with the remaining recommendations
of the First Court Expert.
Additional Recommendations
7. Adjust the level of nurse staffing to assure that patient-inmates with significant physical
and mental disabilities have their medical, physical, and safety needs met.
8. The IDOC needs to perform an assessment of housing for disabled, and elderly inmates
who need skilled nursing care. IDOC needs to build or otherwise find acceptable housing
for these inmates.
9. Transfer patients whose clinical needs exceed the capability of the MCC infirmary to a
licensed clinical skilled-nursing facility either within IDOC or in the community.
10. Educate, monitor, and track the comprehensiveness of the provider infirmary notes to
assure that progress notes adequately document the clinical status of the patient and the
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current treatment plan. Failure to document this information puts the health of the
patient at risk.
11. Educate, monitor, and track provider notes to assure that the clinical justifications and
reasons for clinical decisions and treatments are documented. Failure to document this
information puts the health of the patient at risk.

Pharmacy and Medication Administration
First Court Expert Recommendations
The First Court Appointed Expert made no recommendations concerning pharmacy and
medication administration.
Current Recommendations
1. Adopt a computerized provider order entry (CPOE) program to eliminate handwritten
orders. Replace handwritten transcription of orders to the MAR with printed labels after
the pharmacy has reviewed and verified the order. Medications which must be started
urgently may be transcribed in handwriting onto the MAR. When the label arrives, it
should be affixed to a new line on the MAR and documentation continued there.
2. Order implementation should take place within 24 hours. Adopting CPOE eliminates
delays in treatment resulting from not transcribing orders timely.
3. Medication should be administered in patient specific, unit dose packaging. The practice
of pre-pouring and the use of multiuse envelopes should be stopped.
4. The use of a list to prepare controlled substances and the placement of doses for multiple
patients into a collective container should be stopped immediately.
5. Alternative forms of medication should be used rather than crushing and floating (liquid
or injectable).
6. The MAR should be used by the nurse to verify the medication, dose, and route of
administration is correct immediately before giving the medication to the patient. The
nurse should have the MAR available to answer any questions or concerns the patient has
about the medication.
7. When medication is dropped on the floor, the patient should be offered a replacement
and not be forced to choose between going without or ingesting a medication that is
unsanitary.
8. Medication should be documented on the MAR at the time it is administered. When
medication is not given, the reason must be documented on the MAR.
9. Every MAR should have the signature and initials of every nurse who has administered
medication to that patient. An electronic MAR would document the identity and
credentials of any person administering medication automatically.
10. Printed labels should be provided to place on the MAR when a new order is dispensed.
Orders should not be handwritten on the MAR unless it is a medication to be given
immediately.
11. A system for timely renewal of chronic disease and other essential medications should be
developed.

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12. Nurses should refer any patient who does not receive three consecutive doses of
medication critical in managing a chronic disease (insulin, Plavix, factor H, HIV medication,
antirejection medications, etc.) to the treating provider. The treating provider should
meet with the patient and determine if treatment can be modified to improve adherence.
13. Patient adherence with KOP medications prescribed to treat chronic disease should be
monitored at regular intervals (monthly by nursing and by the provider at each chronic
disease visit).
14. Revise the policy and procedure for medication administration to provide sufficient
operational guidance to administer medications in accordance with accepted standards
of nursing practice.
15. The CQI program should develop, implement, and monitor quality indicators related to
pharmacy services and medication administration.
16. Root cause analysis and corrective action plans should be used to target the causes of
performance that is below expectations. Corrective action should consider system
improvements such as computerized provider order entry, use of bar coding, patient
specific unit dose packaging, EMAR, etc., to support desired performance.

Infection Control
First Court Expert Recommendations
1. Continue to aggressively monitor skin infections and boils. We agree with this
recommendation.
2. Assure a practice of appropriately laundering and sanitizing infirmary bedding and linens
either in the healthcare unit or institutional laundry. If laundering in the healthcare unit,
water temperatures should be monitored and recorded daily to assure a 160°F or 140°F
reading. We agree with this recommendation and further recommend that a policy and
procedure be written on how patient linens are laundered to include instruction to send
linens soiled with body fluid to the institution laundry, that water temperature be tested
and logged periodically, and that a booster be added to the hot water inlet on the washing
machine.
3. Train all healthcare unit porters in blood-borne pathogens, infectious and communicable
diseases, and the proper cleaning and sanitizing of infirmary rooms, beds, furniture,
toilets, and showers. This recommendation has been accomplished.
4. Since there are no visual or audible alarms for the infirmary negative pressure respiratory
isolation rooms, when a patient is isolated due to respiratory infection, gauge readings
should be monitored and recorded each shift. When the rooms are empty or being used
for purposes other than respiratory infection, gauge readings should be monitored and
recorded weekly. Pressure is monitored and recorded consistent with this
recommendation.
5. Install, at a minimum, an audible alarm to immediately notify infirmary staff of the loss of
negative pressure in respiratory isolation rooms. Audible alarms are in place for the
isolation rooms; therefore, this recommendation has been accomplished.
6. Critically monitor cellhouse sick call areas for cleanliness, the use of a paper barrier
between patients on examination tables or assure table tops are sanitized between
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patients, and appropriate hand washing/sanitizing is occurring between patients. This
recommendation has been accomplished.
7. Each month, critically inspect upholstered equipment and mattresses for any tears or
holes in the outer cover and assure the items are taken out of service until repaired. We
agree with this recommendation and suggest that it be added to the Safety and Sanitation
Rounds. We found numerous upholstered items which need to be removed and repaired.
Additional Recommendations
8. Infections and communicable disease data should be analyzed and discussed as part of
the monthly and the annual CQI meetings. This should include discussion of trends,
updates from the CDC, and review of practices.
9. Update the IDOC Infection Control Manual now and at least every two years.
10. Update the Health Services policies and procedures that relate to sanitation and infection
control now and at least every two years.

Dental Program
Dental: Staffing and Credentialing

First Court Expert Recommendations: None.
Current Recommendations
1. Hire two dentists immediately.
2. Until three full-time dentists are hired, and the backlogs are reduced, Wexford should
provide one or more full-time PRN dentists.
3. An additional 0.5 FTE dental hygienist should be hired.
4. Dentist staffing should be revisited after dentists incorporate bite wing x-rays and
periodontal probing into their examinations, since it is likely that additional pathology will
be identified when examinations and treatment comport accepted professional
standards.

Dental: Facility and Equipment

First Court Expert Recommendations
Replace or repair the x-ray developers in the North 2 and R&C clinics immediately.
1. The space in the HSU clinic that houses the two main dental units is too small to allow
efficient care flow and any sense of privacy, and enlargement should be considered for
efficient care delivery and safety considerations.
2. All electric outlets should be wall-mounted or protected by the cover for the junction box
at the foot of the chair. Loose wires should be neatly arranged and out of traffic flow. We
note that this issue has been addressed.
3. All the units, chairs, and cabinetry should be replaced, and surface areas should be better
able to accommodate disinfection.
4. Replace the radiograph unit in the clinic immediately with a wall-mounted unit capable
of digital radiography.

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5. The Panelipse [panoramic] radiograph unit should be replaced. This is critical for a
reception center.
We agree with these recommendations.
Additional Recommendations
6. While the quality of the radiographs is adequate, given the age of the panoramic x-ray
unit and the R&C mission of MCC, a replacement should be high in the capital equipment
replacement list. Moreover, the replacement should be digital.

Dental: Sanitation, Safety, and Sterilization

First Court Expert Recommendations
1. Sterilization at the HSU clinic is improper. MCC should develop a sterilization system that
implements a proper flow from dirty to sterile. We agree, but note that notwithstanding
the inadequate design, the instruments were sterilized appropriately.
Additional Recommendations: None.

Dental: Review Autoclave Log

First Court Expert Recommendations
1. Spore test the autoclaves, and sterilizers should be tested on a weekly basis and proper
logs should be maintained. We note that the previously identified deficiencies have been
corrected.
2. Safety glasses should be provided to all patients receiving dental care.
3. Biohazard warning signs should be posted in the sterilization areas in the dental clinics.
4. Warning signs should be posted in the area where x-rays are taken to warn pregnant
females of potential radiation hazards.
We agree with these recommendations.
Additional Recommendations
5. The dry heat sterilizer in the HCU clinic has been out of service for approximately two
years and should be removed.

Dental: Comprehensive Care

First Court Expert Recommendations
1. Comprehensive “routine” treatment should be provided only from a well-developed and
documented treatment plan.
2. The treatment plan should be developed from a thorough, well documented intra and
extra-oral examination, to include a periodontal assessment and thorough examination
of all soft tissues.
3. In all cases, appropriate bite wing or periapical x-rays should be taken to diagnose caries.
4. Hygiene and periodontal care should be provided as part of the treatment process.
5. Care should be provided sequentially, beginning with hygiene services and dental
prophylaxis.
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6. Oral hygiene instructions should be provided and documented.
We agree with these recommendations and emphasize that current MCC practice falls well below
accepted professional standards.
Additional Recommendations
7. Treatment performed should be reported using standard (American Dental Association)
definitions and procedure codes or entries that can be mapped to the treatment codes.
8. Biennial exams should include a documented oral cancer examination.

Dental: Intake (Initial) Examination

First Court Expert Recommendations
1. Oral hygiene instructions should be provided at the time of the initial examination.
We agree. However, the OHI provided at the intake screening was inadequate.
2. The area where x-rays are taken should have warning signs posted that clearly warn of
potential radiation hazards to pregnant females. We agree with this recommendation.
3. A consent form should be developed and used for pregnant females that explains
radiation hazards and gives the examiner permission to take the x-ray. This is moot since
MCC is a male facility.
Additional Recommendations
4. The oral hygiene instructions provided by the dentist should be more thorough, or in the
alternative, they should be provided by other dental personnel.
5. The dentist should view the panoramic x-ray while the patient is being examined.
6. The dentist should wash hands before re-gloving or, in the alternative, use alcohol
wipes.199
7. The initial exam should document Periodontal Screening and Recording (PSR), which is a
professional standard.

Dental: Extractions

First Court Expert Recommendations
1. A proper diagnosis should be part of the treatment process. We agree with this
recommendation; however, we note that the diagnoses were appropriate in the charts we
reviewed.
Additional Recommendations
2. When an antibiotic is prescribed for a tooth-related infection, the tooth should be
extracted within the therapeutic window of the antibiotic. A follow-up appointment for
the extraction should be made so that the tooth is extracted within 10 days.
3. The health history should be updated before a tooth is extracted.

Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations
for Safe Care. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; October 2016,
p.7.
199

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4. The consent form should specify the tooth to be extracted and the reason for the
extraction (i.e., the diagnosis).

Dental: Removable Prosthetics

First Court Expert Recommendations
1. A comprehensive examination and well developed and documented treatment plan,
including bitewing and/or periapical radiographs and periodontal assessment, precede all
comprehensive dental care, including removable prosthodontics.
2. Periodontal assessment and treatment should be part of the treatment process and that
the periodontium should be stable before proceeding with impressions.
3. All operative dentistry and oral surgery as documented in the treatment plan be
completed before proceeding with impressions.
We agree with these recommendations and note that current practice is substantially below
accepted professional standards.
Additional Recommendations: None.

Dental: Sick Call/Treatment Provision

First Court Expert Recommendations
1. All treatment should proceed from a proper diagnosis.
2. A system should be implemented immediately that insures that inmates with urgent care
complaints (pain and swelling) are seen and evaluated by medical/dental staff within 24-48
hours from the date on the request form. It is from this face-to-face evaluation that
scheduling, and treatment should proceed. The appropriate medical staff in the units should
be utilized in this effort. We note that patients who sign up for nurse sick call with complaints
of dental pain or swelling are seen within 48 hours by a nurse and are offered non-narcotic
analgesics. Furthermore, patients who sign up for nurse sick call generally have timely faceto-face assessments and receive analgesics when appropriate.
We agree with these recommendations.
Additional Recommendations
3. Nurses should triage all requests for dental care. Non-urgent requests (cleaning, routine
exams, fillings, etc.) should be sent to the dental clinic for scheduling. All other dental
complaints should be assessed at nursing sick call, treated for pain as needed, and
referred to the dentist based upon clinician urgency.
4. The Wexford contract should be amended to specify a maximum wait time for a routine
care appointment to 90 days.

Dental: Orientation Handbook

First Court Expert Recommendations: None.
Additional Recommendations: None.

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Dental: Policies and Procedures

First Court Expert Recommendations
1. The dental program should develop a current, detailed, thorough, and accurate policy and
procedure manual that defines how all aspects of the program are to be managed. Once
developed, it should be reviewed and updated on a regular basis and as needed for new
policies and procedures. We agree with this recommendation.
Additional Recommendations
2. The Dental Director should sign the policies. Moreover, all dental personnel should sign a
memo acknowledging having read the policies.

Dental: Failed Appointments

First Court Expert Recommendations
1. Develop a comprehensive CQI study to evaluate reasons for missed appointments and
seek remedies to correct the problem and improve getting inmates to their
appointments. We agree. Although the failed appointment rate has fallen to a yearly low,
it is still worthwhile to see if there remains room for improvement. Furthermore, the
refusal rate is worth studying.
Additional Recommendations: None.

Dental: Medically Compromised Patients

First Court Expert Recommendations
1. The medical history section of the dental record should be kept up to date and that
medical conditions that require special precautions should be red-flagged to catch the
immediate attention of the provider.
2. Blood pressure readings be routinely taken of patients with a history of hypertension,
especially prior to surgical procedures.
We agree with these recommendations.
Additional Recommendations
3. Diabetics should be referred for a periodontal assessment that includes periodontal
probing every six months.
4. Diabetic patients diagnosed with periodontal disease should be offered an oral
prophylaxis and non-surgical periodontal treatment (i.e., scaling and root planing) every
six months if clinically indicated. This should be part of the chronic care program.

Dental: Specialists

First Court Expert Recommendations: None.
Additional Recommendations: None.

Dental: CQI
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First Court Expert Recommendations
1. Develop vigorous CQI studies that address the weaknesses presented in this report and
put in place steps to correct the problems. We agree with this recommendation.
Additional Recommendations
2. IDOC should hire an individual experienced in health services research to guide the local
CQI studies effort.

Internal Monitoring and Quality Improvement
First Court Expert Recommendations
1. The QI policy and the training connected to it must be redone in order to facilitate quality
improvement effectively occurring at each institution. This will entail a lengthy discussion.
We agree with this recommendation.
Additional Recommendations
2. The paperwork requirements of putting together information for the annual CQI report
need to be separated from the role of leading CQI efforts in improving care.
3. The Governing Body of the health care program needs to be predominantly medical
personnel.
4. CQI plans need to be specific to the facility and address major concerns or problems at
that facility.
5. A mortality review process needs to be initiated. This process should be managed and
performed by non-vendor personnel under direction of the Office of Health Services. This
group should review all deaths and sentinel events to identify problems and offer
solutions that the facility CQI program addresses and responds to.

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Appendix A
Position
HCUA
DON
Nursing
Supervisor
Office
Coordinator
Office Assistant
Staff Assistant
Office Associate
Clerk II
Health Info Assoc
RN
LPN
LPN
Dental Director
Dentist
Dental Assistant
Dental Assistant
Dental Hygienist
Medical Director
Physician
NP
Wexford Site
Manager
Med Room Asst
Radiology Tech
Phlebotomist
Optometrist
PT aide
Physical Therapist
Total

May 21-24, 2018

Staffing for Menard Correctional Center
State or Wexford
Filled
Vacant
State
1
0
State
0
1
State
3
0

LOA

Positions
1
1
3

State

2

0

2

State
Wexford
State
State
State
State
State
Wexford
Wexford
Wexford
Wexford
State
State
Wexford
Wexford
Wexford
Wexford

1
1
2
1
2
18
12
4
0
1
2
1
1
1
0
2
1

3
0
0
0
0
10
8
2
1
1
0
0
0
0
2
1
0

4
1
2
1
2
28
20
6
1
2
2
1
1
1
2
3
1

Wexford
Wexford
Wexford
Wexford
Wexford
Wexford

2
1
1
1
1
0.1
62.1

0
0
0
0
0
0
29

Menard Correctional Center

1

1

2
1
1
1
1
0.1
91.1

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Northern Reception and Classification Center
2nd Court Appointed Expert Report
Lippert v Godinez

Visit Date: January 29-February 1, 2018

Prepared by the Medical Investigation Team
Mike Puisis, DO
Jack Raba, MD
Madie LaMarre MN, FNP-BC
Catherine Knox, MN, RN, CCHP-RN
Jay Shulman, DMD, MSPH

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Table of Contents
Overview ............................................................................................................2
Executive Summary ............................................................................................3
Findings ..............................................................................................................7
Leadership, Staffing, and Custody Functions.................................................................................. 7
Clinic Space, Sanitation, Laboratory, and Support Services ......................................................... 15
Medical Records............................................................................................................................ 22
Medical Reception ........................................................................................................................ 27
Intrasystem Transfer ..................................................................................................................... 34
Nursing Sick Call ............................................................................................................................ 35
Chronic Care .................................................................................................................................. 40
Urgent/Emergent Care.................................................................................................................. 50
Specialty Consultations ................................................................................................................. 51
Infirmary Care ............................................................................................................................... 56
Pharmacy and Medication Administration ................................................................................... 62
Infection Control ........................................................................................................................... 67
Dental Program ............................................................................................................................. 68
Internal Monitoring and Quality Improvement ............................................................................ 84

Recommendations ............................................................................................ 94
Leadership, Staffing, and Custody Functions................................................................................ 94
Clinic Space, Sanitation, Laboratory, and Support Services ......................................................... 95
Medical Records............................................................................................................................ 95
Medical Reception ........................................................................................................................ 96
Intrasystem Transfer ..................................................................................................................... 98
Nursing Sick Call ............................................................................................................................ 98
Chronic Care .................................................................................................................................. 99
Urgent/Emergent Care................................................................................................................ 100
Specialty Consultations ............................................................................................................... 101
Infirmary Care ............................................................................................................................. 102
Pharmacy and Medication Administration ................................................................................. 102
Infection Control ......................................................................................................................... 104
Dental Program ........................................................................................................................... 104
Internal Monitoring and Quality Improvement .......................................................................... 110

Appendix A ..................................................................................................... 111
Appendix B ..................................................................................................... 112
Appendix C ..................................................................................................... 115

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Overview
From January 29, 2018 through February 1, 2018, the Medical Investigation Team visited the
Northern Reception and Classification Center in Joliet, Illinois. This report describes our findings
and recommendations. During this visit, we:
•
•
•
•
•

Met with leadership of custody and medical
Toured medical services areas and housing units
Talked with health care staff
Reviewed health records and other documents
Interviewed inmates

We thank Warden Randy Pfister and his staff for their assistance and cooperation in conducting
the review. We had complete cooperation from the Illinois Department of Corrections (IDOC).1
The Stateville Northern Reception Center’s (NRC) primary mission is a reception center where
staff performs intake processing of new inmates before they are sent to other IDOC facilities
within the state. It was built in 2004 and is the largest reception center in the state of Illinois.
On 1/29/18, the first day of our visit, the NRC census was 1,493 inmates, with an additional 188
inmates housed in the minimum security unit (MSU), for a total of 1,681 inmates. The NRC
population includes 53 inmates in segregation, and 15 inmates in boot camp.
In 2017, the NRC received 15,942 inmates or approximately 307 inmates a week. NRC has a 20bed infirmary; 12 beds are assigned to medical and eight beds are assigned to mental health.
NRC is part of a two-facility complex that includes Stateville Correctional Center (SCC). SCC is
the parent facility of this complex and a single Warden manages both facilities. Each of these
facilities is a stand-alone facility; they are not physically connected. They are separated by
security perimeters and one must drive a short distance and reenter a second security gate to
enter the other facility.
The population design capacity for NRC is not calculated separately from SCC. For SCC and NRC
combined, the population is currently 89% of design capacity. Twenty-nine inmates were
housed at the facility greater than 90 days. We note that this is significantly fewer than the 587
individuals who remained at the facility greater than 60 days at the time of the First Court
Expert’s NRC report.2 This implies that intake evaluations and transfers are occurring at a faster
rate than previously. The 29 inmates who remain at NRC greater than 90 days include 12
inmates who remain at the facility for medical reasons. Of these, six have disabilities and are
We did not experience complete cooperation from Wexford Health Sources. Their attorney required that he be present for
interviews with Wexford staff but was unable to attend our tour, prohibiting some interviews with the Medical Director,
physician assistant, offsite scheduler, and follow-up questions with the Director of Medical Records. We are in discussions
about how to improve the cooperation with Wexford so that it does not impair our ability to conduct interviews with staff.
2 Northern Reception Center (NRC) Report, January 21-23, 2014 prepared by the Medical Investigation Team.
1

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awaiting ADA placement at other facilities. The remaining six individuals are on hold for medical
reasons, mostly for continuing specialty medical treatment. NRC has a consistent mental health
caseload of approximately 450 inmates and eight rooms designed for mental health watches.
Inmates attending Court in the northern district are housed at both SCC and NRC. These are
called WRITS. The combined population of WRITS at SCC and NRC is 55.

Executive Summary
Based on a comparison of conditions as identified in the First Court Expert’s report, we find that
conditions appear to have deteriorated. We find that NRC is not providing adequate medical
care to patients. There are systemic issues that present ongoing serious risk of harm to patients
and result in preventable morbidity that could also result in mortality. The deficiencies that
form the basis of this opinion are provided below.
Though NRC is a large facility with over 1400 inmates, it is still treated as part of SCC. NRC and
SCC share a Warden, Assistant Warden of Programs, and medical staff. These facilities are
unique facilities, each with a different mission; they need separate medical staff and need to
operate independently due to their separate and unique missions.
While the leadership staff is now in place, they are all recently hired. The Medical Director is a
nuclear radiologist and performs inadequately in primary care, and provides little to no clinical
leadership. He has been with Wexford for years and has continued to perform poorly, and yet
has been assigned to be a Medical Director. There is no evidence that Wexford performs any
credentialing or privilege assessment except to ascertain that the provider has a license. This is
below community standard of practice. Wexford has hired an ex-warden without formal
medical training as Regional Manager, which in our opinion is unacceptable.
NRC has inadequate staffing. There is a 42% vacancy rate, which is extraordinarily high. The
mixed staff of Wexford and IDOC employees creates confusion regarding supervisory lines of
authority. The IDOC has not performed a staffing needs assessment. Some areas of service are
understaffed or not staffed at all (e.g., infection control, quality improvement and clerical staff).
Relief factors are not incorporated into projecting staffing needs. The numbers of custody staff
appears inadequate to support the medical requirements of providing security to nurses as they
administer medication and to transport inmates for clinical appointments.
We found that the conditions of confinement are a major impediment to the delivery of health
care. At NRC, inmates are locked down 24 hours a day except for four hours per week. We have
not observed the conditions of confinement found at NRC at any other correctional facility in
the country except supermax prisons, where even these inmates are granted one hour out-ofcell time per day.
As a result, NRC inmates are unable to confidentially submit their health requests into locked
boxes accessed only by health care staff because they are not allowed out of their cells. Nurses

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do not adhere to standards of nursing practice with respect to medication administration due
to the conditions of confinement. This has resulted in systemic medication errors and ongoing
risk of harm to patients. (See Pharmacy and Medication Management).
NRC has a number of clinical space and sanitation problems. Inmates in the housing units are
not brought to the health care unit for nursing sick call and these evaluations are performed in
housing unit rooms unacceptable for clinical evaluations. The number of providers exceeds the
number of examination rooms in the health care clinic, which results in prioritization of work
schedules and promotes missed evaluations. In almost every clinical area, sanitation and
maintenance of the physical plant was not at an acceptable level for provision of health care.
Some equipment was non-operable, negative pressure rooms were not functioning, patient
examination tables lacked paper barriers, examination tables and infirmary beds were
nonadjustable, and sinks and faucets all had mineral deposits, making them harder to sanitize.
Adequate clean linens were not in supply on the infirmary for incapacitated patients who
frequently soil themselves. These deficiencies are typically addressed by a regular sanitation
schedule and performance of environmental rounds, which do not happen at this facility.
Medical records are inadequate and promote poor clinical care. Because of the lack of staffing,
NRC does not maintain the medical records in accordance with its own administrative
directives. It also does not maintain medical records in accordance with guidelines from the
Illinois Department of Human Services. Documents are not present in the medical record in an
organized manner, making the record difficult to use. Laboratory and consultation reports are
often not present in the medical record, making it difficult to provide adequate clinical care.
The medical record room is undersized, cluttered, and not secure. There is no medical records
tracking system to provide accountability for the location of medical records.
Although the timeliness of reception screening has improved since the First Court Expert’s
report, there are still numerous deficiencies. Equipment is not maintained or calibrated. Visual
acuity testing is inaccurately performed and yields inaccurate results. Staff incorrectly read
Tuberculin skin tests and inconsistently record results in the health record. HIV opt-out testing
is inconsistently performed. Intake evaluations uniformly lack adequate history, and physical
examinations are cursory. Providers do not consistently perform adequate assessments or
order labs tests necessary to determine the patient’s disease control. Providers often omit or
change a patient’s medications upon arrival without clinical indication. Nurses do not
consistently initiate a medication administration record when giving patients stock medication
in the reception area. Provider medical reception orders are inconsistently carried out. Provider
follow up of abnormal reception laboratory tests is not consistently and timely performed.
Inmates are not provided access to approved health request forms and do not have a secure
location to place these requests, which creates a barrier to access to care. Staff do not collect
health requests daily and do not date-stamp requests when they receive them. Requests are
not triaged within 24 hours and nurses do not indicate the urgency of follow up evaluations.
Requests are evaluated without the patient’s medical record. Nurses conduct health request
evaluations in rooms that are inadequately equipped and supplied. Health requests are
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inconsistently filed in the medical record. Correctional Medical Technicians/Licensed Practical
Nurses perform assessments but are not licensed to perform independent assessments. A
recently established sick call log does not adequately track the status of each patient request.
The IDOC Administrative Directives provide insufficient operational guidance regarding nursing
sick call.
NRC does not track persons with chronic disease because the nurse assigned to perform this
task is typically pulled for other assignments. Because patients with chronic illness are not
tracked, many are not followed for their chronic illness even when they remain at the facility
for extended periods of time. The provider notes for patients with chronic illness are deficient.
They lack adequate history, reasons for modifying treatment plans, and have inadequate
physical examinations. Diabetes care, in particular, is not provided consistent with
contemporary standards of care. There were significant gaps on medication records, making it
appear that inmates do not receive ordered medications for their chronic illnesses. Patients
with problems beyond the expertise of NRC providers were not referred for appropriate
consultation.
The emergency response bags and equipment were disorganized and not sanitized. Emergency
response drills were conducted but the critique was limited. When deficiencies were identified
there was no corrective action plan. NRC does not track emergency response on a log so it is
not possible for the program to evaluate its performance through the CQI program.
Planned staffing for the infirmary is appropriate but actual staffing shows lack of staffing and no
RN coverage for some shifts. Provider notes are generally written on a weekly basis, even when
patients had need for more frequent notes. The quality of physician care on this unit was
inconsistent and often inadequate. Progress notes lack documentation of the rationale for
therapeutic plan changes and fail to identify a differential diagnosis or clear treatment plan.
There was no documentation that pertinent physical examinations were being performed. We
noted that care of persons with diabetes was especially problematic. The level of provider care
placed patients on this unit at risk of harm.
Medication administration is impaired because of lack of sufficient cooperation by security
staff, which appears to be due to insufficient custody staff. Nurses do not administer
medication consistent with accepted nursing practice. Administration is not hygienic. Nurses do
not appropriately confirm the identity of the patient receiving medication. Doors are not
opened for medication administration and nurses pass medication through cracks in the door
and do not adequately visualize patients to confirm their identity. Nurses do not document on
the medication administration records at the time they administer the medication to the
patient. When inmates do not take medication there is no process to refer the patient to a
provider for counseling. The nursing medication room is dirty, cluttered and disorganized.
Process issues with the contract pharmacy result in nurses having to transcribe large numbers
of medication orders onto new medication administration records (MARs) at the end of each
month instead of the pharmacy providing preprinted MARs. This creates an enormous work
load for nurses and results in documentation errors. CQI reports indicate that staff repeatedly
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commit errors in medication administration, yet an effective correction action plan has not
been developed.
NRC has no infection control program, and no one assigned for this work. Sanitation,
disinfection, and environmental inspections are not done or are poorly performed. No one
evaluates the effectiveness of infection control issues, including: TB skin test reading,
effectiveness of intake infection control screening, or surveillance for contagious or infectious
disease.
The dental clinic is small, with capital equipment approaching the end of its useful life cycle,
and there is no replacement plan. While critical equipment has been repaired, recent history
suggests that there are systemic problems in obtaining repairs. There is no documentation that
the dental x-ray units have been inspected by a therapeutic radiological physicist per Illinois
Administrative Code. Clinic disinfection and infection control are adequate; however, infection
control at the intake screening exams is unacceptable and must be addressed immediately.
Routine dental treatment occurs without a comprehensive oral examination (i.e., intraoral xrays, a periodontal assessment, and a treatment plan), placing patients at risk of preventable
pain and tooth loss. Clinical notes are inadequate. Antibiotics and analgesics are often
dispensed without a diagnosis having been recorded, and the patient’s chief complaint is rarely
recorded. The dental sick call process is disorganized, and it is not possible to determine how
long patients wait to be treated, or the failed appointment rate. There is no process for midlevel providers to triage and palliate patients whose sick call request states or suggests pain or
infection when the dentist is not available. The dental program has not changed materially
since the First Expert’s Report. It represents a substantial departure from accepted professional
treatment standards and is not minimally adequate.
Quality improvement is a critical form of self-monitoring and is necessary to identify and
correct defective systemic issues. NRC did not have its own Continuous Quality Improvement
(CQI) program until recently. It has not yet become effective. The Traveling Medical Director is
an ineffective leader and ineffective in promoting quality improvement. No one at NRC has
experience, training, or dedicated time to perform or lead the CQI effort. The NRC CQI plan is
identical to the SCC CQI plan, even though these are different institutions. The CQI coordinator
has no training in CQI, does not understand what CQI consists of, and has a full-time assignment
that restricts her CQI to a few hours a month, which are mainly occupied in secretarial
functions. The CQI program does not monitor for quality of clinical care. Peer review is
ineffective and does not reflect the current status of clinical care. Mortality review and sentinel
event reviews are not done. Data support for the CQI program is insufficient.

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Findings
Leadership, Staffing, and Custody Functions
Methodology: We interviewed leadership of the health care program, the Warden and some of
the Warden’s staff. We evaluated staffing documents and discussed these with the leadership.
We reviewed other selected documents.
First Court Expert Findings
The First Court Expert found that leadership provided by the Medical Director and Health Care
Unit Administrator (HCUA) was deficient and resulted in a program ill-organized to provide
quality services. The HCUA was on leave and her absence left the facility bereft of
administrative leadership. The lack of leadership resulted in the absence of performance
review, lack of data provided by tracking logs, and disorganized medical records, which were
ascribed to the lack of leadership. The HCUA was a position shared with SCC. Staff was shared
between SCC and NRC, which made it difficult to know how many staff work at each of these
facilities.
Current Findings
Our review showed one improvement. NRC now has its own budgeted leadership team,
including its own HCUA, Director of Nursing (DON), and Medical Director, even though these
positions are not all filled.
The remainder of the problems cited in the First Court Expert’s report persist. We identified
additional findings, including:
• None of the leadership staff at NRC, including the Warden, was aware of or had read the
2014 First Court Expert’s Lippert report. The leadership at NRC was not aware of the
First Court Expert’s recommendations or findings even when the IDOC agreed with the
First Court Expert’s findings or recommendations in their response to that report.
• The Medical Director position is vacant and filled by a “Traveling Medical Director” who
does not adequately fill those responsibilities and who is poorly qualified to provide the
type of medical care needed at this facility.
• The practical implementation of “Traveling Medical Directors” does not address the
responsibilities required of a Medical Director.
• The Wexford Regional Manager for this facility is an ex-warden and has no formal
training in health management.
• All leadership positions (HCUA, DON, Medical Director, and Director of Medical Records)
are only recently filled. The HCUA is the longest tenured leadership position and this
was filled nine months ago.
• NRC is understaffed, yet the program does not have a staffing plan that matches the
medical needs at the facility.

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NRC still shares staff with SCC. There are not clear lines of authority in the table of
organization with respect to assignment and supervision of staff that move between
facilities. The hours shared-employees work at each facility are ineffectively tracked.
A relief factor has not been used for staffing at NRC, which will result in understaffing.
The budgeted staffing does not include clerical positions, quality improvement nursing
hours, or infection control nursing hours.
Budgeted positions do not appear to have been developed with respect to current
workloads for many categories of employees, including physicians and mid-level
providers, nurses, medical record clerks.
There is no current document reflecting actual staffing at this facility.
None of the senior staff at NRC participated in the development of the schedule E for
this facility, indicating the lack of participation of local leadership in developing a needs
assessment for the facility.
There is a lack of custody staffing to timely assist nurses during medication
administration. Inmates are not all brought timely for their medical appointments.

NRC no longer shares medical leadership with SCC, which is an improvement. This is consistent
with one of the First Court Expert’s recommendations. The HCUA, DON, and Director of Medical
Records positions are all filled. The Medical Director position is now vacant, but this position
was filled during the time of the First Court Expert’s report. An NRC staff physician was recently
promoted and is currently serving as the “Traveling Medical Director” at NRC, which is
equivalent to a coverage position. The IDOC and Wexford both perform regional oversight of
the medical program. The Northern Regional Coordinator, a nurse position for the IDOC, is
filled. The Regional Manager and the Regional Medical Director for Wexford Health Services are
both filled.
The Wexford Regional Manager was unable to be present for our tour. We learned from
Wexford Vice President of Special Projects that the Wexford Regional Manager is an ex-warden
by training.3 We have concerns that a person with criminal justice training will not have the
skills necessary to manage a clinical medical program. This was confirmed in our discussion with
the HCUA, who thought that the Wexford Regional Manager did not always understand medical
issues as presented in the quality improvement meetings and, as an example, did not
understand that using drop files in medical records is inappropriate.
The Regional Coordinator for the northern district of the IDOC is an RN and has an additional
Bachelor of Science in nursing. This well-qualified individual has been in his position for two
years. He covers 10 facilities for the IDOC, which is a large span of supervision. He does
participate in quality improvement meetings and appears to be an active participant in issues at
NRC and was present and engaged during our tour.
NRC leadership positions have only recently been filled. The HCUA is an IDOC employee and
started at NRC in April of 2017. She is a RN and was previously a nurse at the Sheridan facility
3

Interview with Cheri Laurent 1/25/18.

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and transferred as the HCUA at Pontiac before transferring to NRC as the HCUA. The HCUA told
us that she inherited a facility that had not been properly managed for years. The DON, also an
IDOC employee, started in September of 2017, only four months before our tour. The Medical
Record Director, a Wexford employee, started two months ago in her position. The Medical
Director position had been vacant for an extended time period. The physician assistant at NRC
told us that over the past five years there have been seven Medical Directors. During the same
five year period there was no Medical Director for a period of about 24 months. According to
the HCUA, several months ago a physician moved from Dixon to serve as the NRC Medical
Director. A few weeks ago, this physician, after being at NRC as Medical Director for only
approximately three months, was moved to be Medical Director at SCC when its Medical
Director died.
The NRC Medical Director position is now vacant but is filled by a “Traveling Medical Director.”
The HCUA was not pleased with the current Traveling Medical Director’s lack of participation in
leadership functions. The HCUA told us that she needed a strong medical leader in the Medical
Director position and attempted to have the newly appointed SCC Medical Director remain at
NRC but was unsuccessful.
The title of “Traveling Medical Director” is a misnomer, in our opinion. At NRC, the current
Traveling Medical Director does not provide typical duties of a Medical Director based on our
discussion with the HCUA. A full-time Medical Director knowledgeable in primary care medicine
is needed. Furthermore, it appears from staffing documents provided to us from Wexford that
physicians and Medical Directors are frequently moved from facility to facility.4 The lack of
coverage by a consistent Medical Director detracts from having effective guidance from a
reliable physician with respect to clinical issues at the facility. The lack of a permanent Medical
Director at NRC significantly impairs the ability of the leadership team to improve the program
through active participation of a physician in quality improvement and other activities.
The newly appointed Traveling Medical Director at NRC was the Medical Director at the Hill
facility during the last First Court Expert visit to that facility and was described in that report as
not performing some administrative responsibilities, having “clinical concerns,” and having
interpersonal deficiencies. Also, a Wexford discipline report of 11/26/17 lists this physician as
having been given a final warning on 2/16/16 for performance.5 We also noted, in record
reviews, our own clinical concerns for this physician. Given his history and lack of clinical
proficiency, we have concerns that he will be successful in this new role.
The NRC is grossly understaffed. The lack of staffing is reinforced by NRC management in
several comments in quality improvement meeting minutes, including:

40C0134-IL Physicians Report 9-19-14 key; 42P5643-IDOC Position History 7-1-2015 to 11-22-17 Bates #520-548; and
4253412-IDOC Physicians as of 1-25-18 Bates #124.
5 Bates document #549, 42P5751 Discipline Report – Employees Disciplined between 7-1-15 to 11-26-17 for Misconduct or
Performance.
4

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“Not enough nurses or staff assistants. [The IDOC Regional Coordinator] wants some
numbers. [The Wexford Regional Manager] said to let him know and he’ll get them.
Breakdown of how many of each for every shift. Do staffing plan and review.”6
“Mandates causing mistakes because nurses are working a lot but they are getting good
pay and can still lose their license for their actions.”7
“AWP says we are doing good with lack of staff…[Regional Coordinator] says things fall
through because no nursing/staff or tracking issue.”8
“[Director of Nursing] was supposed to assign a nurse for 30-day assignment to be held
accountable. There is not enough staff for accountability.”9

Every individual we spoke with told us that staffing shortages were the most significant
problem at this facility. However, an adequate and thorough staffing analysis based on need
has not been done.
Staff is still shared between NRC and SCC. We were told that between September and October
of 2017, the IDOC negotiated a labor agreement with the Illinois Nurses Association (INA) to
have all registered nurse (RN) staff at five facilities (Menard, Pontiac, Dixon, Graham, and NRC)
become state employees under the INA union contract and that all licensed practical nurses
(LPNs) would be Wexford employees. For NRC this was intended to be part of a plan for NRC to
function independently from SCC. The Vice President of Special Projects for Wexford, the
Northern Regional Coordinator for the IDOC and the HCUA of NRC all told us that this
arrangement was in planning stages but that there was no written agreement that they had
seen.
Related to that negotiation, on October 6, 2017, only three months before our visit, the
Regional Coordinator for the northern region estimated, for purposes of these negotiations,
that NRC needed 33 nurses.10 This analysis was given to us as a staffing needs assessment at the
facility. This analysis did not take supervisory nurses into account and did not address special
functions, such as chronic disease nursing, quality improvement, or infection control. The
negotiation was with the nursing union and only nursing staff was addressed in the staffing
analysis. More importantly, this analysis did not include a relief factor, which means that the
number of necessary nurses may be 1.4 to 1.7 times (46-56 nursing positions) as high as the 33
nurses given in this analysis.11 An adequate staffing analysis needs to be done to determine
adequate staffing levels for all staffing categories required to accomplish tasks. Also, because
many tasks are not now being performed, it will be difficult to perform this analysis until

September 19, 2017 Quality Improvement Meeting minutes.
September 19, 2017 Quality Improvement Meeting minutes.
8 November 21, 2017 Quality Improvement Meeting minutes.
9 August 15, 2017 Quality Improvement Meeting minutes.
10 Email from Joseph Ssenfuma to Edward Jackson, Natalie Norther, Robin Best, Kim Hugo, and Steven Meeks on 10/6/17.
11 A relief factor analysis determines how many hours of staffing does one post require for a year. The total coverage hours
required for each position is divided by the number of hours each full-time employee is available to work. The number of hours
each employee is available to work is calculated by the paid hours minus the hours off for vacation, holidays, weekends, sick
leave, and training. In my management experience, each full-time post requires approximately 1.7 to 1.9 FTE employees.
6
7

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leadership includes all tasks required by the administrative directives (AD) into a staffing
analysis.
Because staff is shared between SCC and NRC, three different managers supervise NRC nursing
staff: the NRC HCUA, the SCC Wexford DON, and the SCC HCUA. This results in supervisory
conflicts that arise due to union contract rules. Wexford staff must be given assignments and
have personnel actions given by Wexford supervisors. State employees must be given
assignments and have personnel actions given by state supervisors. This means that when a
Wexford employed staff works at NRC where there is no Wexford nursing supervisor, the staff
at NRC does not have the ability to discipline or technically to make an assignment. The current
table of organization does not provide clear lines of management authority and does not reflect
this confusing supervisory structure. This makes managing NRC complicated, difficult, and can
result in confusion.
SCC is the parent facility in its relationship to NRC. Since SCC and NRC are sharing staff,
someone has to be responsible for making decisions on who is to get greater staffing, especially
during times when staff is off sick or on vacation. This responsibility has not yet been assigned.
We were told that the HCUAs of SCC and NRC are trying to work out a staffing schedule of
shared staff and for assignment of nursing staff from SCC who will assist at NRC. Shared-staffing
assignments appear to be an extemporaneous negotiation. When the SCC Wexford staff
provides service at NRC, their hours are tracked by the Wexford management. The HCUA has
complained to the Regional Manager of Wexford that the hours provided at NRC by the
Wexford nursing staff from SCC are inaccurate. This shared staffing arrangement creates a
“nightmare” as described by the HCUA.
The current schedule E provided to us by the IDOC is not accurate, as it does not reflect the
recently negotiated changes in nursing staff at NRC and does not represent the portion of
shared staff from SCC that can regularly be counted on to work at NRC. The HCUA could not
provide me an official document that describes state medical employees and Wexford medical
staffing at NRC. A table in Appendix 1 was based on the HCUA and the IDOC Regional
Coordinator giving me the current configuration of staffing at NRC, which is not yet
memorialized in a document. Shared staffing between NRC and SCC is not definitively
apportioned in budget documents.
Our staffing table shows a total vacancy rate of 42%, although this reflects a large number of
newly allocated positions. Still, this is an extraordinary vacancy rate. We note that this staffing
level has not been developed with respect to staff needs at all levels. At best, it is a reflection of
a recent analysis of nursing need without relief factor.
NRC provider staffing consists of two physician assistants, one staff physician, and a Medical
Director. There are four budgeted providers but only three providers positions filled at NRC. We
were told that all three providers work in the morning in the clinic, seeing patients for physical
examinations, physician sick call, chronic care visits, and infirmary visits. At about noon, we

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were told that all three providers go to intake to perform physical examinations. In the 2016-17
annual CQI the following statistics were provided:
Intake evaluations
PA sick call
MD sick call
MD urgent care
MD encounters
Referred to MD
Total

17847
3062
2369
616
6190
1088
31172

This amounts to 599 provider encounters per week or 119 encounters per day in a five-day
work week. If there are four providers, each provider must see 29 patients per day. If there are
three providers, each provider must evaluate 39 patients per day. At 29 patients per day, this is
approximately four patients per hour if no lunch is taken. At 39 patients a day this is
approximately five patients per hour if no lunch is taken. This does not include infirmary
patients or review of labs, x-rays, collegial reviews, review of consultant reports, hospital
reports, and quality improvement activity. This is consistent with the First Court Expert’s report,
which noted that providers may perform 25 or more physical examinations in three to four
hours.12 These are unrealistic patient loads not likely to promote quality care. This staffing
pattern does not include a relief factor. This patient load is made worse given the lack of
adequate support services, particularly poorly maintained medical records and failure to
provide consultant reports to providers. This may account for an almost complete absence of
adequate history taking and incomplete evaluations of many patients identified on record
reviews.
An important aspect of physician staffing is physician credentialing. Administrative Directive
04.03.125 Quality Improvement Program requires one-time primary source verification be
conducted by the vendor and presumably reviewed by the IDOC. Primary source verification is
defined as verification from the original source of a specific credential to determine the
accuracy of the qualification of an individual health care practitioner. Credentials include
completion of medical school, training, licensure, and board certification if applicable. This
would mean, for example, that one-time primary source verification would include:
• Query of the AMA Physician Masterfile for verification of US medical school graduation
and postgraduate education completion. Alternatively, a letter from the medical school
verifying graduation.
• Query of the Education Commission for Foreign Medical Graduates (ECFMG) for
verification of a physician’s graduation from a foreign medical school.
• A letter from a residency training program or hospital internship program regarding
completion of internship or residency in part or in full.

12

Northern Reception Center (NRC) Report, January 21-23, 2014, p. 9.

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The American Osteopathic Association (AOA) Physician Database for pre-doctoral
education accredited by the AOA.
The Federation of State Medical Boards for all actions against a physician’s license or the
National Practitioner Data Bank full report.
A letter from fellowship programs for any fellowships completed.
Query of the American Board of Medical Specialties (ABMS) for verification of a
physician’s board certification.

We agree with the requirement of the AD and believe this information should be available to
the IDOC Agency Medical Director and Regional Coordinators so they can know whether the
assignment of physicians by Wexford is appropriate from a clinical perspective.
Currently, in the IDOC, primary source verification is currently interpreted as including
verification of only the physician’s current medical license and DEA license. The HCUA and
Regional Coordinator were unaware of the meaning of primary source verification in typical
physician credentialing. The Medical Director at NRC told us that he completed three years of
training in radiation oncology but did not finish the program. He then completed two years of
nuclear medicine training and said he finished the program but never practiced in nuclear
medicine. After finishing nuclear medicine training, this physician began working in the IDOC as
a primary care physician. It is our opinion that this credential does not make this physician
qualified to serve as a Medical Director or to obtain privileges to practice primary care
medicine. When we spoke with the Agency Medical Director on January 19, 2018, we asked
whether he would seek care from a nuclear radiologist if he had diabetes. He answered no and
stated that using nuclear radiologists as primary care physicians in inconsistent with community
standards. With respect to his prior emergency medicine business, he stated that he had never
hired a nuclear radiologist and agreed that most Illinois residents seeking primary care would
see a primary care trained physician.
There is no clerical support staff at NRC. The need for clerical staff needs to be taken into
account in development of a staffing plan.
The schedule E is the staffing requirements of the existing vendor contract. Remarkably, none
of the senior supervisory staff involved in the medical program we talked to are involved in the
development of staffing needs that ultimately become incorporated into the schedule E. We
understand that the last contract was developed well before any of the current leadership was
in place. Nevertheless, current staffing needs are not reflected in the current schedule E. We
asked the recent Vice President of Operations for Wexford, the Agency Medical Director, the
IDOC Regional Coordinator, and the HCUA if any of them had input or created the schedule E
staffing pattern. None of them had final authority or significant input into the schedule E. This
means that the staffing needs of the facility are not brought to the attention of whoever is in
charge of contracting for medical services or who is in charge of approving positions for the
IDOC.

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Though we did not review custody staffing, we heard complaints from supervisory staff that
there are insufficient custody staff to escort patients to their appointments and to ensure that
nurses have a custody escort when nurses administer medications to inmates. Because of lack
of ability to bring segregation inmates for their appointments, doctors often go up to the
segregation unit and see patients in a room not equipped for examinations and which only has
a chair.
The Warden told us that there are no post orders for how officers are to assist nurses when
they pass medications and no post orders or procedures for how inmates are to be scheduled
and brought for their medical appointments. The health care program does not track how many
people do not show up for appointments and there is no tracking of how often nurses
encounter difficulties with respect to administration of medication. The Warden agreed that
officers may monitor more than one housing unit due to staffing and that this was not their
desired staffing arrangement. Medical staff told us that when that occurs, nurses have to wait
for a custody escort, which delays medication administration. We were told that this is
particularly problematic on the evening shift.
The CQI program should track the number of patients who fail to show up for all categories of
appointments to determine if there is a problem with custody escorts. A custody staffing
analysis should be done to determine if there is sufficient custody staff to ensure that patients
are timely medicated and brought for ordered medical care.
With respect to a comparison of our findings with the findings and recommendations of the
First Expert report, NRC now has its own leadership team, allocated in the budget, which was a
recommendation of that report. There was a Medical Director in place at the time of the First
Expert report. However, the Medical Director position is now vacant and is temporarily filled by
an individual who is ineffective in that role and who has a history of clinical deficiencies and
who Wexford has given a final warning with respect to clinical care. The First Expert report
recommended a separate staffing grid for NRC. We agree with that recommendation but a
staffing needs assessment and staffing allocation specific for NRC is still not in place. Staffing is
still a combination of state and Wexford positions, which causes confusion and supervision
problems.
The First Expert report found that the majority of problems could be traced to the lack of
leadership at the facility. The condition does not appear to have improved, because the
leadership team is only recently been formed and because the Traveling Medical Director does
not provide clinical or administrative leadership in his role. Tracking logs and other data sources
are still not reliable and therefore ineffective in analyzing processes of care. The leadership
team also has not yet developed a plan of action, evidenced in their CQI plan, to correct
systemic problems at the facility.

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Clinic Space, Sanitation, Laboratory, and Support Services
Methodology: Accompanied by a nurse supervisor, we inspected the intake reception area,
housing units, mental health crisis unit, medical infirmary, and the outpatient clinic (exam
rooms, interview room, treatment room, storage closets, and x-ray suite). Staff in these areas
were interviewed.
First Court Expert Findings
The First Court Expert found the reception space adequate and well maintained. At the time of
the First Court Expert visit, the infirmary was not being used at NRC. The medical unit clinic had
three examination rooms and an emergency care/urgent care/procedure room. The First Court
Expert found the medical unit clinic clean and well maintained. The First Court Expert noted
that there were no clinical spaces in the housing units to adequately perform sick call or
physical examinations.
Current Findings
We agree with the First Court Expert’s finding that there are no adequately equipped and
supplied clinical examination rooms in which to perform sick call within the housing units. We
identified additional findings and confirmed some of the First Court Expert’s findings as follows:
• Since the First Court Expert’s report, the 12-bed medical infirmary has been opened.
• There are functional patient-activated call assistance devices on the wall next to each
medical infirmary bed.
• Overall, the reception area is adequate in size and is acceptably maintained except for
the provider examination rooms, which are unsanitary, cluttered, and have poorly
maintained furnishings.
• There are two negative pressure rooms in the medical infirmary. The negative pressure
monitor was not working at the time of the current visit. The vent in one of the two
negative pressure rooms was taped shut, disabling the negative pressure capability of
that room.
• The recently relocated nurse office/work station in the medical infirmary is cramped and
does not have a sink, phone, computer, or electrical outlets.
• The designated clinical spaces in the housing units are unsuitable for the provision of
sick call and physical examinations, lacking exam tables, appropriate chairs, desks, paper
towels, and in some rooms, sinks for hand washing.
• The three exams rooms in the clinic are insufficient to accommodate all four providers,
nursing staff, and the UIC telemedicine physician, who may need to see patients at the
same time.
• The interview room used as an overflow exam room lacked an examination table and
clinical equipment.
• The wall mounted oto-ophthalmoscopes were non-functional in all the exam rooms.
• There was broken equipment (scale and refrigerator) in the clinical area.
• The providers’ desks in the health care unit examination rooms were poorly maintained.

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The exam tables were flat and nonadjustable. The head could not be raised. There was
not an electric exam table in the clinic that could be used by non-ambulatory and
disabled patients.
All the health care unit and infirmary clinical and patient spaces were poorly maintained
and inadequately sanitized.
There were a number of infection control violations and safety hazards noted in the
clinical areas.
None of the examination tables in the clinic had paper barriers that could be changed
after use by a patient. The gurneys in the treatment room did have paper barriers.
The nurse sick call rooms in the housing units, the clinic examination rooms, storage
spaces, the treatment room, and the infirmary beds and patient rooms are not properly
cleaned, are poorly maintained, and disorganized, creating unprofessional and
unacceptable work and patient care areas. Environmental and infection control rounds
must be immediately instituted, and corrective actions aggressively pursued as
indicated. There is no sanitation schedule for cleaning and sanitizing clinical medical
areas.
Sinks in multiple areas have mineral deposits in the sink bowl and on faucets.
The quantity of linens was inadequate to meet the needs of the medical infirmary
patient population.
The lockdown practices of this facility force health care staff to conduct clinical
interactions on the housing units (medication administration, reading TB skin tests,
nurse sick call, and provider examinations) in conditions that are inappropriate for the
clinical interaction and do not permit adequate care to occur.

The intake reception area is essentially the same as was described in the First Court Expert’s
report. The reception area is designed to perform a production line screening of all new
admissions to the NRC. Once the security team has completed its intake process, new
admissions are guided through a step-by-step clinical screening process including phlebotomy,
dental, nurse history, and provider physical examinations. The phlebotomy area and nurse
screening areas were clean and orderly. The examination rooms where providers perform
examinations were dirty and furniture was in disrepair. Examination tables did not have paper
to provide infection control between patients. There is accumulation of mineral deposits on
faucets and in sinks, impeding sanitation and infection control.13 There is no schedule of
sanitation and disinfection practices to be carried out in these rooms.
The Minimum Security Unit (MSU) at NRC is a dormitory setting with a capacity of 272 beds
housing inmate workers. The main NRC prison housing consists of 24 housing units A through X.
A, B, and C are segregation units; the remainder are general population housing units. All the
housing units at NRC are structurally the same. Each unit has three tiers with cells housing one
or two individuals. The cells have a vertical glass slot and a chuck hole. We were told that the
inmates on these units were allowed out of their cells for three showers a week and for two 213 NRC has “hard” water (i.e., high mineral content) which causes build-up of mineral deposits in pipes, faucets, and sinks. The
institution needs a water-softening system; however, according to custody leadership, there is no funding for it.

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hour yard sessions per week. During inclement weather, the yard sessions are cancelled,
resulting in men not leaving their cells except for showers and medical care. There are no pill
call lines. Nurses pass medications, read tuberculosis skin tests, and not uncommonly do sick
call interviews cell by cell with the cell door locked. There is a correctional room/office on the
first level of each unit with a sink/phone/desk and a cut-down tool and a first aid kit. Next to
the security office, there is an approximately 8’ x 10’ room that is used by the nurses to do sick
call when the inmates cannot be moved to the first level. None of the nurse rooms inspected
had an exam table or a desk. Not all the rooms had a sink. There were two chairs in one of the
rooms and four bolted metal chairs with shackles in another. The room on housing A had a sink
with hot water but no soap or paper towels. There is no equipment in these rooms. We were
told that nurses bring equipment with them when they use these rooms for sick calls. Providers
also use these rooms for the completion of intake physical exams that were deferred during the
reception process. We were also told that these rooms are occasionally used for chronic care
clinic visits. Sanitation of these rooms was poor. Floors and sinks were dirty. Although these
rooms are well situated to increase access of the inmates to sick call services and minimize
inmate movement to the clinic, in their current condition they are unacceptable for the
performance of sick call or provider clinical examinations.
The infirmary has a separate entrance from the main corridor and a short internal connecting
hallway that links the infirmary with the clinic. Although the mental health crisis beds have
been utilized for some time, the medical section was only opened in 2016. The medical
infirmary was not opened during the First Court Expert’s visit in 2014 and resulted in a
recommendation to open and staff this unit. There is a wing with eight single cell mental health
crisis beds and an adjoining corridor with 12 medical beds (six rooms, each with two beds). The
nursing office was recently moved away from the mental health wing due to environmental
concerns when mental health patient-inmates would flood their cells or MACE was used. The
new office was previously a closet and has one desk, a dressing cart, a medication cart, a file
cabinet, and a medical record holder in a very cramped space. There is no sink, no phone, no
electrical outlets, and no computer. There were two unmounted sharps boxes in the room. It
was reported that work orders have been submitted to address these deficiencies, which
currently hamper the efficiency of the nursing staff. Unprotected paper memos and directives
were taped on the walls, creating a fire safety issue.
The medical infirmary was inspected. Eleven of the 12 medical beds were occupied. There is a
call buzzer at each bed. The buzzers were found to operational in all rooms that were tested,
and the patient-inmates understood how to use this system. There were two negative airflow
rooms (A-105-106), but the monitoring panel was not operational; the maintenance team was
contacted and was working on this problem on the final day of our visit. The ceiling vent in A106 was also taped over, interfering with the operation of the negative airflow system. Porters
(inmate workers) were directed by a nurse supervisor to remove the tape.
The medical infirmary rooms were shabby. The beds are fixed in a flat position without the
capability to raise the head or raise/lower the height of the bed. Most of the mattresses had
open cracks and thus could not be adequately sanitized. One patient bed lacked a mattress and
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had an uncovered porous foam egg crate full bed cushion that was dirty and absolutely could
not be cleaned and sanitized. Even though two-thirds of the 11 individuals housed in the
medical infirmary were chronically ill with issues of fragility, ambulation, self-care, disability, or
continence, there were no adjustable hospital beds in the infirmary.
The mental health infirmary is generally for short-term crisis management. Three men were
housed in the eight-bed mental health unit during the site visit. One of the individuals was
smearing feces on the walls of his room.
The health care unit has administrative offices, a medical record room, a pharmacy/medication
prep room, three examination rooms, one interview room, a single chair dental suite, a
treatment room, a plain film x-ray room, a Panorex unit, and a central nursing station. Four
providers are budgeted for doctor/provider sick call visits and chronic care clinics on MondayFriday. A single provider also staffs a Saturday sick call. In the evening, nurse sick call is done.
The clinic treats all urgent referrals in the treatment room. Each of the three exam rooms have
non-adjustable upholstered tables without paper rolls, a sink, a wall mounted
sphygmomanometer, and a desk. All of the desks no longer have veneer on the edges.
Uncovered paper memos/directives/guidelines are taped on the walls. The mounted otoophthalmoscopes were missing electric cords and were non-functional in all the exam rooms.
One room had a functional backup oto-ophthalmoscope placed on the exam table. There was
not a single adjustable exam table or electric table in the clinic, making it extremely difficult to
impossible to examine certain types of disabled patients. The sinks in the exam rooms were
crusted with mineral deposits. One room lacked hand drying paper. A broken scale was in one
room. Three crutches were stacked in the corner of one examination room for the entire site
visit. There is an interview room with a desk and sink but without an examination table that is
used by a provider when all four providers are on duty or one of the exam rooms is in use by
the UIC Telemedicine specialty clinic. There were boxes on the floor and a broken desk-top
refrigerator on a counter next to the desk. There were two closets in the interview room. One
was stacked from the floor to almost the ceiling in violation of infection control and fire safety
standards. The other closet was completely filled with oxygen tanks. Most were appropriately
in security racks but six to seven were not; this is a safety hazard.
This clinic has an insufficient number of examination rooms. There are only four examination
rooms and there are four providers. However, during morning sessions when all providers work
in the health care unit, all rooms are occupied. There is then no space for a nurse to evaluate
patients or for the UIC HIV/Hep C telemedicine clinic sessions. This lack of space results in
prioritization and promotes failed appointments.
The treatment room had a suction unit, four secured oxygen tanks, two AEDS (one had an
expired pad), crash cart, an EKG machine, two wall mounted oto-ophthalmoscopes without
electric cords, and nebulization units. The crash cart is inspected on every shift; this was verified
on the crash cart log. An emergency bag was inspected and was noted to have a variety of
appropriate equipment (ambu bag, BP unit, stethoscope, dressings, ammonia capsules,

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glucagon, thermometer, FSBG testing materials but not naloxone (Narcan). The treatment room
was somewhat cluttered but operational.
In summary, we had additional findings as compared to the First Court Expert. We agree with
the single recommendation of the First Court Expert that there should be a designated
examination room in each housing unit appropriately equipped to conduct sick call. We have
additional recommendations found at the end of this report.
Sanitation Schedule
Methodology: The reception screening area, the sick call rooms on housing units, the mental
health crisis unit, the medical infirmary, and the clinic were inspected. Nurses, nurse supervisor,
correctional officers, a sanitation sergeant, porters, and patients in the medical infirmary were
interviewed.
First Court Expert Findings
The previous Court Expert reported that the clinical spaces were well maintained.
Current Findings
Although the First Court Expert had no findings with respect to sanitation, we noted multiple
problems including:
• The level of sanitation in almost all the clinical areas has deteriorated since the visit of
the First Court Expert.
• The cleanliness of the designated clinical spaces in the housing units, the mental health
crisis unit, the medical infirmary, and the clinic was notably deficient, creating an
unsanitary and non-professional clinical environment.
• The cleanliness of the reception screening was overall acceptable.
• Although requested, no documentation of training provided to the porters who sweep,
mop, and sanitize the clinic and the infirmary beds was provided. The porters stated
that they had received no environmental training and had learned their duties on-thejob. This may violate OSHA rules that govern exposures to blood borne pathogens.
• The porters wore surgical gloves that they did not change as they cleaned infirmary
rooms/sinks/toilets and the clinical areas.
• Mattresses in the medical infirmary and the treatment room’s gurneys’ upholstery were
torn and cracked.
• There was no documentation in the medical infirmary correctional log that beds and
mattresses were sanitized before a new admission was assigned to a bed.
• There are no regular/monthly environmental or infection control rounds being
performed at NRC.
NRC had posted a sanitation schedule in the clinic nursing station, but it does not specifically list
the clinic and infirmary on the schedule. Interviews with a sanitation sergeant and two porters
(inmate workers) related that the clinic and the infirmary are swept and mopped one to two
times per week and as needed. The floors in both of these clinical areas are clearly not routinely

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buffed. There is no record in the infirmary correctional log about the routine disinfection of
occupied mattresses or after a bed has been vacated and before a new patient is assigned to
that bed. The porters were noted not changing surgical gloves while they moved between
infirmary rooms after cleaning sinks, toilets, and showers. They related that they had not
received any training about their cleaning duties and the use of protective gear.
The porters are also responsible for the cleaning and disinfection of mental health crisis rooms
that had been smeared with fecal material. They reported that there are Hazmat kits (gowns,
face shields, gloves, booties) that they are to wear while cleaning body fluid on exposed
floors/walls. However, the Hazmat kits are not always in stock. (Three Hazmat kits were found
in the nursing supply area.) The sanitation sergeant stated that he did not know if there was
any documented record/log about the sanitation training provided to the porters. The general
uncleanliness of the infirmary and clinic is indicative of poorly trained and supervised workers.
The reception screening area was generally clean and in good condition except for the provider
rooms. As noted in the Reception Screening section of this report, nursing staff sanitize their
own work stations, but this service should be provided by porter staff in an organized manner
for all areas, including provider examination rooms.
The overall cleanliness of the medical infirmary and mental health crisis unit was extremely
poor. The sinks, toilets, and showers were functional but crusty and poorly cleaned. The floors
in some of the infirmary rooms were painted, some were tiled. The painted floors were faded,
and the blue color was discoloring the socks of the occupants. The edges of all the rooms had a
rim of smudge and dirt. The wall in one medical room was splashed with some dried liquid
material. Only one room (A-O6) was judged to be acceptably clean; this room was occupied by
two more physically able patient-inmates who regularly clean their own space. The tile floor
was shiny, the sink and toilet were not crusty, and the shower was clean. One vacant room in
the mental health crisis unit was inspected; a section of the wall had a missing chunk of plaster,
the floor was dirty and not been swept, the toilet had not been cleaned, the borders of the
floor were dirty. The hallway in the mental health unit had missing and cracked tiles.
The edges of the clinic floors were smudged and dirty. The veneer on the sides of the providers’
desks was missing, making it difficult to clean and sanitize. The supply cabinets in the clinic’s
exam rooms were cluttered and disorganized. Beverages/coffee were on the desks in two of
the rooms. A provider’s lunch was found in one of the cabinets.
The two gurneys in the treatment room had tears and cracks in the upholstery. The treatment
room was disorganized and cluttered.
The infirmary and institutional sheets and bedding are washed in the central laundry. The
plumbing staff maintains a log of the temperature of the hot water provided to these washing
machines. The temperature logs from 10/1/17 to 1/29/18 noted 10 of the 121 days when the
temperature was less than the 165 degrees (range 160-164 degrees) recommended in IDOC
Administrative Directive 05.02.140.
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In summary: The cleanliness and sanitation of nearly all of the clinical and patient care areas in
NRC is notably deficient. There is an urgent need for the institution of vigilant, regular
sanitation, and environmental and infection control rounds. The training of the inmate porters
is nonexistent. Additional recommendations are noted at the end of this report in the Clinic and
Sanitation and the Infection Control sections.
Environmental Rounds
Methodology: The HCUA, a nurse supervisor, nurses, and a sanitation sergeant were
interviewed.
First Court Expert Findings
The First Court Expert did not address environmental rounds.
Current Findings
The NRC clinical leadership stated that routine environmental are not being done at NRC.
Accordingly, there is no available documentation of such rounds. If the rounds were regularly
performed, many of the deficiencies noted in the Clinic Space and Sanitation section would
have been identified and corrective actions initiated. HCUA and nurse supervisors
communicated that work orders are submitted for the repair or removal of broken equipment
and furniture.
Radiology
Methodology: We toured the radiology unit and the radiology technician was interviewed.
First Court Expert Findings
The previous Court Expert did not comment on the radiology suite.
Current Findings
• There is no waiting list or backlog for plain x-ray studies at NRC.
• The turnaround time for the radiologist’s reading and report is one to three days.
• During the upcoming visit to SCC, additional requests will be made to obtain any
radiation physicist’s reviews and certifications for NRC radiology units and discuss
whether IDOC x-ray technicians are candidates for the use of monitoring devices as
outlined in Illinois Administrative Code 32 -340 510 and 520.
NRC has a radiology suite in the clinic area that does non-contrast plain films. X-rays are
performed Monday-Friday. A radiologist is onsite on Tuesday, Wednesday, Friday, Saturday,
and Sunday to read films and write handwritten reports. The turnaround for receiving the
radiologist’s readings is one to three days. Six x-ray reports of films taken on 1/30/18 were
audited; five were read within one day, and one was read in two days. There is no backlog and
no waiting list for x-rays. Six patients were scheduled for studies on 1/31/18. Four had been xrayed before noon; the arrival of other two men was awaited. It was reported that “no shows”
are always rescheduled on the next working day.

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It was not clear whether a Nuclear Radiation Physicist inspects the radiology unit in the clinic.
There was not a certification posted in the suite. The administrative personnel who might have
the certification was off duty during the four-day inspection. The x-ray technician stated that
repairs are quickly done if so needed. The x-ray technician was not wearing a radiation
exposure dosimetry monitoring device (badge); she was advised that this was not necessary at
NRC.
In summary: Additional investigation is needed to verify whether the NRC Radiology unit is in
compliance with the State of Illinois Radiation Safety regulations.

Medical Records
Methodology: We interviewed medical records staff, toured the medical record room, and
performed record reviews from which we determined the state of the medical records.
First Court Expert Findings
The First Court Expert and his team had enormous difficulty in reviewing medical records
because of “drop filing.” The First Court Expert found that drop filing creates “chaos for
clinicians” and that important information will not be located. The First Court Expert found that
stapling intake documents together was not unreasonable. The First Court Expert also found
that there was no system of logging and tracking medical records. The First Court Expert
recommended drop filing should not be done for patients with significant problems and all
patients at NRC for more than 30 days.
Current Findings
We agree with all of the findings of the First Court Expert with one exception. We disagree with
the practice of stapling intake medical documents together as a substitute for creating a
medical record folder. We add the following additional findings:
• The medical records room is too small to accommodate the number of staff.
• Medical records are not maintained in accordance with IDOC requirements or in
accordance with guidelines from the Illinois Department of Human Services.
• The medical record room is not secure. Unauthorized medical record staff can access
the room at will. NRC fails to maintain privacy and confidentiality of the medical record.
• There is no tracking and accountability system for medical records. Because there is no
sign-out process for medical records, it is not possible to know who has the medical
record.
• Any staff member can pull and re-file medical records. This promotes loss of medical
record documents and does not safeguard confidentiality or use by unauthorized
persons.
• The intake packets of medical record documents include separate documents for dental,
medical, and mental health. These are unified at a later date. There needs to be a
unified medical record at the time a medical record is initiated.

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The medical record at NRC is a paper record maintained in a green pressboard binder. There is
a small medical record office in the health care unit to maintain and process the documents
contained in the medical record. This office is too small for the number of staff. There are
currently four medical record clerks and the room appears too small for this number of
employees. Due to the inability to file records, five additional clerks have been added to this
group. The space appears too small to accommodate nine employees and the volume of
medical records. One wall of the records room is lined by file cabinets containing green medical
record binders and manila folders containing individual inmate medical record documents.
Opposite the file cabinets are a series of several desks used by medical records clerks to
conduct their work. The space is extremely cramped and cluttered.
Medical records are not maintained in accordance with requirements of the IDOC
Administrative Directives14 or with the Illinois Department of Human Services requirements15
for maintaining medical records. Medical records are so poorly maintained that the poorly
maintained records are likely to adversely affect clinical care. This is similar to the finding in the
First Expert report.
The Administrative Directive 04.03.100 Offender Medical Records gives requirements for how
medical records are to be maintained. It states:
“A medical record for each offender shall be established by the appropriate reception and
classification center.”
The AD describes the manner of maintaining a medical record, including:
• The tabbed sections of the medical record
• The tabbed section of the medical record that documents are kept in
• That medical records are confidential
• That every entry is legible
• That progress notes are filed within one day
• That reports from community health providers are filed within 14 days
• That consultation reports are filed within three days.
The IDOC AD on medical records requires use of a green binder for all inmates. This binder is a
thick hard-backed pressboard folder with a medical record number. Each binder has nine tabs
corresponding to the major types of documents including:
• Database
• Medical progress notes
• Consultations
• Mental Health Reports
• Dental/Vision
• Chronic clinic sheets/Flow sheets
14
15

Illinois Department of Corrections Administrative Directive 04.03.100 Offender Medical Records.
Illinois Department of Human Services website as found at http://www.dhs.state.il.us/page.aspx?item=40657.

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•
•
•

Medications
Laboratory and X-ray reports
Miscellaneous

The medical records at NRC are not maintained in accordance with the IDOC’s AD on medical
records. Many inmates housed at NRC do not have a green binder medical record. Those
inmates at NRC who do have a green backed medical record have a record that is not
maintained in accordance with AD requirements. Most files are loose paperwork in a manila
folder or are loose paperwork placed in no particular order in a green binder. A significant
number of files are merely an intake packet and any other medical record documents stapled
together without any binder. The filing that occurs consists of placing medical record
documents in a binder or stapling to a packet in no particular order. Documents are not
separated into the pertinent section of a green binder. This situation has gone on for so long
that this irregular and unacceptable medical record practice is institutionalized and accepted as
normal.
For persons housed at NRC for extended periods and frequently seen for repeated treatments
at UIC or John Stroger Hospital, their records become so disorganized that it is extremely
difficult to find documents in the record. We noted on mortality reviews that two records of
inmates who had been housed at NRC were missing medical record documents. We note that
the IDOC response to the First Court Expert’s report stated that, “The IDOC disagrees that
recommendations voicing preference for the manner in which record-keeping and
administrative duties are performed rise to the level of constitutional obligations.”16 We
disagree with this assertion. Not only does the manner of maintaining medical records violate
the IDOC AD, but it also violates existing guidelines of the Illinois Department of Human
Services. Also, significant risk of harm can arise when a medical record file is disorganized and
fails to include all documents, as clinical staff may be unable to locate important documents.
We note some problems in the specialty care section of this report whereby recommendations
of consultants were not noted, possibly due to disorganized medical records and failure to
provide consultation reports to clinical staff. We evaluated several patients who had large
charts. These charts are unacceptable for routine use for clinical care. That clinical medical
leadership has not objected to the state of these records reflects negatively on medical
leadership.
The records process begins at intake. On each day of intake, a medical record clerk obtains the
list of the number of arriving inmates and staples together a medical record packet for every
inmate expected to arrive at NRC. Mental health and dental each have their own packets. The
medical packets contain the sheets that are used in the intake process, including:
• A medical history form filled out by nursing
• A physical examination form filled out by a provider
• A problem list
• A progress note
16

Pages 13-14; email letter to Dr. Shansky on 11/3/14 sent by William Barnes representing the IDOC.

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•
•
•

A transfer summary form
An HIV counseling form
An influenza vaccination form

A packet is made for each incoming inmate. Inmates who arrive from the Cook County Jail
arrive with a packet of limited medical information from the jail that includes their medication.
This information is attached to the packet for the corresponding inmate. Mental health and
dental documents are not initially included with medical documents and are added to the
record at a later date. All documents need to be maintained as a unified medical record. After
conclusion of intake the packets are brought to medical records and maintained in vertical desk
sorters by date. Each sorter contains all the packets for each day after intake. The sorters are
kept on top of a file cabinet. The packets are kept in the vertical sorters until a physical
examination is done. When the physical examination is done, the packet is placed in a basket.
The packet is kept in a basket until the Mantoux skin test for TB is read. Once the Mantoux skin
test is read, the intake packet is complete, the staple is removed and the documents are placed
loosely in a green binder, not in chronologic order. Patients who are technical parole violators
or are on Court Writs have their documents placed in a manila file folder in no chronologic or
consistent order. Any subsequent medical record document is merely placed into the green
binder in no particular order. Documents are not sorted into the nine types of tabbed
document separators and filed into the corresponding tab section. Documents need to be
sorted into the nine types of document tab section and within each tab filed in chronologic
order. This does not occur until the medical record arrives at the destination IDOC facility. The
reason for this was reported as lack of staffing.
The medical records room promotes non-confidential practices and promotes loss of medical
record documents. This room is unlocked and the medical records are unattended by official
medical record clerks for most of the day. Numerous staff wander into the room at will and
take medical record documents without any documentation of what record they are taking or
where they are taking it. Charts are not signed out when removed from the file room. Nonmedical records staff also re-file medical records. There is no accountability for records
removed from the medical records room. Medical record clerks work daytime hours. For the
remainder of the day the room is open and staff walks in to obtain records as needed. This
violates medical record practices, as unauthorized persons are to be excluded from the medical
records storage area on the basis of confidentiality of the medical record. It is the practice at
NRC that charts for all clinics (nurse sick call, PA sick call, MD sick call, and nurse treatment call)
are pulled by nurses. Mental health staff pulls their own charts. Typically, non-medical record
staff are considered unauthorized personnel and are not allowed to take or re-file a medical
record without signing out a record. Given these practices, it would not be surprising that there
would be a high volume of lost documents and records. While we were not able to investigate
the number of lost documents and records, on the last day of our tour we listened to a senior
staff in health care searching for a chart of a patient who was transferring, but the chart was
lost.

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The practices in this medical record program also fail to conform to Illinois Department of
Human Services medical record guidelines, which require:
• Medical records are confidential and must be safeguarded against loss or use by
unauthorized persons.
• Medical records rooms will be locked after regular work hours.
• The agency must have policies in place regarding the retention and destruction of
medical records. For advice on record destruction, public agencies are to contact the
Illinois Secretary of State’s Illinois State Archives.
• Medical records must be maintained in accordance with accepted medical standards,
including:
o Readily accessible
o Systematically organized and in chronological order
o Confidential
o Safeguarded against loss or use by unauthorized persons
o Secured by lock when not in use.
We had an initial interview with medical record staff, including the Medical Record Director.
We reviewed multiple records. All larger records were disorganized and were not in
chronological order. These documents were so difficult to use that use of such a record would
significantly prolong patient encounters unless providers failed to review the record
appropriately. We believe the latter happens, based on record reviews. On record reviews, labs
were often not reviewed during follow-up patient evaluations, consultation reports were not
documented as reviewed at subsequent clinical encounters, and prior adverse clinical events
were not noted. For several record reviews, we noted missing labs or notes which the records’
department brought to us on the following day. These items were not timely filed.
We also noted that consultation reports and hospital discharge summaries are mostly not
present in the medical record. Of a sample of 22 consultations and one hospitalization, only
36% of medical records included a report of those consultations. A physician assistant told us
that consultation and hospital reports frequently did not make it into the medical record. In the
IDOC response to the First Court Expert’s report, the IDOC states that they have no control over
hospitals and consultants and cannot be responsible for obtaining those reports.17 Obtaining
hospital and consultant reports is sometimes difficult. The IDOC is ultimately responsible to
ensure that the reports are obtained. In our own experience in managing correctional
programs, we sometimes have had to negotiate with hospitals and consultants but have always
been able to obtain a hospital discharge summary and consultation reports of offsite services.
The inability to do this is a reflection of the quality of management of Wexford. We note that
the Regional Manager for Wexford is an ex-warden and lack of knowledge of how to do this
may be an issue.
This medical record system is broken and unacceptable from a clinical medical perspective and
violates Illinois Department of Human Services standards and the IDOC AD requirements. To fix
17

Pages 21-23; email letter to Dr. Shansky on 11/3/14 sent by William Barnes representing the IDOC.

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this system would require a complete overhaul. In the case of NRC, obtaining an electronic
record would be an easier solution than attempting to fix the existing broken system. In any
case, the current arrangement is unacceptable.
We confirmed all of the findings in the First Court Expert’s report and had additional findings
with respect to confidentiality and lack of adherence to the IDOC AD and state regulations. We
disagree with the First Court Expert’s recommendation that medical records should be
maintained in the same manner as in permanent institutions but only for persons who remain
in the MSU for greater than two weeks. All patients should have a properly maintained record
beginning as soon as they arrive. It is our opinion also that NRC should conform to the IDOC AD
on medical records and the Illinois Department of Human Services’ requirements for
maintaining clinical medical records. This would require that a green backed medical record file
be initiated upon arrival at the facility and maintained throughout the stay at NRC. An easier fix
to this problem would be to institute an electronic medical record. The First Court Expert also
recommended that medical record staffing be sufficient to ensure that medical records are
adequately maintained, and we agree with that recommendation. While additional staff has
been budgeted, they have not yet been hired. The question as to whether the additional staff
will resolve medical record problems identified in this report is not answerable at this time.

Medical Reception
Methodology: To evaluate medical evaluation of newly arriving inmates we toured the medical
reception area, observed the medical reception process, interviewed health care staff,
reviewed IDOC health record forms, and reviewed 20 health records. Of the 20 records, 10
were selected from a log documenting referrals from the reception nurse to the provider. Ten
records were selected from nursing sick call logs and from the list of inmates at NRC greater
than 90 days.
First Court Expert Findings
The previous Court Expert found substantial delays in medical processing of newly arriving
inmates. Medical records were disorganized and inhibited the provision of adequate health
care. IDOC forms used by nurses and medical providers did not include questions designed to
elicit current symptoms (e.g., chest pain, shortness of breath, abdominal pain, etc.) that may
indicate serious disease. Approximately 30% of records reviewed found lack of timely follow-up
of abnormal labs and chronic diseases. Providers did not document significant medical
diagnoses on the problem list.
Current Findings
NRC’s primary mission is to process and classify newly arriving inmates before transfer to other
state institutions. In 2017, NRC received 15,942 inmates or approximately 307 a week.18 Newly
arriving inmates transfer from county jails and also arrive as parole violators. On Wednesdays,
NRC receives inmate transfers from around the state who are on a writ to appear in Cook
18

When the previous court expert evaluated the institution in 2014, the volume was approximately 500 inmates per week.

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County court or inmates requiring medical services in the Northern Illinois area. These inmates
are managed as intrasystem transfers and not medical reception inmates.
Our review showed that improvements have taken place with respect to the timeliness of
completion of the medical reception process, including labs and provider physical examinations.
Nurse and phlebotomy stations are clean and well organized. Medical providers document
medical conditions on patient problem lists.
However, we found persistence of problems noted in the previous Court Expert’s report as well
as identified new problems. These include:
• Medical records are universally poorly organized with loose filing.
• Weight scales are not calibrated and are inaccurate.
• Nurses do not correctly measure visual acuity and do not consistently record results in
the medical record.
• Nurses do not consistently record tuberculin skin test results in the medical record.
• Nurses do not change gloves or wash hands between patients.
• HIV opt-out testing is not being consistently performed.
• There is no schedule of sanitation and disinfection activities performed in medical
reception. Instead of a system for routine sanitation and disinfection, the level of
sanitation at each station is determined by the conscientiousness of individual staff.
• Provider examination rooms were filthy and furniture was in disrepair.
• Examination tables had no paper to provide an infection control barrier between
patients.
• The dentist did not change gloves, wash hands, or change light-fixture infection control
barriers between patient intake dental screening examinations.
• IDOC medical reception forms do not contain an adequate past medical history section
and review of systems (e.g., chest pain, shortness of breath, abdominal pain, blood in
stools, etc.) to detect recent or current symptoms of potentially serious medical
conditions.
• Medical provider physical examinations are cursory and do not adequately explore the
patient’s medical history, including a pertinent review of systems, to determine whether
a patient’s chronic diseases are well or poorly controlled.
• Medical providers do not provide continuity of care with respect to patients’ chronic
disease medications, either omitting or changing medications (e.g., insulin types)
without a clinical indication.
• Nurses transcribing provider medication orders do not initiate a medication
administration record (MAR) when they have given the patient medications from stock
supply.
• Medical providers do not consistently order chronic disease labs to be available at the
initial visit (e.g., HbA1C).
• Medical provider orders (EKG, chest x-ray, blood pressure monitoring, etc.) are not
consistently implemented by nurses.
• Medical providers do not timely address abnormal lab tests results.

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•

Medical providers do not complete the initial chronic disease form when seeing patients
for follow-up.

Observation of Medical Reception
Medical reception is conducted in a large room, with inmates moving from station to station to
complete each step of the process. The stations where nurses and phlebotomists work are
clean and well-organized.19 Staff had access to gloves and sharps containers.
As inmates begin the process, a phlebotomist collects blood for labs that include serum
chemistry, syphilis, and opt-out HIV and hepatitis C antibody testing. Although HIV and hepatitis
C testing are supposed to be opt-out, nurses consent inmates for HIV testing, which is an opt-in
methodology.20 Record review showed that HIV testing was not consistently performed even
when patients requested HIV testing.21 January 2018 CQI minutes showed that more than 1500
lab draws were performed that included 1300 hepatitis C tests, but only 278 HIV tests. This
suggests that opt-out testing is not working as intended.
After phlebotomy, an RN performs a medical history, tuberculosis symptom screen, height and
weight, vital signs, visual acuity, and tuberculin skin test (TST). Typically, there are two to four
nurses assigned to this component of medical reception, depending on patient volume and/or
nurse availability. Observation showed that the medical reception process went smoothly;
however, we noted issues with the accuracy of clinical information. One of the court experts
stepped on two different scales and found a 10-pound discrepancy in weight, indicating that
the scales are not calibrated. Snellen charts to measure visual acuity are posted on the wall
behind each nursing station with a piece of tape placed on the floor at approximately 20 feet
away. However, nurses had patients read the Snellen chart sitting in a chair which was
approximately 10 feet from the chart and at angle. Nurses also did not measure visual acuity in
each eye by having the patient cover one eye at a time. Record review showed that nurses
documented visual acuity in only 50% of the records, in most cases documenting 20/20 vision in
both eyes which, given our observations, are likely not accurate. We observed that nursing staff
did not consistently change gloves or wash hands between each patient.
Staff reads patient tuberculin skin tests (TST) 48-72 hours after administration by going cell to
cell in the housing units. We interviewed staff, who reported that sometimes the officer opens
up the food port slot to have the inmate stick out his arm for staff to read the TST and other
times the inmate holds up his arm in the cell window and staff reads the TST through the
window. The correct method of reading TSTs is to palpate the TST site for induration, which
cannot be done by looking through a window. Thus, the current practice likely results in
inaccurate reading of tuberculin skin tests and missed cases of TB infection. We also found that
staff does not consistently document tuberculin skin tests in the health record. We interviewed
There is no schedule of disinfection activities for the medical reception area. Nurses we spoke with made it their personal
practice to organize and disinfect their work stations prior to seeing patients during medical reception.
20 Opt-out testing means that testing will be performed unless the patient refuses the test. Opt-in testing means that the
patient is offered testing and is performed only upon patient consent.
21 Medical Reception Patients #1, 5, 19.
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a staff person responsible for documenting test results who reported that she does it “if she has
time.” In several records we found that staff inexplicably documented planting the TST in
January 2018 but reading the TST on 12/31/17.22
We note that the TST is a labor intensive and human error prone methodology to identify
individuals who have tuberculosis infection or disease. Many correctional systems are switching
to drawing blood for interferon-gamma release assays (IGRAs), which is more reliable and less
error prone. Use of IGRA testing will free up a significant amount of nursing time that can be
devoted to other clinical duties. This test would be especially useful at this facility, where
officers do not open cell doors, so that nurses can appropriately read the Mantoux skin test.
Following the medical history, nurses immediately refer patients with acute conditions and/or
chronic diseases to a medical provider. Staff reported that typically three medical providers are
assigned to perform patient physical examinations and develop a treatment plan, including
ordering medications. As noted in the previous Court Expert report, on days in which the
volume of intakes is high, providers may perform 25 or more physical examinations in three to
four hours, which was “unlikely to reflect an appropriate quality standard.”23
The examination rooms where providers perform examinations were dirty and furniture was in
disrepair. Examination tables did not have paper to provide barriers between patients. There is
accumulation of mineral deposits on faucets and in sinks, impeding sanitation and infection
control.24 There is no schedule of sanitation and disinfection practices to be carried out in these
rooms.
Depending on volume, one or two dentists perform oral screening at reception. We observed
one dentist who did not change his gloves or wash his hands between patients, even when he
incidentally touched the patient’s lips while examining teeth and oral cavity.
IDOC Medical Reception Forms
We note that the IDOC Offender Medical History Past Medical History section of the form is
limited with respect to chronic diseases and does not include chronic obstructive pulmonary
disease (COPD), thyroid, kidney, liver, or autoimmune diseases, or cancer. The form also does
not include a section for review of systems (e.g., chest pain, shortness of breath, abdominal
pain, blood in stool, difficulty with urination, etc.) that are typically included in a comprehensive
history and physical examination. This poses a risk that important medical diagnoses or
symptoms of serious illness will not be medically evaluated and missed, increasing risk of harm
to the patient. The IDOC Offender Physical Examination form (DOC 0099, Rev. 11/20/12)
includes a section for substance abuse, risk factors for blood borne infections (e.g., HIV and
HCV), and TB symptoms, but does not include a section for chronic disease review of systems

Medical Reception Patients #5, 8.
Lippert Report, p. 9.
24 NRC has “hard” water (i.e., high mineral content) which causes build-up of mineral deposits in pipes, faucets, and sinks. The
institution needs a water-softening system, however, according to custody leadership, there is no funding for it.
22
23

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(e.g., chest pain, SOB, polyuria, polydipsia, neuropathy, etc.), which contributes to the
assessment of disease control.
Medical Provider Examinations
With respect to provider history and physical examinations, we found them to be cursory and
lacking in quality. Providers did not consistently elaborate on positive findings noted by the
nurse. Providers took no additional medical history of the patient’s chronic diseases, including a
review of systems (ROS) to assess disease control at the time of admission. In many cases, a
medical transfer summary was received by the sending institution, but providers did not
document that they reviewed the information and, in some cases, missed important medical
diagnoses (e.g., prostate cancer) or medications for high blood pressure (e.g.,
hydrochlorothiazide).
Providers wrote orders to enroll patients into the chronic disease program in 30 days and
assigned patients low bunk/gallery status as clinically indicated. Providers also ordered
diagnostic tests (e.g., chest x-ray, EKG) and labs for some chronic diseases (e.g., thyroid,
anticoagulation), but did not order HbA1C for any diabetics. Providers usually ordered
continuation of each chronic disease medication; however, in some cases they did not continue
medications without documenting the clinical rationale for not providing continuity of care. In
other cases, ordered medications were not timely received.
A clinical concern is that three patients were being treated for heroin withdrawal at the time of
admission, but the provider did not order Clinical Opiate Withdrawal Scale (COWS) monitoring
to assess whether the patients’ symptoms were improving or worsening, and that may have
required changes in medication withdrawal regimens.
Following provider physical examinations, nurses review and note provider orders, including
medications. A concern is inconsistency among nurses with how medication orders are noted.
Some reception nurses transcribe medication orders onto a medication administration record
(MAR) and some do not. Thus, many patients receive medications for which there is no
corresponding MAR documenting that they have received the medication. (See Pharmacy and
Medication Management).
The following cases are illustrative of concerns noted above.
• This 58-year-old man arrived at NRC on 1/12/18.25 His medical history includes diabetes,
hypertension, asthma, seizures, BPH, prostate cancer, s/p total prostatectomy in 2008,
latent TB infection, chronic alcohol abuse, depression, bipolar disorder, and PTSD. The
provider did not elaborate on all positives noted on the nurses’ medical history form or
on the medical transfer form, including asthma, hypertension, alcohol abuse, or
prostate cancer. The provider documented that the patient had a total prostatectomy
but not prostate cancer. He did not order a HbA1c to assess diabetes control or PSA to
assess for possible recurrence of prostate cancer.
25

Medical Reception Patient #4.

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•

A 43-year-old man arrived at NRC on 1/8/18.26 His medical history includes
hypothyroidism, substance abuse, depression, and right ear surgery with tube
placement in 2016. The provider did not document whether the patient still had a right
ear tube. The physician ordered levothyroxine for the patient’s hypothyroidism but
there is no medication administration record that shows the patient received
levothyroxine. Thyroid labs showed the patient’s hypothyroidism was in poor control
(TSH=19.1, normal=0.5-4.5). The physician reviewed the report, but as of 2/1/18 had not
increased the patient’s thyroid medication.

•

A 56-year-old man arrived at NRC on 1/10/18.27 His medical history includes diabetes,
hypertension, hyperlipidemia, mitral valve replacement (MVR) and venous stasis. His
medications included coumadin, metformin, metoprolol, losartan, and Pravachol. On
the day of arrival, labs showed the patient’s INR was therapeutic (INR=2.2, goal=2-3). On
1/18/18, eight days after arrival, a provider performed a physical examination. The
provider ordered medications and an EKG. The provider did not order a HbA1C or enroll
the patient into the chronic disease program. The EKG was not performed. On 1/25/18,
a provider saw the patient for follow-up of MVR and venous stasis. He did not take a
history of the patient’s diabetes or MVR. He ordered an INR, EKG, and chest x-ray. As of
1/31/18, neither the EKG or chest x-ray had been performed.

•

A 69-year-old man arrived at NRC on 1/19/18 following discharge from a hospital for
pulmonary embolism.28 His medical history also included hypertension, atrial fibrillation,
hypothyroidism, COPD/asthma, and trigeminal neuralgia. The provider did not elaborate
on the patient’s recent medical history of atrial fibrillation and pulmonary embolism.
The patient’s hospital discharge medications included Pradaxa, but the provider
changed it to Coumadin without documenting the clinical rationale. On 1/19/18, the
patient’s INR was subtherapeutic (INR=1.5, goal=2-3). On 1/24/18, a provider reviewed
the report but did not increase the patient’s Coumadin dosage. Labs also showed the
patient was hyponatremic (Na=128, normal=135-146), most likely due to treatment with
Trileptal, but as of 1/30/18 a medical provider had not addressed the abnormal lab
report. We referred this record to the Nursing Director.

•

A 56-year-old man arrived at NRC on 1/16/18.29 The patient’s medical history included
diabetes and hypertension. Transfer information from Cook County Jail showed that he
was prescribed Glargine Insulin 100 units every night and rapid-acting Insulin Aspart
before meals. The physician changed the patient’s insulin from long-acting glargine
insulin to intermediate acting NPH insulin without documenting a clinical rationale for
the change. The patient’s blood sugar was 337 upon arrival but the provider did not
note this high glucose level or order insulin coverage at that time. Reception labs
showed the patient’s syphilis test was positive with a titer of 1:2. On 1/27/18, the

Medical Reception Patient #8.
Medical Reception Patient #14.
28 Medical Reception Patient #9.
29 Medical Reception Patient #6.
26
27

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physician saw the patient but took no syphilis history, except that the patient denied a
history of syphilis. The physician did not stage the patient’s syphilis (primary, secondary,
latent, or late latent) and treated him with one dose of Bicillin, which would not be
adequate treatment for late syphilis.
•

This 46-year-old man arrived at NRC on 1/18/18.30 His medical history includes diabetes
and psychiatric history. The provider did not perform a history of the patient’s diabetes
or perform a diabetes or cardiovascular review of systems (ROS). The provider ordered
Metformin, but his MAR showed the patient did not receive Metformin until 1/22/18.

•

This 48-year-old man arrived at NRC on 1/11/18.31 His medical history includes diabetes,
myocardial infarction s/p stents in 2015, and high cholesterol. The provider did not
perform a diabetes or cardiovascular ROS. The provider ordered medications including
metformin, glipizide, Plavix, carvedilol, and gabapentin. There is no MAR showing the
patient received keep on person (KOP) medications. Gabapentin was ordered on
1/12/18 but not received until 1/17/18. The provider ordered an EKG that was not
performed. The patient consented to an HIV test, but it was not done. The patient’s
tuberculin skin test result was not documented in the health record.

•

This 37-year-old man arrived at NRC on 12/22/17.32 His medical history includes obesity,
hypertension, opioid dependence, and sleep apnea with C-PAP machine. The patient
accepted HIV testing, but it was not done. A physician saw the patient and ordered
lisinopril, hydrochlorothiazide, and aspirin. There are no MARs in the record showing
that he received these medications. On 1/19/18, the physician saw the patient for blood
pressure follow-up. He did not complete a chronic disease form. The patient’s
hypertension was poorly controlled (BP=153/113 mm Hg.) The provider ordered one
dose of clonidine 0.2 mg, increased Lisinopril to 20 mg twice daily and ordered blood
pressure checks for seven days. The physician did not renew the patient’s
hydrochlorothiazide. On an unknown date, the patient wrote a health request that he
was “supposed to have his blood pressure checked for 7 days….my pressure has been
high plus I haven’t been called to get it checked.”

•

This 37-year-old man who arrived at NRC on 12/28/17.33 His medical history includes
heroin use, seizure disorder, asthma, hypertension, multiple injuries secondary to
suicide, s/p splenectomy 2004, and left hand infection. His medications included
Dilantin, hydrochlorothiazide, enalapril, QVAR inhaler, Neurontin, and doxycycline.
There is no documentation that the patient was given medications at medical reception.
Five days later, on 1/3/18, the patient received Dilantin, ibuprofen and Robaxin. The
provider did not document hypertension on the problem list. At intake, his Dilantin level
was subtherapeutic (6.3, normal=10-20), but a provider did not follow-up on this

Medical Reception Patient #3.
Medical Reception Patient #1
32 Medical Reception Patient #19.
33 Medical Reception Patient #20.
30
31

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abnormal report. On 1/24/18, the physician saw the patient and renewed Lisinopril, not
hydrochlorothiazide. There are no physician order forms containing medication orders
in the record. All medication orders were transcribed from provider progress notes, not
physician order forms. On 1/30/18, a provider ordered Dilantin, Lisinopril, and
Neurontin, but not hydrochlorothiazide.
•

This 36-year-old man arrived at NRC on 1/19/18.34 His medical history includes injection
drug use, HIV infection, anxiety, and depression. The provider did not perform a HIV
review of systems or order HIV labs in advance of the patient’s chronic disease visit.
Although HIV patients are treated by an outside provider, NRC providers should perform
an evaluation to determine if the patient has any symptoms or lab test results
warranting urgent referral.

In summary, although improvements have been made with respect to timeliness of the medical
reception process, there are multiple systemic issues that create an ongoing risk of harm to
patients.

Intrasystem Transfer
First Court Expert Findings
The previous Court Expert reviewed 10 records of patients detained at NRC for >60 days and
found that five patients with chronic diseases had not been enrolled into the chronic disease
program.
Current Findings
Due to its mission as a reception center, NRC does not have a large volume of intrasystem
transfer to NRC. Some inmates transfer to NRC to go out to court or to receive medical services
in Cook County. Upon arrival, transferring inmates are subject to a process similar to medical
reception. We reviewed medical records of five inmates who transferred to NRC and/or had
been at the facility for greater than 90 days. Two of five inmates had no medical conditions
requiring follow up. One patient with COPD transferred to NRC on 10/19/17 and received a
history and physical examination on 10/24/17.35 The patient was not enrolled into the chronic
disease clinic and a provider did not see the patient until 2/1/18. In another record, the patient
was timely processed in October 2017. In December 2017, a provider saw the patient for
chronic disease management. The provider treated the patient for an exacerbation of asthma,
for which the provider ordered prednisone 10 mg for three days; however, a nurse transcribed
the order to be given for five days and the patient actually was given the medication for nine
days due to a nurse’s failure to properly transcribe the order. The provider did not timely see
the patient for follow-up.

34
35

Medical Reception Patient #10.
Intrasystem Transfer Patient #23.

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Nursing Sick Call
Methodology: We evaluated nursing sick call by reviewing IDOC Administrative Directive
Offender Health Care Services, (04.03.103K), Wexford Non-Emergency Health Care Requests
and Services (P-103), IDOC Treatment Protocols, and the NRC Offender Handbook. We also
interviewed health care leadership, staff, and inmates; inspected areas where sick call is
conducted; and reviewed tracking logs and health records.
First Court Expert Findings
The previous Court Expert Report found that there are no logs to track each health request and
the corresponding staff response; inmates do not have the ability to confidentially submit
health requests; health requests are not filed in the medical record; and there were problems
with the quality of health assessments.
Current Findings
Our review concurred with the findings of the previous Court Expert. We also found that the
basic components of a nursing sick call program are not in place. At NRC, patients do not
receive timely and adequate access to health care, creating a systemic risk of harm to the NRC
population. These problems include:
1. Inmates are not provided approved health request forms to submit health requests;
therefore, inmates submit requests on scraps of paper or generic Offender Request
forms.
2. Inmates are not provided the opportunity to confidentially submit their health requests
on a daily basis.
3. Health care staff does not collect health request forms on a daily basis.
4. Staff does not date, time, and sign when health requests are received.
5. Nurses do not triage patient health requests within 24 hours.
6. Nurses do not document the urgency of the disposition (e.g., urgent, routine).
7. Nurses do not assess patients with symptoms within 24 hours of triage.
8. Nurses do not have medical records available to them when seeing patients.
9. Nurses conduct sick call in inadequately equipped and supplied rooms in housing units
without access to a sink for handwashing.
10. Health requests are not consistently filed in the medical record.
11. Correctional Medical Technicians/Licensed Practical Nurses perform sick call, exceeding
their scope of practice that prohibits them from performing independent nursing
assessments.
12. Nurses do not timely refer patients to providers in accordance with IDOC Treatment
Protocols.
13. A Nursing Sick Call Log has been recently implemented and does not track the status of
each patient request.
14. IDOC Administrative Directives provide insufficient guidance regarding implementation
of Nursing Sick Call.
Information supporting these findings is described below.

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Access to Care
Upon arrival to NRC, inmates are provided an orientation manual that states that “inmates are
educated regarding the sick call process and provided with a nurse sick call slip (Offender Sick
Call/Medical Services Request. STA 0202 Rev 4/2013) they can use to access care. Additional
nurse sick call slips are available to offenders from nursing and security staff upon request.” The
slips are to be picked up twice daily during the morning and evening medication pass.36 Health
requests are to be triaged and seen within 24 hours of receipt and provider referrals in 72 hours
or at the next scheduled physician clinic.37
However, actual practice shows that inmates are provided two generic Offender Request forms
(DOC 0286, Rev. 4/2010) at intake and thereafter are not provided routine access to Medical
Services or Offender Request forms. Instead, our review showed that inmates submit their
health requests on scraps of paper they have in their possession or borrow from other inmates.
Inmates may or may not have pens or pencils to write their health requests. Staff reported that
inmates could borrow a pen from another inmate, but an officer commented to a court expert:
“Yes, but it will cost them a lunch tray.” We interviewed staff who confirmed that inmates are
not provided Medical Request forms.
The previous Court Expert Report indicated that inmates were to submit their health requests
in locked boxes accessed only by health care staff; however, we did not find that these boxes
had been installed in the housing units.38 Moreover, NRC inmates are locked down 24 hours a
day except for four hours per week, and therefore do not have the ability to leave their cells to
submit their requests on a daily basis.39 Thus, the institutional practice to lock offenders down
24 hours per day is a serious obstacle to access to care.
Instead, inmates submit their health requests by placing slips of paper through the cracks of
their cell door. These slips are typically picked up by officers or health care staff; however,
anyone walking by a cell door could pick up these health requests, including other inmates (e.g.,
inmate porters). When officers pick up the forms, some place them in an unsecured, open
folder in the housing unit or deliver them to health care staff.40 It is also possible that officers
misplace health requests or otherwise fail to deliver them to health care staff. Nurses also
collect health requests during medication pass, but if an inmate is not receiving medication, it is
unclear that the inmate would be able to notify a nurse to request a health request form or
deliver a completed form to a nurse.
Offender Sick Call/Medical Services Request. STA 0202 Rev 4/2013.
The IDOC administrative directive regarding sick call states that “Health care staff shall review offender sick call requests
within 24 hours of receipt;” that “When appropriate health care staff will schedule an evaluation within 24 hours of receipt, 72
hours on weekends, or sooner, as clinically indicated;” and when a request results in a referral to a provider, the evaluation will
“Take place within 72 hours or upon the next scheduled visit by a primary care physician.”
38 Although the IDOC Regional Medical Coordinator testified that these boxes had been installed in his region, this is not the
case at NRC.
39 We received conflicting information about how much out of cell time NRC inmates were provided. An officer and a nurse
stated that they were allowed out of cell once a week for four hours at a time. A Superintendent said they were allowed out of
cell twice a week for a total of four to five hours.
40 However, an officer and nurse reported that not all officers will pick up the forms, as they do not see it as part of their duties.
36
37

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Once collected, inmate health requests are transported to the medical clinic and placed in an
open bin in the main medical clinic. We observed that it is possible for any person walking
through the clinic to pick up these health requests, including officers and possibly inmates in
the clinic area. Either a registered nurse or CMT/LPN is to triage the health requests within 24
hours to determine the urgency of the request (e.g. emergent, urgent, routine, etc.). However,
nurses/CMTs do not document when the health requests are received or when they are triaged.
Once triaged, the nurse is to enter each request onto the nurse sick call log which is to be used
to schedule patients the next day.41 However, staff reported that until recently, not all of
inmate written requests were retained, addressed, and filed in the medical record. Staff
reported that some of the requests were thrown away. For example, staff reported that if a
CMT/LPN triaging the request noted the patient had not yet had a physical examination, the
request would be thrown away under the assumption that the complaint would be addressed
at the time of the physical. Likewise, if the CMT/LPN noted that a provider saw the patient in
the last day or two, the request would be thrown away under the assumption that the
complaint had been addressed. We were informed that this practice was recently stopped and
now all health requests are addressed and filed in the medical record. However, while this
practice was in effect, some inmates did not have timely access to care. This was supported by
our finding that inmates submitted forms in which they wrote that they had submitted multiple
requests to have their health need addressed.
Either a registered nurse or CMT/LPN performs sick call. Nurses are to have the health record
available to them for a sick call encounter, but during our tour, a nurse reported she was only
able to locate three of 10 health records of patients she was scheduled to see. Staff performs
sick call in housing unit cells that are not adequately equipped and supplied. The rooms do not
have an examination table, exam table paper, chairs and desk for the nurse and patient to sit,
or access to a sink for handwashing. Nurses bring some equipment and supplies with them to
these rooms, including blood pressure cuff, stethoscope, thermometer, scale, alcohol wipes
and some over-the-counter (OTC) medications. However, nurses do not have otoscopes
available to examine ears, throat and oral cavity. We inspected a cart used to transport this
equipment that was dirty, with tape residue stuck to the cart. Thus, nurses do not have medical
equipment and supplies to perform adequate patient assessments.
At NRC, both RNs and LPNs perform sick call using Treatment Protocols. In the State of Illinois,
LPNs are to practice “under the guidance of a registered professional nurse, or an advanced
practice registered nurse, or as directed by a physician assistant, physician…to include
“conducting a focused nursing assessment and contributing to the ongoing assessment of the
patient performed by the registered professional nurse.” LPNs may also collaborate in the
development and modifications of the RN or APRN’s plan of care, implement aspects of the
plan of care, participate in health teaching and counseling, and serve as an advocate for the
patient by communicating and collaborating with other health service personnel.42 However,
41
42

We were informed that the log was started in November or December 2017.
Illinois LPN Scope of Practice. Section 55-30.

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Illinois scope of practice does not permit LPN’s to perform assessments independent of a
registered professional nurse or higher level professional, as is currently being done at NRC.
Neither does the scope of practice permit LPNs to perform independent assessments according
to protocols. LPNs do not have the requisite education and training, including physical
assessment skills, needed to perform independent assessments.43 Thus, some NRC patients do
not receive evaluations by health care staff licensed to perform independent assessments. This
increases the risk of harm to NRC patients.
We reviewed the Nursing Sick Call Log for the Month of January 2018.44 Staff does not
completely fill the log out, including the date the request was received and including whether
or not a nurse saw the patient. From 1/1/18 to 1/30/18, 282 requests were received, averaging
approximately 10 per day. This is an extremely low number given the population of
approximately 1400 inmates. On four days, no health service requests were noted as collected,
and on seven days, less than five requests were collected. This is consistent with inmates not
having forms to fill out and/or staff not collecting health requests on a daily basis.
We selected and reviewed 10 health records from entries on the Nursing Sick Call Log for the
month of January 2018. In addition, we reviewed health requests found in medical reception
records. The following cases are illustrative of problems noted above.
• This 31-year-old man arrived at NRC on 1/3/18.45 His medical history includes seizure,
asthma and bipolar disorder. On 1/25/18, the patient submitted an Offender Request
(OR) form for back pain stating “this is the 10th time I have put in. I am almost out of
my seizure medications.” On 1/26/18, an RN saw the patient and did not assess his back
pain, only that he was running out of seizure medications.
• This 20-year-old man arrived at NRC on 12/13/17.46 His medical history included drug
use. On 1/9/18, he submitted an OR form for chest pain with deep breathing, laughing
or coughing. “I have put in several slips but haven’t gotten a response.” On 1/25/18, he
was listed on the nursing sick call log. On 1/26/18, an RN assessed the patient using the
chest pain protocol. He complained of chest pain seven of 10 in severity. His vital signs
were normal. The nurse did not notify a provider in accordance with the IDOC chest
pain protocol, but referred the patient to a PA for 2/7/18, approximately 10 days later.
This referral time frame is also not consistent with IDOC Administrative Directives for
referral to take place in 72 hours.

NCCHC defines Qualified Health Care Professionals to include nurses without distinguishing between registered and licensed
practical nurses. However, RN and LPN practice must remain within their education, training, and scope of practice for their
respective state.
44 The log has undergone several revisions. At the beginning of 2018 the log included the name and ID number of the patient,
complaint, date the request was written, date received, and date seen, treatment protocol used, whether the patient was
referred to a provider, and a co-pay assessed. Later the log was changed so that the date the inmate submitted the request was
not included, just the date the request was received and the date the patient was seen.
45 Sick Call Patient #1.
46 Sick Call Patient #2.
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• This 56-year-old man arrived at NRC on 1/10/18.47 He had a history of diabetes,
hypertension, mitral valve replacement, and lower extremity venous stasis. On 1/23/18,
the patient was listed on the sick call log for leg wounds. There is no health request
form or nursing sick call visit in the health record. On 1/25/18, a provider saw the
patient for follow-up of MVR and venous stasis.
• This 37-year-old man arrived at NRC on 11/30/17.48 His medical history included
seizures and anxiety. His medication was gabapentin. On 12/14/17, an RN saw the
patient for complaint of not receiving gabapentin for neuropathy after two weeks.
BP=145/85 mm hg. The nurse advised the patient that the provider would address his
issues. On 12/18/17, the patient submitted a scrap of paper stating, “I was called to sick
call yesterday morning but sent back due to crowding. I was told to come back but was
never summoned. Please advise as my medication has still not been verified.” An
unsigned note documented “already seen,” without documenting resolution of the
complaint. On 1/17/18, he was listed on the sick call log for a rash and on 1/23/18, for
possible urinary tract infection (UTI). On 1/23/18, a nurse saw the patient for the rash
but did not address the UTI complaint.
• This 38-year-old man arrived at NRC on 1/4/18.49 His medical history included
pulmonary embolism. He was prescribed a blood thinner (Eliquis) since 2016. On
1/14/18, the patient signed a nursing sick call refusal form but there is no health
request form in the record. On 1/19/18, the patient submitted a request complaining of
having “blood clot cramps.” There is no documentation on the form of when it was
received or triaged by a nurse. On 1/26/18, a nurse completed a refusal form, stating
that the patient refused to sign. On 1/27/18, the patient was scheduled to see the
physician, but as of 1/31/18, there is no documentation in the record that the
encounter took place.
• This 42-year-old man arrived at NRC on 11/9/17.50 His medical history includes hepatitis
C infection. On 12/13/17, a nurse saw the patient for back pain using the back-pain
protocol.51 The nurse documented no physical examination of any kind, only vital signs.
The nurse treated the patient with ibuprofen. On 1/9/18, the patient was listed on the
sick call log for dental pain. On 1/10/18, an RN saw the patient using the toothache
protocol. The patient complained of exposed nerve pain for four to five months that
was 10 of 10 in severity. The patient was afebrile. The exam showed bleeding and
swelling. The nurse noted that the patient met the referral criteria for 24-hour referral;
however, the nurse did not contact the dentist. The nurse gave the patient ibuprofen
200 mg 1-2 tablets three times daily.

Sick Call Patient #4.
Sick Call Patient #6.
49 Sick Call Patient #7.
50 Sick Call Patient #8.
51 The credentials of the staff who assessed the patient are illegible.
47
48

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• This 37-year-old man arrived at NRC on 12/22/17.52 His medical history includes obesity,
sleep apnea, hypertension, and opioid dependence. The patient submitted an undated
piece of paper that said, “Blood in stools, please help.” An unknown person wrote
“refused” without date, signature and credentials. On 1/17/18, an RN saw the patient
for constipation. The patient reported that on 1/16/18 that his stools were dark red and
soft. The problem started in November 2017. The RN noted that he was being seen by
GI and was previously scheduled for colonoscopy. The patients pulse was rapid
(pulse=114/minute). The nurse documented a plan to refer the patient to the doctor if
symptoms persisted for three days. On 1/19/18, a physician saw the patient for followup of his blood pressure (BP=153/113 mm Hg). The physician did not address the
patient’s complaint of blood in his stools. We referred this record to the Director of
Nurses for follow-up with the provider.
In summary, at NRC the basic components of a system to access health care are not in place
and patients do not have timely access to care for their serious medical needs. The practice of
24 hour lockdown is a serious obstacle to access to care. Inmates do not have the means to
timely and confidentially submit their health requests. When submitted, staff does not timely
respond. Patients are seen by CMT/LPNs who are not licensed to perform independent
assessments, and therefore exceed their scope of practice whenever they perform independent
assessments. Patients are not examined in a clinical setting with adequate lighting, equipment,
supplies, and access to handwashing. Finally, nurse to provider referrals are not made when
clinically indicated, and when made, they are not timely.

Chronic Care
Methodology: The medical records of 13 patients with chronic medical illnesses and conditions
were reviewed. There was limited opportunity to interview NRC providers due to restrictions
imposed by Wexford. The Office of Health Services Chronic Illness Treatment Guidelines dated
March 2016 was reviewed as needed.
First Court Expert Findings
The previous monitor noted that a lower number than expected of individuals were enrolled in
chronic care clinics, the chronic care form had not been revised for 12 years, and that not all
eligible individuals had their first visit to a chronic care clinic within 30 days of admission to
NRC. He noted concern that COPD was not included on the list of chronic care diseases and
advised that asthma, COPD, and chronic bronchitis be cared for under a pulmonary disease
clinic.
Current Findings
We agree with all of the findings in the First Court Expert’s report. In addition, we found the
following problems:

52

Sick Call Patient #9.

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•
•
•

•
•
•
•

Not all individuals with chronic illnesses are being evaluated in a chronic care clinic
within 30 days of admission.
Provider notes about the status of the chronic conditions, the reasons for modification
of treatments, and the pertinent physical examinations are deficient. Quality of care,
overall, was poor.
The diabetic care at NRC fails to provide basic screening tests and vaccines that are
recommended in the IDOC Diabetes guidelines (HbA1C, microalbumin-creatinine ratio,
pneumococcal vaccination, foot exams). In addition, the guidelines should be revised to
include routine screening for diabetic retinopathy and intake testing for HbA1C.
Problem lists should be universally and accurately completed during the reception
screening. Failure to complete the problem list puts the patient at risk for a disruption of
care.
The MARs demonstrated gaps (blanks spaces) in documentation of insulin
administration. Insulin refusals are not regularly reported to the providers.
There are unacceptable delays in obtaining specialty consultations and diagnostic tests.
Patients with problems which appeared to be beyond the expertise of NRC providers
were not referred for specialty care.

NRC has chronic care clinics for asthma, diabetes, hypertension, multiple sclerosis, seizure
disorder, sickle cell disease, and tuberculosis. Individuals with human immunodeficiency virus
(HIV) and hepatitis C are referred to the UIC infectious disease telemedicine consultation clinic.
All other diseases are managed in a general medicine chronic clinic. The admission packets
containing clinical information and medications from Cook County Jail or other correctional
facilities in Illinois are rapidly reviewed by the NRC providers so that those new admissions with
acute or chronic conditions are prioritized and seen more expeditiously during the reception
screening.
During intake, a TB skin test is placed, and blood is drawn for HIV, hepatitis C, syphilis, and a
basic metabolic panel (glucose, BUN, creatinine, electrolytes), and liver profile. These tests are
meant to screen all inmates for potential infectious and certain chronic illnesses. However, if an
inmate has a known chronic illness, there is no routine screening testing performed to ascertain
the current status of the patient’s chronic condition. Providers can ask the phlebotomists to
add additional testing for some patients (e.g., HIV viral loads and immunodeficiency panels for
HIV patients or International Normalized Ratio (INR) testing for those on anticoagulation). The
lack of obtaining routine blood tests useful for determining the status of a patient’s chronic
illness is a major deficiency, as it delays identification of out-of-control status and delays
initiation of a fully informed therapeutic plan. We noted this problem particularly for persons
with diabetes, few of whom have a HbA1C test or microalbumin test obtained during the
reception process. In part, it is our opinion that this deficiency is related to the order of
reception steps. Phlebotomy is the first step of the medical process. The provider examination
is typically the last step. If phlebotomy were the last step, then all tests necessary to determine
the chronic disease status could be ordered by the examining provider and drawn before the
inmate leaves the reception area in addition to the routine screening tests that are performed

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on all persons coming through reception. In addition to blood screening, peak expiratory flow
rates (PEFR) are measured on asthmatics, capillary blood glucose (CBG) point-of-care testing is
done on diabetics, and viral load and immunodeficiency panels drawn for patients with HIV.
All new admissions with any chronic condition are to be seen no less than 30 days after
admission to NRC. We were told that nurses performing reception screening record all
individuals with chronic illnesses. At the conclusion of intake, a clinic nurse takes all intake
paperwork and develops a list of all patients who have chronic illness and inserts newly
identified patients onto a chronic illness roster. Because this nurse is so frequently pulled for
other assignments, this task is mostly not done, resulting in extremely low numbers of patients
enrolled in the chronic care program. Providers evaluating persons with chronic illness can also
refer patients for a chronic care follow up. But this system is ineffective. Only nine of the 13
medical records reviewed documented that a chronic care visit had been scheduled or
completed in <30 days and one within 60 days. Three of the 13 did not have a chronic care
referral or a chronic care visit documented in the medical record.
We could only estimate the number of persons with chronic illness who are not tracked, but it
appears to be more than the majority of patients. At NRC, there were 1493 inmates and 188
inmates at MSU, for a total of 1681 inmates on the NRC campus. There were only a total of 60
(4%) inmates on the chronic disease roster. We estimate the number of persons with chronic
disease to be approximately 30%. This would mean that an estimated 504 (1681 X 0.3) inmates
at NRC can be expected to have a chronic illness. Yet only 60 (12%) of inmates with chronic
illness are on the chronic care list. A National Commission on Correctional Health Care study
estimated chronic disease prevalence in state prison populations as 3.2% for heart disease,
16.7% for high blood pressure, 2.1% for diabetes, and 7.2% for asthma.53 These are only for the
more common conditions. This also excludes hepatitis C, which is estimated at above 10%.
While some patients have multiple chronic illnesses, the rate of all unique individuals with any
chronic illness is clearly higher than 4% of the NRC population.
As an example, there were 11 men on the diabetes chronic care list compared to 35 individuals
on the list of patient-inmates being administered injectable insulin. This does not even include
the many persons on oral diabetic agents. The diabetes chronic care list significantly
underestimates the number of diabetics. This is consistent with the findings of the First Court
Expert, who identified that not all individuals with chronic illnesses were being enrolled in
chronic care clinics. This raises concerns that individuals with significant chronic illnesses could
be delayed from receiving needed care or, at worst, could be lost to follow-up while at NRC.
The provider’s documentation in the medical record is extremely brief and rarely contains
clinical information needed to clarify the state of a patient’s chronic illness or justify a change in
the treatment plan. The only possible way to try to understand if a chronic condition was
uncontrolled or over-controlled is to speculate. This lack of clinical documentation is a
The Health Status of Soon-To-Be-Released Inmates, A Report to Congress, Volume 2, National Commission on Correctional
Health Care, April 2002 as found as a PDF at https://www.ncchc.org/filebin/Health_Status_vol_2.pdf.

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significant barrier to the continuity and quality of care. Because multiple providers see patients,
the comprehensiveness of the previous clinical note is key to assuring that care delivered to a
patient-inmate is coordinated and seamless.
Many of the charts reviewed had completed problem lists; however, records were reviewed
that did not have a problem list and others had a serious chronic illness that was not noted on
the problem list. Eight the 12 medical records reviewed had completed problem lists, two
problem lists had not been completed, and two were incomplete (serious chronic illness not
noted).
The care of diabetics was uniquely problematic. Without regard to the level of control or other
needs of the patient, all insulin-requiring diabetics have their community or previous facility
insulin types and dosages changed to twice a day NPH dosing accompanied by twice a day
capillary blood glucose (CBG) testing.54 Because patients have individual needs, this one-sizefits-all protocol has risks of deterioration of diabetes control and disrupts the continuity of care.
Microalbumin-creatinine ratio, lipid profile, and HbA1C are not consistently drawn at the first
provider visit as directed in the IDOC Office of Health Services Diabetes Treatment Guidelines
(March 2016). Only one of the five diabetic charts reviewed had a HbA1C lab done, one had an
order for this test, and three did not have an order or results in the chart. Pneumococcal
vaccine was not being ordered. One of the five diabetics already had been vaccinated but four
did not have a history of previously being vaccinated, nor was it ordered by NRC. The providers’
notes do not detail their inspection and examination of the feet of the diabetics. On routine
diabetic clinic visits, the providers check a box that lower extremity exam was done. Detailed
notes about sensation, callouses, or the presence or absence of ulcers or other foot
abnormalities are not documented in the medical record. None of the diabetic records
reviewed had evidence that a retinal screening for diabetic retinopathy had been recently
performed or had been ordered by NRC providers. The IDOC Office of Health Service’s
Offenders Diabetes Guidelines we received does not include a recommendation for routine
retinal screening for diabetics; this is not in alignment with national USA standards of care. We
believed that the IDOC Diabetic Chronic Care guideline was missing pages and we asked for but
did not receive any further copies.
The medications for some new admissions were not ordered at intake, putting at risk the
control of the chronic illness that is being treated. Lab reports are not always in the medical
record. Medication administration records (MARs) and specialty consultation reports were not
consistently found in the medical record. MARs have blanks where the nursing staff failed to
note whether they administered insulin doses or refusals. The provider and nursing notes do
not document that insulin refusals are regularly reported to the provider. Intake physical exams
are not always done within seven days of admission.55

54 These are point of care finger stick blood glucose tests that civilian diabetics perform themselves but in correctional facilities
are often performed by nurses.
55 IDOC Administrative Directive 04.03.101 Offender Physical Examination.

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Eleven of 13 (85%) patient records reviewed had problems demonstrating quality of care issues.
The following patient care summaries illustrate some of the concerns noted above.
•

This patient was admitted to NRC on 1/4/18.56 Medical and mental health screenings
were done on 1/4/18 and dental screening was done on 1/5/18. The medical history
included tobacco use, hypertension, and aortic valve replacement. A problem list was
completed. Medications included amlodipine, hydrochlorothiazide, and warfarin. During
the 26 days he was at NRC, three INRs had been performed. All were in the therapeutic
range. His problem list was complete. He was scheduled for a chronic care clinic on
2/3/18. As of 1/29/18, almost a month after reception, his admission physical exam had
not yet been performed.

•

Another patient was admitted to NRC on 11/17/17.57 Medical history, physical exam,
mental health screening, and dental screening were done on 1/17/18. The patient had
diagnoses of pituitary tumor, type 1 diabetes, hypertension, hypercholesterolemia,
hypothyroidism, sleep apnea, and a urological problem (note illegible). The problem list
was completed. Medications included metoprolol, amlodipine, aspirin, Lisinopril,
metformin, insulin, and levothyroxine. A low TSH resulted in his thyroid medication
being held. On 11/21/17, he passed out and suffered a forehead contusion which
required four sutures; a finger stick CBG test was not done, an electrocardiogram (EKG)
was not immediately done, and the provider did not comment on the cause of the
syncope. At a chronic care clinic visit on 12/16/17, the provider noted that the patient
was missing some medications and his EKG was normal. The same dose of insulin was
continued. Depo Testosterone, which has a single FDA indication for hypogonadism, was
initiated on 12/29/17 with no explanatory note by a provider. It was not clear what was
wrong with the patient. He was next seen by a provider on 1/16/18. His CBG tests in the
first two weeks of January 2018 ranged from 200-300 (poor control) and the provider
increased the insulin dosage. His CBG tests from 1/17 to 1/30/18 continued to range
from 200-300 but there were no further intervention/visit/notes as of 1/30/18.
In summary, pneumococcal vaccine was not offered, HbA1C was not ordered, detailed
foot exam was not done, retinal screening was not ordered. The response to the
syncope and the ordering of additional testing were deficient. Although the insulin
dosage was increased on 1/16/18, the CBG tests continued to be elevated (200-300) for
the next two weeks with no further intervention and adjustment of insulin dosage. The
patient was placed on testosterone without a documented indication.

•

Another patient was admitted to NRC on 11/17/17.58 A nurse identified a history of
type 2 diabetes. A physical examination was done. His medications were insulin,
metformin, atorvastatin, aspirin, and Lisinopril. The admission glucose was 240, which is

Chronic Care Patient #1.
Chronic Care Patient #2.
58 Chronic Care Patient #3.
56
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elevated, yet a HbA1C test was not ordered on admission. CBG tests from 11/17/17 to
12/2/17 ranged from 130-339 (mean >200). This indicates poor control of his diabetes.
The MAR for insulin administration during these dates had 11 blanks, indicating that the
patient did not receive insulin, or the nurse did not document administration of insulin.
At a chronic care visit on 12/2/17, the insulin dosage was not increased despite the poor
control of his diabetes over the preceding month. The provider ordered a HbA1C and a
follow-up clinic in eight weeks. CBG tests from 12/3/17 to 1/30/18 ranged from 126-236
(mean >150), and during this period the MAR for insulin had two blanks and 25 refusals.
There was no intervention concerning the insulin refusals or elevated CBG tests. There
was no provider visit from 12/2/17 until 1/30/18, the day of our visit.
In summary, there was no problem list, pneumococcal vaccine was not
offered/administered, there was no detailed foot exam, retinal screening was not
ordered, there was no HbA1C ordered on admission, and there was no referral to a
physician for failure to take insulin.
•

Another patient came into NRC on 1/19/18.59 Medical history, physical, and dental
screening were done on intake. The diagnoses included: type 2 diabetes, hypertension,
asthma, BPH, seizures (not on anti-epileptic medication and no seizure since 2002).
There was no problem list in the medical record. The medication list that transferred
with the patient from Cook County Jail included glargine and regular insulin, metformin,
albuterol/QVAR, atorvastatin, metoprolol, Tamsulosin, amlodipine, enalapril, and
pneumococcal 23 vaccine given. A NRC provider switched the patient’s insulin to NPH
BID with sliding scale regular insulin, and metformin. Laboratory tests included a CBG
test of 212, a hepatitis C test reactive, and serum glucose 234. The blood pressure was
136/57. A provider requested a chronic care clinic appointment for 2/17/18. The MAR
for insulin from 1/19 to 1/30/18 had two blanks/two refusals, with CBG values ranging
from 76-235 (mean>140).
In summary, there was no detailed foot exam, no microalbumin-creatinine ratio, retinal
screening was not ordered, and no HBA1C was done on intake. The hepatitis C antibody
positive status was not added to the problem list.

•

59
60

Another patient was admitted to NRC on 11/20/17.60 The patient was a 58-year-old
man. The medical history, physical examination, and mental health screening were done
on intake. The diagnoses included: type 2 diabetes, hypertension, asthma, chronic
obstructive lung disease (COPD), and carotid stenosis. Carotid stenosis was not on the
problem list. Medications included: insulin, Lisinopril, metoprolol, aspirin, and
amlodipine; influenza vaccine was given at the Cook County Jail. The admission
laboratory tests included: glucose 111. The blood pressure was 161/80, the peak
expiratory flow rate (PEFR) was 330. A doctor saw the patient on 12/1/17. The blood

Chronic Care Patient #5.
Chronic Care Patient #6.

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pressure was 159/78, which is high for a person with diabetes, and the CBG test was
200, which is high. The provider ordered amlodipine as it was not ordered at intake. On
12/5/17, the HbA1C was 7.0. On 12/14/17, at an RN visit the patient was “dizzy” with a
blood pressure of 130/84 and a CBG value of 131. On 12/25/17, an RN evaluated the
patient who was “dizzy” with blood pressure of 163/94 (elevated) and pulse was 82. On
12/16/17, a provider saw the patient and documented left carotid bruit. An ultrasound
had been done at Weiss Hospital and the record from Weiss was requested. The
provider started atorvastatin. At the 1/18/18 provider visit, the blood pressure was still
elevated at 167/114. The provider administered an immediate single dose of blood
pressure medication and increased routine blood pressure medications. On 1/20/18, the
patient had “chest discomfort.” The blood pressure was 177/105, which is very high.
The EKG was negative. A provider only gave a once-only dose of clonidine, which is not
an acceptable standard of treating elevated blood pressure. On 1/22/18, the medical
record documented that the patient was “Not taking BP meds.” On 1/28/18, the blood
pressure was 161/88 (which is elevated), but was not addressed. The MAR for insulin
1/1/18 to 1/30/18 had seven blanks and two refusals, with CBG tests ranging from 95227 (mean >150).
In summary, there was no pneumococcal vaccine offered/administered, blood pressure
medication was not started at intake, there was no detailed foot exam, and retinal
screening was not ordered. Additional evaluation for dizziness/syncope should have
included a thorough history and neurologic examination, and depending on findings,
further testing (Holter monitor) might have been indicated. The blood pressure was not
controlled and yet providers did not appropriately adjust anti-hypertension medications.
This was particularly important since the patient had diabetes and history of carotid
artery diseases and was therefore at risk of stroke and other cardiovascular diseases.
The carotid ultrasound report from Weiss Hospital requested on 12/16/17 was not yet
received as of 1/30/18.
•

Another patient was admitted to NRC on 1/23/18.61 He was a 33-year-old. A medical
history and physical examination were done on intake. Diagnoses included: type 2
diabetes, hypertension, and hepatitis C. Hepatitis C was not noted on the problem list.
The medication list from Cook County Jail included: Lisinopril, metformin, and glipizide.
The CBG was 153, which is high. The blood pressure was 177/94, which is also elevated.
The TST was negative. A provider noted that the blood pressure was not controlled and
referred the patient to chronic care clinic on 2/13/18. There were no lab reports in the
chart.
In summary, there was no pneumococcal vaccine offered/administered, there was no
definitive foot exam, no retinal exam ordered/done, and no HbA1C done on intake. The
doctor evaluating the patient at intake should have evaluated whether the patient had

61

Chronic Care Patient #7.

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taken his blood pressure medication that day and considered adjusting the blood
pressure medication.
•

Another patient was admitted to NRC on 6/20/17.62 He was a 29-year-old. Medical
history, physical, dental, and mental health screening were done at intake. The
diagnoses identified included: ankylosing spondylitis (HBL-27 reactive). A problem list
was completed. A follow-up in medicine clinic was ordered. Medications included:
prednisone and sulfasalazine. The laboratory tests ordered at intake included: BMP,
CMP, liver profile, all of which were normal. Laboratory tests were repeated on 8/8/17,
11/13/17, and 12/27/17, and all tests were normal. At a six-month chronic care clinic
visit, a doctor noted that prednisone was decreased to 10mg/d with a follow-up in six
months.
In summary, there was no documentation about presence/absence of symptoms or
assessment of functional status with respect to ankylosing spondylitis. Pneumococcal
vaccine was not offered/administered even though patient is on prednisone, a chronic
immunosuppressive medication. Sulfasalazine does not have an FDA indication for
ankylosing spondylitis and prednisone is not recommended for long-term use in
ankylosing spondylitis, yet a thorough medication history was not obtained to
understand why the patient was taking these medications; it did not appear that the
providers understood how to manage ankylosing spondylitis and yet did not refer the
patient to a specialist who typically manages this disease. We note that patients with
ankylosing spondylitis typically are managed with tumor necrosis factor alpha antagonist
medications, which was not offered to this patient.

•

62
63

Another patient was admitted to NRC on 8/18/17.63 He was a 49-year-old. Medical
history, physical, mental health, and dental screening were done at intake. Diagnoses
included: right ankle deformity secondary to a fracture in 2016 and motor vehicle
accident in 2017, use of crutches to walk, left total knee replacement, hypertension, and
asthma. A problem list was completed. PEFR tests were 200 and 290 and the blood
pressure was 154/115, which is elevated. Medications included: amlodipine and
albuterol. Intake laboratory tests were normal. On 8/21/17, an x-ray showed a severely
fragmented ankle joint with a suggestion of osteomyelitis or Charcot joint. On 8/25/17,
a blood count was normal. On 10/14/17 at a chronic care clinic visit, the blood pressure
was 157/92 and 136/92, and the amlodipine was increased. The PEFR was 350-400. A
repeat blood pressure was ordered in 30 days. On 11/2/17, an orthopedic consult
apparently occurred after about two months at NRC, but there was no consultant report
in the medical record. On 11/16/17, a CT scan was ordered and approved. There was no
evidence that this CT scan was done as there was no return transfer note in chart upon
return to NRC. On 12/12/17, a CT/MRI of the ankle was approved. On 12/29/17, the
CT/MRI results were noted to be pending. On 1/2/18, an x-ray report showed right ankle

Chronic Care Patient #9.
Chronic Care Patient #10.

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Charcot joint. Orthopedic recommendations included a fasting blood sugar, HbA1C and
testing for lead/heavy metals and a podiatry referral. On 1/3/18, tests recommended by
the orthopedic consultant were ordered. On 1/30/18, lead, copper, and heavy metal
levels were not done due to cancellation. The patient’s uncontrolled blood pressure was
appropriately treated on 10/14/17 by increasing anti-hypertensive dose, but an order
for repeat blood pressures ordered for mid-November was not done. There were no
blood pressure values in the chart for the last three months.
In summary, this patient with severe ankle deformity was not seen by UIC Ortho until
more than two months after NRC admission. The CT/MRI as recommended by the
orthopedic consultant was not done for two months, and the results were not in the
medical record. It is not documented why/who cancelled orthopedics’ recommendation
to do lead/copper/heavy metal levels to evaluate possible Charcot’s joint. Patient has
been in NRC for five months without completion of the evaluation of his damaged ankle.
The patient had an elevated blood pressure at intake, yet blood pressure medications
were not adjusted for about two months.
•

Another patient was admitted to NRC on 7/3/17.64 The patient was a 28-year-old.
Medical history, physical, mental health, and dental screening were done at intake.
Intake labs were normal. Diagnoses included: spastic paraplegia due to a prior gunshot
wound, using crutches to walk, depression, and neurogenic bladder with use of
catheters. The problem list was completed. Medications included; pain medication and
medications for spasm. On 7/17/17, a urine culture and sensitivity was negative and a
blood count was normal. On 8/11/17, the patient had abdominal discomfort. A rectal
examination showed soft stool with a negative guaiac test. An abdominal x-ray was
negative but suggested a possible ileus. On 8/16/17, a physician assistant note
documented a normal white count and BUN test. The physician assistant ordered
antacid. On 8/29/17, Imodium was ordered for diarrhea. On 8/31/17, a muscle relaxant
and gabapentin were ordered. On 9/14/17, a urinalysis showed 6 WBC’s and large
leukocyte esterase which suggested infection; an antibiotic (ciprofloxacin) was started
for UTI. On 10/21/17, a urine dipstick showed leukocyte esterase 70+. On 1/8/18, the
patient fell out of bed and landed on his elbow with development of a new left wrist
drop. An x-ray of the spine/elbow was negative for fracture and a support was provided
(sling) and a urinalysis was ordered. On 1/10/18, the urine culture showed Klebsiella
pneumonia >100,000. On 1/23/18, sensitivities were reviewed by the provider and
Bactrim was ordered.
In summary, a provider completed an appropriate evaluation of patient’s abdominal
discomfort in August 2017. The patient had repeated colonization of his urine but for
persons with neurogenic bladder, treatment is generally reserved for those who are
symptomatic (fever, foul-smelling urine, incontinence, frequency, or dysuria). Initial
management of left elbow trauma/l wrist drop was reasonable but there has been

64

Chronic Care Patient #11.

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unacceptably no follow-up as of 22 days post injury/wrist drop and no referral to
Neuro/Ortho generated.
•

Another patient was admitted to NRC on 12/12/17.65 Medical history and physical
examination were done at intake. Diagnoses included: HIV infection/high CD4, blindness
in his right eye, and seizures (not on anti-epileptic meds; providers did not
comment/address this serious history). The problem list was complete. Medications
included: Genvoya. A viral load showed undetectable HIV, a CD4 716, and hematocrit of
43. On 1/23/18, a UIC Telehealth HIV consultant continued Genvoya, offered an
influenza vaccine and scheduled a four month follow up. A MAR from December was
not in chart as of 1/30/18, but on 1/11/18 KOP Genvoya was given; the quantity of pills
was not listed.
In summary, the intake provider should have commented on the status of the patient’s
history/etiology of seizures and determined whether anti-epileptic meds were indicated
or not. The HIV care was reasonable. The UIC HIV specialty appointment six weeks post
admission was acceptable given the level of viral control documented on intake labs.
The MAR should definitely document, as per established practice, the number of HIV
pills given to the patient for KOP administration.

•

Another patient was admitted to NRC on 11/30/17, and a medical history was done in
reception.66 Diagnoses included: HIV infection and asthma. There was no
documentation in the 11/30/17 intake forms about whether the patient was on HIV
meds. On 12/1/17, a provider performed a physical examination and ordered daily
Bactrim x 30 days. Laboratory results included: VL 95462, CD4 88. No HIV medication
was ordered nor was there any documentation about whether the patient was
prescribed or taking HIV medication. On 12/6/17, the patient was given Bactrim six tabs
KOP even though 30 days of medication was ordered. There was no justification in the
chart for this discrepancy. On 1/5/18, a UIC Telehealth HIV consultant noted that the
patient stopped HIV meds in October 2017. The HIV consultant ordered Genvoya and
TMP/SX (Bactrim)/day. The consultant recommended repeat HIV labs in four weeks/UIC
follow-up consult in six weeks. On 1/5/18, the MAR noted that Genvoya #30 KOP and
Bactrim #15 KOP were given to the patient.
In summary, the intake medical history and physical should have clearly documented
that the patient had not been taking his HIV meds prior to NRC admission. Laboratory
tests reviewed in the 12/1/17 provider note revealed a severely uncontrolled and
immunocompromised state, yet the UIC HIV consultation was not obtained until five
weeks post admission. This was an unacceptable delay in access to much needed
specialty consultation.

65
66

Chronic Care Patient #12.
Chronic Care Patient #13.

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Urgent/Emergent Care
Methodology: We interviewed health care leadership and staff involved in emergency
response, toured the medical clinic, assessed the availability and functionality of emergency
equipment and supplies, reviewed actual or emergency drills, and CQI reports.
First Court Expert Findings
The First Court Expert Report noted that NRC had no useful logs to select records of patients
being sent out for urgent or emergent conditions. A Nursing Telephone Urgent Care Log tracked
only patients that were seen and not all notifications of patients reporting urgent complaints.
The Court Expert recommended that NRC conscientiously use paper or electronic log books to
document urgent/emergent care.
Current Findings
We requested but were not provided an urgent care tracking log. We inspected emergency
response equipment and found that it was poorly organized and maintained. Health care
leadership has not implemented the SCC-NRC Machine/Equipment Check Log Sheet that
requires daily checks of the medical unit for sanitation and equipment such as suction, oxygen
tanks, automatic external defibrillator (AED), EKG machine, EKG electrodes and paper,
backboards, stretchers, biohazardous waste, sharps containers, and trauma bags, etc.
The treatment room where patients with urgent conditions are assessed was dirty and
disorganized. Stretchers in the treatment room were torn. Several oxygen tanks were placed
into a corner; the one closest to the stretcher was empty.
Two AEDs and emergency response bags were not kept in the same location in the clinic. We
inspected the AEDs and found that they were operational, but electrodes had expired in 2016
and in August 2017. Two emergency response bags were found open in the main clinic area on
a countertop. We asked staff whether equipment and medications in the response bag were
standardized, locked, and routinely inspected and we were informed they were not. A CMT
stated that one of the bags was for her personal use and she kept glucagon and a thermometer
in her lab coat pocket and not in the bag.
A mass disaster response bag covered in dust was located on top of cabinets in the medication
room. The bag was not included on the equipment check log sheet as one of the items that
needed to be checked daily.
Emergency events or drills were conducted and critiqued on 11/21/16, 4/11/17, and 5/3/17. A
mass casualty drill was conducted on 5/19/17. The critique of the events was extremely limited.
The mass casualty drill identified a number of weaknesses for which no corrective action plan
was developed or implemented.
No emergency response drills have been conducted in the past eight months, which is not
compliant with NCCHC standards.

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In summary, we concur with the First Court Experts findings regarding urgent care. In addition,
we found that NRC has not developed an adequate emergency response system through the
proper maintenance and checking of emergency equipment. Emergency response drills have
not been performed timely and they have not meaningfully identified areas for improvement.

Specialty Consultations
Methodology: Interview HCUA. Review offsite tracking logs. Review selected medical records of
persons having offsite consultations.
First Court Expert Findings
The First Court Expert found that specialty care for long-term NRC inmates is delayed. He also
identified “problematic” clinical care in several patients who had specialty care. The First Court
Expert recommended that NRC institute a tracking system for all scheduled offsite services and
begin using logs for this purpose. The First Court Expert recommended that high-level security
inmates be held at NRC until their specialty care has concluded.
Current Findings
We noted that of the seven patients we reviewed, several were being held at NRC while their
specialty care was in progress. This was a recommendation of the First Court Expert. However,
the lack of a tracking log made it impossible to verify this for a larger sample. There has been no
improvement with respect to the other First Court Expert’s findings. We identified the following
additional findings:
• Medical record documents (referrals, verifications of collegial review, approvals, and
consultation reports) were mostly not found in the medical record.
• Only 36% of consultations included a formal report.
• The HCUA who is a nurse evaluated denials of specialty care. This evaluation needs to be
by a physician.
• The collegial review process fails to ensure that patients receive timely consultative
specialty care.
IDOC policy requirements regarding specialty care are in two separate ADs.67 The ADs require
that all referrals for specialty care are sent to the Facility Medical Director. It is our opinion that
these are medical record documents (physician orders) and they should be filed in the medical
record. The Facility Medical Director is to make a determination regarding approval or denial of
all referrals. If the Facility Medical Director approves the request, it is to be referred to
Wexford’s utilization management unit in writing or verbally. According to requirements in the
ADs, verbal referrals must be documented in the medical record. A Wexford written response is
to be made within five days and this response, according to the AD, is to be placed in the
medical record. If the referral is denied by the corporate UM reviewer, the denial is to be
referred to the HCUA. The HCUA is to “independently” review all denials and decide if the
denial is medically appropriate. At NRC, the HCUA is a nurse. A nurse has insufficient training to
67

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evaluate whether the consultation is medically necessary; a physician should be making this
judgment. When the HCUA decides that a referral denied by the Wexford UM reviewer should
be approved, the denial is referred to the Agency Medical Director. In this arrangement, the
HCUA might agree with Wexford that some denied consults are appropriately denied when the
Agency Medical Director might decide otherwise. A physician should review all of the denials. If
the patient writes a grievance about a denial, the HCUA is also required to refer to the Agency
Medical Director. The Wexford Regional Medical Director for the northern region told us that
after a specialty consult it is a requirement that the patient is to be seen in follow up in five
days. In the IDOC response to the First Court Expert report, the IDOC stated that when a patient
returns to the prison after an offsite visit, the practice in IDOC is to have a physician evaluate
the patient within three to five days.68 In that response, the attorney for the IDOC stated that a
three to five day follow up meets constitutional adequacy.
Tracking specialty care is useful to monitor the effectiveness of the specialty care process and
to ensure that specialty care consultations are carried out timely. The IDOC agreed69 with the
First Court Expert’s recommendation that:
“The entire process, beginning with the request for services, must be tracked in a logbook,
the fields of which would include date ordered, date of collegial review, date of
appointment, date paperwork is returned and date of follow-up visit with clinician. There
should also be a field for approved or not approved, and when not approved, a follow-up
visit with the patient regarding the alternate plan of care.”70
We agree with the First Court Expert that this manner of tracking specialty care is needed. The
IDOC stated, in their response to the First Court Expert’s report, that there was a logbook
currently in place for offsite services matching the requirements of the First Court Expert. We
asked for but did not receive a logbook and were not given a logbook during our tour. In
preparation for this visit we asked for a tracking log of onsite and offsite specialty care including
the date of referral, date of collegial review, date of service, and the service the patient was
referred for.71 Our visit started Monday 1/29/18. On 1/25/18, we received by email a list of
onsite appointments. This list did not contain the date of referral, the date of collegial review,
and reason for referral. An offsite specialty list was sent to us by email on 2/1/18, the last day
of our tour. We had no internet capability in the facility and were not able to see this document
until after we left the facility. We were able to obtain the same list from the IDOC on the
second day of our visit. However, the list that Wexford sent and also provided by IDOC only
contains the patient name, IDOC number, the destination consultant, the reason for
consultation and the date of service. We learned during the SCC visit that the NRC offsite
scheduler maintains the type of log we had asked for but had not received. We also asked for
but did not receive a list of denials of specialty care.

Page 22, email letter to Dr. Shansky on 11/3/14 sent by William Barnes representing the IDOC.
Page 24, email letter to Dr. Shansky on 11/3/14 sent by William Barnes representing the IDOC.
70 Final Report of the Court Appointed Expert Lippert v. Godinez page 31 of main report.
71 January 8, 2018 email to the Attorney General’s representative.
68
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When we visited SCC we had an opportunity to talk to the scheduling clerk from NRC. She
indicated that she used the same spreadsheet as used at SCC. This SCC spreadsheet did not
always have an accurate referral date but did contain the collegial date and date of the
consultation. Some collegial reviews were documented as occurring before the referral was
documented as having occurred. These tracking logs should be standardized so that the
information can be used to measure adherence to administrative directive timelines. As well,
referrals should be treated as physician orders and should be filed in the medical record as they
occur, not after the consultation is completed.
Also, a key component of consultant care is that providers review the consultation report,
review the findings of consultants, and evaluate all consultant recommendations including
medications changes, further referrals for specialty care, and further recommendations for
additional testing. The findings of these reports should be discussed with the patient. At NRC,
review of consultation reports is ineffectively done and many consultant recommendations are
either not reviewed or not carried out.
We reviewed a number of consultations to determine if the referral, collegial review, and
approval were filed in the medical record. We also looked at specialty care follow-up to assess
whether providers are carrying out the consultant’s recommendations or documenting why
they did not follow the recommendation. We found that specialty care is poorly documented in
the medical record despite being required by the IDOC ADs. We reviewed seven patients who
had 22 consultations and one hospitalization. Of the 22 consultations we found only 14 (63%)
referral forms, only three (14%) collegial reviews, and only nine (41%) approvals in the medical
record. Of the 22 consultations that occurred, only eight (36%) included a formal consultant
report. Some consultations had a few brief lines written on the referral form giving
recommendations, but these did not include information about the status of the patient and
did not include a report of the evaluation. Particularly problematic was that 19
recommendations of consultants were not reviewed or carried out. Given that there were 19
recommendations not carried out in seven patients, there is a serious problem with clinical
follow up of specialty appointments that represents a significant risk of harm to patients. These
represent underutilization or not conducting necessary specialty care. The IDOC and Wexford
have no current process to study underutilization even though it is a significant problem and
patient safety issue. The Wexford collegial review process is so defective that, in our opinion, it
is a patient safety issue and is likely causing harm to patients and therefore should be
eliminated.
We looked for further evidence that Wexford or IDOC performed any audit or review of
specialty care. We noted in the annual CQI report of September 26, 2017 documentation
indicating that there were 273 collegial reviews and that 100% of patients who went offsite
were seen within five days of the return to the facility. This was the only review of specialty
care that we could find in the quality improvement documents provided to us.
Though the quality improvement report documented that 100% of persons were seen within
five days of a specialty visit, our findings were different. Of 23 patients (22 consultations and
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one hospitalization) we reviewed, only 15 (65%) were seen within five days after the
consultation or hospitalization. We found that NRC providers failed to review or act on 19
consultant recommendations. This places patients at significant risk of harm. The report that
100% of patients who went off site being seen in five days misrepresents, in our opinion, the
quality of offsite specialty care and fails to identify significant existing deficiencies in this
service. In our opinion offsite specialty care is inadequately managed and places the patients at
significant risk of harm.
In addition to these findings we noted poor care for six of seven patient records reviewed for
specialty care, which is a similar finding of the First Court Expert. These reviews are as follows.
•

One patient had lupus nephritis, hypertension, and history of pulmonary embolism.72 In
patients with lupus nephritis and significant amounts of protein in the urine, which this
patient had, the blood pressure should be controlled to a level of 130/80. This patient
saw providers 11 times when the blood pressure was elevated. On only one occasion did
a provider adjust long-term anti-hypertension medication and on two occasions a onetime only dose of medication was given. One-time only doses of medication are not
considered appropriate therapy. The lack of blood pressure control was likely to damage
the patient’s kidney function. Consultants recommended that this patient have
laboratory tests monitored, but this was not effectively done. During clinic visits,
laboratory tests that were done were not consistently reviewed. The patient had
significantly low albumin (1.7) and anemia (HGB 11.7), but these problems were not
addressed. These deficiencies placed the patient at risk of harm and may have harmed
the patient.

•

Another patient had primary sclerosing cholangitis, a condition of uncertain etiology
which can lead to severe liver disease, including cirrhosis and hepatocellular
carcinoma.73 Although the patient had abnormal liver function tests and although a
consultant recommended a hepatology consultation, the abnormal tests were not
reviewed or noted and the referral to hepatology did not occur. This placed the patient
at risk of harm. The patient had a cytology examination during a specialized procedure
(ERCP) but the results were never checked.

•

Another patient had prostate cancer.74 Providers at NRC never documented the staging
and status of the patient’s condition. The patient had testicular and groin pain that a
consultant felt was due to a vascular condition as opposed to the patient’s cancer;
consultants also documented peripheral vascular disease as a problem. A
recommendation to refer the patient to a vascular specialist was not noticed or
referred. The patient’s peripheral vascular disease was never identified by NRC
providers as a problem.

Specialty Care Patient #1.
Specialty Care Patient #2.
74 Specialty Care Patient #3.
72
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•

Another patient had pancreatic cancer and was undergoing chemotherapy.75 An
oncologist noted that the patient had elevated liver function tests and should have an
abdominal ultrasound to evaluate potential reasons for this abnormality. Indeed,
abnormal liver function tests were available in the NRC record, and though signed as
reviewed, nothing was done to evaluate for the abnormality. This patient never had an
evaluation of the liver function abnormalities, even though the reason for the abnormal
labs may have been related to the patient’s cancer. This patient also experienced an
episode of loss of consciousness and fell to the floor. The patient had an abnormal pulse
(116) and low blood pressure (102/66). The nurse evaluating the patient did not consult
a provider and did not refer the patient to a higher level of care for evaluation. This
placed the patient at significant risk of harm.

•

Another patient had keratoconus, a disabling condition of the cornea which results in a
malformed cornea and can result in visual disturbances.76 At intake, nurses recorded
20/20 visual acuity in both eyes. Several weeks later an optometrist identified 20/20077
vision in one eye and did not record the visual acuity in the second eye. We noted
problems with intake screening of visual acuity and this example demonstrates this
problem. The patient was also on Plavix and aspirin, two drugs that can cause serious
bleeding as a side effect of the medication. However, the reason for being on these
medications was never determined and there was no corresponding problem listed as a
reason for being on these medications. The patient had diabetes, hypertension, and
high blood lipids but was seen in only one chronic clinic visit over a nine-month period.
The patient had abnormal laboratory results (BUN 33; sodium minimally low at 134:
WBC 12.5 and hemoglobin 11 indicating anemia). These abnormal laboratory results
were not repeated, and providers did not attempt to determine the reason for the
abnormalities. Though the patient was diabetic, the patient never received an HbA1C
test even though this is required by chronic care guidelines for persons with diabetes.
The patient’s chronic illnesses were not being monitored or managed.

•

Another patient had a history of pancreas and kidney transplants but the reason for
these transplants was never identified or documented in the medical record.78 History
of the patient’s illness was substandard. This patient had several consultations but
because the reports were not available in the medical records, the providers at NRC
failed to understand what the patient’s clinical condition was and also failed to
understand the status of the patient’s conditions. We also could not determine the
status of this patient because of lack of consultant reports. This places the patient at risk
of harm. Because consultant reports are not filed in the medical record, when this
patient transfers, subsequent providers will not understand how to care for this patient,
who will be at risk of harm. The patient also had a hemoglobin of 12.7 on 10/5/17,
which dropped to 8.9 on 12/21/17. This significant drop in hemoglobin was unnoticed

Specialty Care Patient #4.
Specialty Care Patient #5.
77 20/200 visual acuity is legal blindness.
78 Specialty Care Patient #7.
75
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and was not being monitored; it indicated a significant risk to the patient yet was
unnoticed. The patient also was being treated for high blood lipids but was not being
monitored for this condition.
We also note that in review of these records, the organization of the medical records was so
poor that it was extremely difficult to discover what was happening to the patient. This was
similar to the finding of the First Court Expert. Papers were merely placed in a folder, not sorted
by type of document or placed in chronologic order. For larger records, examination of the
record was so difficult that use of the record for routine care in a busy clinic would not be
possible.
We were unable to evaluate the First Court Expert’s recommendation that persons who require
specialty care have that specialty care before they leave NRC because of a lack of tracking logs.
We agree with this recommendation in principle, particularly when higher level care at UIC is
needed, in that it ensures continuity of care.
With respect to findings of the First Expert, we agreed with the findings and recommendations
regarding lack of tracking of specialty appointments. Specialty care needs to be tracked. The
IDOC agrees with this recommendation as well. Yet the IDOC has not been able to provide
evidence that this is done at this facility. The First Expert found two of three charts reviewed
showed problems with care. We identified problems with care in six of seven records reviewed.
Our review of medical records found similar findings to the First Expert report, including delays
in perceiving the need for services, delays in following up abnormal results and problems with
follow up. We had an additional finding that the IDOC has no current way to monitor the
effectiveness of access to specialty care. In particular, underutilization or the lack of recognition
of a necessary referral appears significant. For seven patients reviewed, there were 19
recommendations by consultants that were not carried out or determined to be unnecessary.
This should be examined using a root cause analysis to determine why this is happening.

Infirmary Care
Methodology: The clinical space and equipment was inspected, nursing staff schedules
reviewed, clinical charts audited, nursing staff interviewed, correctional staff and porters
questioned, and patient-inmates interviewed. There was only limited contact with the infirmary
physician.
First Court Expert Findings
The medical infirmary was not operational at the time of the First Court Expert’s site inspection.
Individuals requiring infirmary level services were housed in the nearby SCC infirmary. The
infirmary charts of three of the four NRC patients in the SCC infirmary were found to be
inadequate. The provider’s notes were consistently illegible to the experts.
Current Findings

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The First Court Expert recommended opening the medical infirmary, which has since been
done. We had several new findings, including:
• As recommended in the First Court Expert report, NRC opened the medical infirmary in
2016 and has assigned 24/7 coverage with nurses and correctional staff. However, nurse
staffing plans show inconsistent coverage by a RN.
• Provider notes are generally written on at least a weekly basis.
• Infirmary admission notes are not always written by providers within 48 hours of
admission.
• There continue to be problems with NRC providing the needed quantity of bed linens to
the infirmary. This was also noted in the First Court Expert’s report.
• The quality of care provided by the clinicians assigned to the infirmary is inconsistent
and often inadequate.
• The provider progress notes lack documentation of the rationale for changes in
treatment and fail to develop clear treatment plans and differential diagnoses.
• There is virtually no documentation of the status of patient’s chronic illnesses.
• There was no documentation that any pertinent physical examinations were being
performed.
• The care of diabetics is deficient.
• In its current state, the level of provider care in the NRC infirmary puts patients at risk.
The medical infirmary has been operational since December 16, 2016. Eleven of the 12 medical
beds were occupied at the time of the site visit. Two-thirds of the patients were chronically ill
individuals whose fragility, incontinence, and difficulty with ambulation and self-care precluded
their assignment to regular housing units. The infirmary was reported to be staffed 24/7 by RNs
with assistance of CNAs on most shifts. At the time of our exit from NRC, two nurse schedules
for 1/29/18 to 2/4/18 were provided. One schedule had one to two RNs on all shifts assisted by
CNAs on almost every shift; the second schedule had one to two RNs on the day shift with CNA
coverage on six shifts, one RN on six of seven 3 p.m. to 11 p.m. shifts, and only one RN covering
three 11 p.m. to 7 a.m. shifts without any CNA assistance. This lack of staffing is consistent with
the lack of staffing at NRC and with the shared staffing between SCC and NRC. It was reported
that there is a correctional officer assigned to the infirmary on each shift. During the site visit,
one to two correctional officers were stationed in the medical infirmary and the adjoining
mental health crisis beds.
There is a nurse call device/buzzer mounted on the wall next to each bed. The buzzers were
found to be operational in all rooms that were tested, and the patient-inmates understood how
to use this system. There were two negative airflow rooms (A-105-106) but, as noted in the
Clinical Space section, the monitoring panel was not operational at the time of the inspection.
There are multiple deficiencies concerning sanitation and infection control in the infirmary and
mental health crisis unit. The beds are fixed in a flat position without the capability to raise the
head or raise/lower the height of the bed. Even though two-thirds of the 11 individuals housed
in the medical infirmary were chronically ill with varying degrees of disability, there were no

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adjustable hospital beds in the infirmary. The laundry was providing the infirmary with only 12
clean linen changes per week. The nursing staff reported that this quantity was insufficient to
meet the needs of the infirmary patient population (incontinent, diapered elderly patientsinmates frequently soil their sheets) and the nursing staff’s repeated requests for an ongoing
additional stock of sheets had not been granted. We walked to the laundry and the nursing
supervisor asked the laundry correctional officer for doubling of the weekly allotment, and this
was verbally approved. This is a patient safety and sanitation issue.
All forms, notes, and reports generated after admission to the infirmary are kept in individual
divided binders, with the clinical information placed in tabbed sections. This facilitates the
review of the care provided in the infirmary. All care provided at NRC prior to the infirmary
admission are in the same drop-filed loose paper arrangement as described in the medical
records section of this report. This makes it difficult to assess the care provided prior to
infirmary admission. The drop-file records are not all kept in the infirmary. The entire record of
the patient needs to be available when the patient is evaluated.
IDOC Administrative Directive 04.03.120 Offender Infirmary Services has several requirements,
including: admission to the medical infirmary must be authorized by a provider; nurses must
complete admitting notes with vital signs upon admission; and admission notes by the
providers are to be documented within 48 hours of admission. A review of four infirmary
admissions found that nurse admission notes and vital signs were performed on the day of
infirmary admission for all four individuals. Two of the four had provider admission notes
written in less than 48 hours and the other two did not meet the timeliness standard, with
provider admission notes written 11 days and 10 days post admission.
Acute care patients (rapid onset of symptoms, under treatment for acute illnesses, and postoperative status) are to be seen by a provider no less than three times per week and have daily
provider notes. Patients with non-acute illnesses are to have a provider note no less than
weekly. There were two patients (one post-operative and one with fluctuating mental status)
who should have been initially given acute status, but they only had provider notes once a
week.
There was a chronic disease patient who developed an acute serious eye problem and received
an appropriately heightened amount of provider attention, including 14 provider notes in a 39day period. However, the patient’s diabetes status, with elevated CBG values, was not
commented on once and did not include an adjustment of the patient’s insulin. Most of the
provider notes contained little, if any, clinical content, limited, if any, rationale for modifying
treatment plans, a paucity of differential diagnoses about any set of symptoms, no notes about
the control of patient’s chronic illnesses, and only very brief, if any, comments about new or
changing problems. Usually the only indication of a new concern was a new or changed order
unaccompanied by an explanatory provider note. The paucity of the clinical content in the
provider’s notes would make it virtually impossible for a different NRC provider who was asked
to cover the infirmary to understand the treatment plan or status of the patient. This puts the
patient at risk. In addition, the provider’s notes were very difficult to read and were mostly
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illegible. These concerns were also raised in the First Court Expert’s report. The nurse progress
notes were generally more legible and contained more pertinent information of the condition
of the patients.
The following summaries of the infirmary patients’ records highlight the concerns noted above.
•

This patient was admitted to NRC on 11/30/17.79 Physical exam on admission noted,
“c/o pain in right great toe with discoloration.” MD note: Right big toe ulcer with foul
smell, surrounding erythema. The problem list noted: Diabetic R big toe ulcer, dime size,
black x two months. Diagnoses: Diabetes, HTN, hyperlipidemia, renal insufficiency. MD
ordered daily dressing changes, Rocephin 500mg/D. Intake lab: Syphilis/RPR 1:128. No
dressing change log was found in medical. There is documentation that this patient’s
black toe was not evaluated or dressed as ordered until 12/5/17, when RN noted “in
pain” and sent the patient to MD for evaluation. The right big toe was black with foul
smell and erythema. He was sent to St. Joseph Hospital, was diagnosed as having right
toe gangrene with abscess, his toe was amputated, he received treatment for sepsis,
and he was discharged to NRC on 12/22/17 on IV antibiotics. On 12/22/17, he was
admitted to the infirmary. The RN admission noted: IV antibiotics, UIC podiatry and
vascular clinic referrals in one to two weeks. The MD infirmary admission note was
written on 1/2/18, 11 days after admission. Post-hospitalization: Right big toe
abscess/gangrene with sepsis, PICC line on IV antibiotics, angiography showed PVD,
Meds Glipizide, Metformin, Lisinopril. On 12/5/17, RN note, “seen by MD, CPM.” On
1/7/18, RN: red, swelling bottom of foot. 1/10/18, MD noted CPM [continue present
management], but there was no physical exam. On 1/22/18, laboratory tests showed
WBC 6.4, creatinine 0.87, RPR 1:64. On 1/27/18, five weeks after returning from a
complicated hospitalization, the surgical (probably vascular) consultation was still
pending and the podiatry appointment had not been scheduled. On 1/29/18, treatment
for latent syphilis was finally ordered.
The pre-hospitalization care at NRC was deficient. The intake provider should have
directly sent this diabetic with a black, foul smelling ulcer on his toe to the ED for
emergency consultation and assessment for gangrene and osteomyelitis. NRC’s failure
to change dressings and re-evaluate the ulcer for seven days after reception minimized
any opportunity to prevent amputation. The delay in transferring this patient to the ED
contributed to the development of sepsis and jeopardized his life. The intake lab test
identified syphilis; treatment should have been started during the seven days prior to
hospitalization. Upon return to NRC, his abnormal syphilis test was not flagged for
treatment and he was not treated until 1/29/18 (five weeks after his return from the
hospital). The abnormal lab should have been quickly identified and treatment initiated
immediately after his admission to the infirmary on 12/22/17. The infirmary physician
clearly neglected to review the patient’s previous test results upon admission to the
infirmary. During his infirmary stay, the provider never once commented on the status

79

Infirmary Patient #1.

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of the amputation wound site nor documented an examination of his feet. As a posthospital return, the physician should have been initially writing progress notes at least
three times a week. Provider notes were only written weekly. His post-hospital course
was neglectful. Five-and-a half weeks after his return to NRC, he still had not been seen
by a podiatrist and a vascular surgeon as recommended on 12/22/17. During his
infirmary stay, the provider never commented on the control of the patient’s diabetes.
HbA1C, microalbumin-creatinine ratio, retinal screening, and an examination of the
other foot was not documented in the progress notes. Pneumococcal vaccination was
not offered or administered. At every stage of this patient’s care the standards of care in
the community were not followed.
•

This patient was hospitalized from 11/2 to 11/8/17 for altered mental status, falls, and
post-procedure for burr holes.80, 81 On 11/8/17, he returned to NRC and was admitted to
the infirmary. MD admission note on 11/9/17. Diagnoses included type 2 diabetes,
incontinence, decubitus ulcer, lymphoma on chemotherapy, and history of DVT, with
IVC filter. On 11/28/17, lymphoma chemotherapy was completed. On 12/5/17, retinal
vein occlusion was noted, urgent eye referral requested. On 12/7/17, MD called the eye
consultant and had the patient’s eye appointment moved up. On 12/11/17, the eye
consultant recommended anti-VEGF injection, but the patient refused. On 12/15/17,
anticoagulation was restarted. On 12/19/17, INR was 1.8, warfarin dose was increased.
On 12/26/17, INR was 4.9, on 12/27/17, INR was held. On 1/2/18, INR was 2.1. On
1/18/18, the patient consented to treatment in eye clinic. On 1/20/18, the warfarin
dose was increased; the rationale for this increase was not documented. On 1/27/18,
INR was 6.6; the warfarin was stopped for three days. On 1/29/18, a repeat INR was
ordered.
In summary, this patient with multiple chronic problems developed an eye problem. The
infirmary provider appropriately advocated for an urgent eye appointment and helped
convince the patient to accept treatment. The patient was successfully treated. Provider
wrote 14 progress notes during the patient’s 84 days in the infirmary addressing some
more acute bladder, eye, and anti-coagulation concerns. However, it is very
questionable to restart anticoagulation in a patient with an IVC filter who had a recent
subdural hematoma and who was prone to falls. The provider’s note did not provide any
rationale for this decision. The INR test was performed five times between 12/9/17 and
1/29/18, two of which had results which were elevated. Since returning from the
hospital, the provider did not comment about the control of the patient’s diabetes, did
not order a HbA1C, microalbumin-creatinine ratio, adjust the insulin dosage even
though FSBG ranged from 70-273, and did not offer/administer the pneumococcal
vaccine.

Infirmary Patient #2.
Burr holes are holes drilled through the skull to allow accumulated blood to be evacuated. These are typically done for
persons who have subdural hematomas.

80
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•

This patient was admitted to NRC on 1/3/18.82 Diagnoses: alcohol, cocaine, and
hallucinogen abuse, Cryptococcal meningitis as a child that required a VP shunt. On
1/9/18, the patient reported that he was beaten by other inmates. On 1/11/18, he
reported that he fell out of his upper bunk injuring his ribs, hand, and maybe his head.
Mental health reported that he was delusional and grandiose. On 1/19/18, hand and rib
x-rays were normal. The patient was placed on watch in the mental health crisis unit. On
1/20/18, he was transferred to a medical infirmary bed for altered mental status. MD
note: r/o dementia, hypertension, and bipolar disorder. On 1/22/18, the RN noted that
the patient had periods of confusion. On 1/23/18, a doctor noted that the patient was
answering questions but had no dementia. On 1/24/18, an RN described the patient as
incoherent. On 1/26/18, an RN described the patient as disoriented but pleasant. On
1/28/18, the patient was less confused. On 1/29/18, an RN described the patient as
more alert. On 1/30/18, an RN stated that the patient had bruises on his forehead and
top of his head.
In summary, there is no documentation of a neurological exam on this confused and
disoriented patient. Fluctuating mental status with transient episodes of confusion and
disorientation in a patient with alcohol abuse, recent trauma, and a VP shunt clearly
warranted a head imaging study (CT scan) to rule out an intracranial hematoma or
increased intracranial pressure. The provider did not note the patient’s recent history of
trauma, the recent fall from his bed, the bruises on his head, or the VP shunt. It is clear
that he did not review the patient’s ambulatory medical record. The provider did not
even consider these different possibilities. The care of this patient was deficient if not
negligent.

•

82
83

This patient was transferred from Hill Correctional Center.83 He was admitted to the
infirmary on 12/23/17. Diagnoses included recent fractured jaw with intramedullary
fixation, insulin resistant diabetes mellitus on NPH, and sliding scale regular insulin. On
12/26/17, an oral surgery consultant rewired his jaw. On 1/2/18, a doctor wrote an
infirmary admission note 10 days after admission to infirmary. On 1/10/18, a doctor
documented low glucose and glucagon was ordered with a subsequent increase of the
glucose to 378. On 1/13/18, a RN noted that the inmate was shaking and unresponsive;
the blood sugar was 37 and glucagon and oral glucose were given. On 1/13/18, a doctor
ordered that sliding scale insulin be held. On 1/14/18, an RN noted a blood sugar of 34.
MD again ordered that sliding scale insulin be held. On 1/16/18, a nurse noted blood
glucose of 42 and food was given. On 1/17/18, an RN noted blood glucose of 433 and a
doctor was called. On 1/22/18, sliding scale insulin was resumed. On 1/23/18, a doctor
decreased sliding scale insulin dosages. A urine test of protein was 150. On 1/24/18, the
patient was referred to oral surgery. On 1/25/18, the NPH insulin dosage decreased. On
1/26/18, the NPH dosage increased.

Infirmary Patient #3.
Infirmary Patient #4.

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In summary, this patient who is on insulin had intermixed episodes of hypo and
hyperglycemia. His jaw was wired, and his nutritional intake was entirely liquid. Even
though he was using a lower sugar content nutritional supplement, the calorie intake
can widely vary. This puts him at risk for surges and drops in his glucose levels. The
infirmary provider does not comment on this nor is a treatment plan developed that
addresses the risks of giving sliding scale insulin to a patient with a wired jaw and unable
to eat normally. Insulin dosages were increased and decreased without the provider
commenting on the rational for each change. The provider’s note does not comment on
whether this patient has Type 1 diabetes mellitus (produces no insulin and is at risk for
ketoacidosis) or Type II (produces insulin and is at decreased risk of ketoacidosis). There
may be very limited risks of ketoacidosis and regular insulin may not be needed. The
lack of a clear plan about caring for this diabetic who temporarily is unable to eat solids
has put this patient at serious risk. The urinalysis reported an elevated level of protein.
This test was not repeated nor was a microalbumin-creatinine ratio ordered to
determine if this patient should be placed on an ACE inhibitor to protect his renal
function. No routine labs were drawn. The patient’s renal function was not evaluated.
HbA1C was not ordered. Pneumococcal vaccine was not offered or administered. The
IDOC diabetes guidelines are not being followed.

Pharmacy and Medication Administration
Methodology: We conducted a comprehensive review of pharmacy and medication services
from the time a medication order is written until medication is delivered to the patient. We met
with health care leadership and staff involved in pharmacy and medication services, toured
pharmacy and medication administration areas, observed medication administration, reviewed
medication administration records and continuous quality improvement meeting minutes and
reports.
First Court Expert Findings
The First Court Expert Report noted that no security staff was initially available to escort nurses
for medication administration. The report also noted that nurses transfer medications from a
pharmacy dispensed blister-pack to small white envelopes that nurses use to transport
medications to housing units. Officers were supposed to open up food ports so the nurse could
administer medications, but this did not take place and medications were passed through a
crack in the door. Neither nurses nor correctional staff performed oral cavity checks.
Current Findings
Our review was consistent with the findings in the First Court Expert report. We found that
pharmacy and medication administration practices do not assure the five “Rights” of
medication administration: the right patient, the right medication, the right dose, the right
route at the right time. Our review noted the following problems:
• At medical reception, nurses administer medications to patients from a stock supply,
but do not consistently initiate a medication administration record (MAR) and document
that medications were administered to the patient.
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•
•
•
•
•
•
•
•
•
•
•
•

•
•
•

Medical records do not contain physician order forms for all ordered medications.84
The nursing medication room is dirty, cluttered, and disorganized. There is no schedule
of sanitation and disinfection activities.
Nurses transfer medications from a properly labeled pharmacy dispensed blister pack
into a small white envelope that is not properly labeled.
To prepare medications, nurses do not consistently compare the MAR against the
medication blister pack to ensure that the medication matches the physician order;
instead, nurses use white envelopes that are not properly labeled.
The white envelopes are repeatedly used and not hygienic.
Inmates are not requested to present their identification badges at the time of
medication administration.85
Nurses pass medications to patients through a crack in the cell door, not the food ports.
Inmates do not have cups to fill with water to take their medications.
Neither officers nor nurses perform oral cavity checks.
If inmates are out of cell at the time of medication administration there is no procedure
to go back later to administer the medication, even if it is a once a day medication.
Nurses do not document administration of medications onto a MAR at the time they are
administered.
BosWell Pharmacy prints MARs for the following month for any prescription written by
the 15th of the month, requiring nurses to handwrite MARs for all medications orders
from the 16th to the end of the month, creating an enormous nursing workload and
increasing the risk of transcription errors.
Review of multiple MARs show numerous blank spaces, demonstrating that nurses do
not document the administration status of each medication dose.
Monthly pharmacy/CQI audits throughout 2017 show pervasive and systemic
medication issues, including blanks on MARs, administering medications beyond stop
dates, and pharmacy and nursing medication errors.
Health care leadership has not developed or implemented an effective corrective action
plan to address the systemic medication issues.

Information supporting these findings are noted below.
Pharmacy Services
BosWell Pharmacy Services is a national company that provides medication services to NRC
through a “fax and fill” process. BosWell dispenses medications in blister packs that are either
patient-specific or for stock supply. We interviewed two pharmacy technicians who reported
that for prescriptions faxed to BosWell before 2:30 p.m. each day, medications are received
within 24 hours via United Postal Services (UPS). Prescriptions faxed after 2:30 p.m. are
84 Physicians write medication orders in two places: a physical examination form or progress note, and a physician order form
that is used to fax the order to the pharmacy. We found that some records contained the medication order only on the
progress note and there was no physician order form. It is unclear whether the physician did not write the order on the
physician order form or whether it was not filed in the medical record.
85 There are typically two inmates to a cell. Inmate ID badges are posted in the window of the cell rather than the inmate
presenting his ID to a nurse.

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received in two days. If medications are urgently needed, staff uses a local pharmacy, JewelOsco Pharmacy in Joliet, Illinois.
Transcription and Filling of Medication Orders
We toured the rooms where pharmacy technicians receive and sort medications. The rooms
were clean and well organized. However, there is a faucet and sink covered with mineral
deposits that impede sanitation and disinfection. Pharmacy technicians have established an
accountability system for stock medications in which nurses sign out a stock medication blister
pack for each patient. Narcotics are not stored in these medication rooms.
A large volume of prescriptions are generated at medical reception. Providers typically write
orders onto a physical examination form as a component of the treatment plan and also onto a
physician order form which is to be faxed to the pharmacy. However, we reviewed records in
which the provider wrote the medication order only on the physical examination form and not
a physician order form. Since the physician order form is the document faxed to pharmacy, this
poses a risk that the medication order will not be faxed to the pharmacy.
After the provider writes the medication order, a reception nurse reviews it and determines
whether it is a Keep on Person (KOP) medication available in stock supply in the medical
reception area. If so, the nurse retrieves the medication from stock supply, writes the patient’s
name on it and delivers it to the patient. The nurse writes the number of tablets given to the
patient beside the medication order on the physical examination form and/or physician order
form. This enables a BosWell pharmacist to know not to fill the prescription. A concern is that
when nurses give the patient stock medications, some nurses transcribe the medication order
onto a MAR and document that the medication was administered and some nurses do not.
Therefore, some patients are administered medications for which there is no MAR documenting
that the patient received the medications.
Some medications are not administered to the patient in medical reception because it is not
available in stock supply, is a nurse administered medication (e.g., psychotropic), or is nonformulary. Nurses do not transcribe these medication orders onto a MAR at reception. The
prescription is forwarded to a pharmacy technician who faxes the order to BosWell. Because a
nurse did not create a MAR at reception, if for any reason the medication order is not faxed to
BosWell or the medication is not received from BosWell, medication nurses do not know to
expect the medication and to follow-up if the medication has not been received.
When a medication delivery arrives from BosWell, a pharmacy technician checks off what
medications were received along with corresponding BosWell generated MARs. A pharmacy
technician separates KOP medications from Nurse Administered (NA) medications and
determines the patient housing locations. Pharmacy technicians write MARs for some KOP
medications from the blister pack, not the original provider order. A registered nurse does not
review these MARs for accuracy with the original physician order. Medications and MARs are
transported to the nursing medication room for storage in medication carts and subsequent
administration to patients.
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Medication Administration
The nurse’s medication room is cramped, disorganized and dirty. Metal shelving used to store
medical supplies is rusted with bent shelves. Medication cart surfaces are dirty, with tape
residue on carts. The refrigerator containing insulin and other medications was not clean. There
is no sanitation schedule for cleaning the room or refrigerator. Narcotics are double-locked.
Because inmates are locked down at NRC, nurses deliver medications cell to cell. We observed
nurses preparing medications for administration in the medication room. Nurses compared
MARs against medication blister packs to ensure the accuracy of the order and then pop
medication out of the blister pack into their gloved hands. Nurses then placed medication(s)
into a small white envelope that is labeled with the name of the patient, ID, housing location,
and name of the medication. The envelope did not contain order start and stop dates. The
same envelope is used repeatedly. Thus, nurses transferred medications from pharmacy
dispensed properly labeled containers to improperly labeled containers. Nurses then placed
medication envelopes into a clear plastic bag to take to the housing units. Nurses did not
transport MARs to the housing unit along with the medications.
We accompanied a nurse escorted by a correctional officer to R unit. Each cell had one or two
inmates. For each patient receiving medication, the nurse called out the inmate’s name and
informed him she had medication. The nurse did not identify the patient by having him state his
name and a second identifier (e.g., date of birth, inmate ID number). Instead, the nurse looked
at the inmate’s identification badge taped to the window. The nurse then passed the
medication envelope to the patient through a crack in the door rather than an open food port.
The patient took the envelope, poured medication into his hand and passed the envelope back
to the nurse through the door crack. Several inmates did not have cups of water to take their
medications. The nurse asked patients if they had their juice carton from breakfast to fill with
water to take medication. Some did and some did not. Neither the nurse nor the officer
attempted to perform oral cavity checks.
The nurse did not document administration of the medication onto the MAR at the time she
gave the medication. We asked the nurse what happens if the patient is out of cell when she
came to the housing unit, and she replied that the patient would miss his medication for that
dose. There is no procedure to determine where the patient is and make arrangements to
deliver the medication at a later time, even if the medication is to be taken once daily. We
reviewed nursing documentation on multiple MARs and found numerous blank spaces,
indicating that nurses did not document the administration status of each dose of medication
(e.g., given, refused, etc.).
The process we observed is problematic for several reasons:
• Repeated use of the same envelopes is not hygienic, particularly because they are
handled by the patient and returned to the nurse.
• We observed torn envelopes which would allow one or more medications to fall out
unnoticed.

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•
•
•
•

Inmates may refuse one or more of the medications, and if they are similar in
appearance (both are a small white pill) the nurse will not know which medication to
administer and which not to administer.
In three cells, the light was not working and it was difficult to see and positively identify
the patient.86
Failure to perform oral cavity checks for high risk medications (e.g., narcotic,
psychotropic, etc.) increases the risk of drug diversion or non-adherence.
The failure of the nurse to have the MAR and document administration of medications
at the time they are given does not meet standards of nursing practice.

Moreover, while we observed nurses preparing medications using the MAR and medication
blister pack, CQI minutes show repeated medication errors because nurses used the medication
envelope rather than the MAR to prepare medications. Medication audits and CQI minutes
throughout 2017 also show pervasive problems with nurses’ failure to document on the MAR
for scheduled doses.
Changing Medication Administration Records Over at the End of the Month
At the end of each month, BosWell sends a pre-printed MAR for every prescription continuing
into the next month that was written before the 15th of the month. The cutoff date of the 15th
means that at the end of each month, nurses must handwrite MARs for all medication orders
written from the 16th to the end of the month. This equates to hundreds of MARs and is a huge
workload. Handwriting each medication order increases the risk of transcription errors with
resulting medication errors.
We observed the impact of this practice during the site visit. On 2/1/18, staff reported that
nurses on the evening and night shifts were unable to “flip” or transcribe the MARs to February.
Several nurses were hurriedly transcribing the MARs and preparing medications for the
morning pass, but stated that they would not be able to finish transcribing the MARs before
passing medications. The nurses reported that completing transcription of the new MARs
would take place on the evening shift. When we asked the nurses how they would document
administration of medications given to patients that morning, they did not have an answer. NRC
pharmacy technicians proactively suggested that if the cutoff date for BosWell to send preprinted MARs was the 27th or 28th of each month, the nursing workload would be dramatically
reduced, as well as the risk of transcription and medication errors.
Renewal of Chronic Disease Medications
There is not an effective system for timely renewal of chronic disease medications following
arrival. At intake, providers write chronic disease medications for a duration of 30 days and
refer the patient to the chronic disease program for follow-up. Nurses reported that they
review MARs for expiring chronic disease medication orders to notify the provider. However, as
The inmates in these three cells reported that the lights had been out in their cells since they arrived at NRC. In two cases the
inmates had been at NRC for over a month, since 12/21/17. We reported the names of these inmates to the Superintendent.
The following day we were informed that the inmates had been moved to other cells and that the cells were “condemned.”

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noted earlier in this report, nurses do not consistently transcribe MARs for chronic disease
medications given to patients at intake. Therefore, there will be no MAR in the book to alert
nurses that the medication order requires renewal. If the patient’s chronic disease appointment
is scheduled to take place prior to 30 days, providers can reorder medications to ensure
continuity of medications; however, our review showed lapses in medication renewals.
Continuous Quality Improvement (CQI) Minutes and audits performed in 2017 show systemic
and pervasive problems with pharmacy and medication administration at NRC.87 These include:
• Pharmacy dispensing errors
• Medication carts that are not clean
• Nurses preparing medications using medication envelopes (with incomplete and
incorrect information) instead of using the MAR, which is the legal order for the
medication, using the wrong envelope
• Failure to transcribe medication orders onto the MAR
• Medication blister packs not matching the MAR
• Missing medications
• Nurses not documenting on MARs following medication administration
• Nurses not documenting medication order stop dates onto the MAR and administering
medications beyond stop dates
• Shortages of sharps, insulin, and tramadol
• Open insulin and Tubersol vials with no documented opening and expiration dates
• Lack of timely tracking and response to medication errors
The 2016-2017 Annual CQI report showed that pharmacy made 14 errors and nursing staff
made 66 errors during the review period. However, with respect to nursing performance, this is
a gross underestimation of errors when failure to document medication administration is
included as an error of omission. Monthly medication room and MAR audits were performed
showing systemic problems with medication discrepancies and documentation on the MARs. Of
particular concern is the frequency with which audits showed the medication was not available
in the medication cart or medication orders had expired and were not discontinued. However,
the CQI report does not include root cause analysis, corrective action taken, and reevaluation of
performance to determine if the root causes of the problems were addressed.
In summary, the medication administration system creates a systemic risk of harm to patients
at NRC. The conditions of confinement (i.e., 24-hour lockdown) are a major contributor to the
systemic risk of harm.

Infection Control
Methodology: We interviewed health care leadership, reviewed the Infection Control Manual
and other documents maintained related to communicable diseases and infection control.
87

NRC Annual CQI Report 2016-2017.

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First Court Expert Findings
The First Court Expert Report noted that there were no budgeted infection control positions
and that infection control duties were add-on duties rather than a primary assignment.
Current Findings
Our findings are consistent with the First Court Expert’s findings. NRC does not have an
established infection control program. There is not a budgeted infection control position and
infection control duties have not been formally assigned. Leadership reported that a physician
assistant has assumed responsibility for submitting case reports to the state health department.
There is no schedule of clinic sanitation and disinfection activities in clinical areas. We found
many clinical areas to be dirty and disorganized. Stretchers and chairs were torn and in
disrepair, inhibiting infection control. This increases the risk of infection to patients and staff.
As noted earlier in the report, staff reads tuberculin skin tests (TST) through cell windows
instead of inmates being escorted to the medical clinic for staff to properly read TSTs by
palpating patient arms and documenting the results in the patient’s medical record. Medical
record review showed that staff does not record TST results in the record. We interviewed a
staff member who reported that she records results in the medical record “if she has time.”
CQI Minutes and Annual Report shows that staff collects data regarding communicable
diseases, including HIV and hepatitis C antibody test results. There is no assessment of HIV,
HCV, and TB infection rates among newly arriving inmates. CQI Minutes also report statistics
regarding skin infections due to methicillin-resistant staphylococcus aureus (MRSA), but there is
no meaningful discussion regarding their significance and whether measures can be taken to
reduce the incidence of infection. Data does not include tracking of skin infections due to other
pathogens.
As noted earlier in this report, the water supply at NRC is hard, with a high mineral content,
causing mineral deposit build-up in pipes, faucets, and sinks throughout the institution. This
impedes effective infection control. The institution would benefit from a water softening
system, but there is no money in the budget for this expenditure.
In summary, NRC does not have an effective infection control program.

Dental Program
Dental: Staffing and Credentialing

Methodology: Reviewed staffing documents, interviewed dental staff, reviewed the Dental Sick
Call Log and other documents.
First Court Expert Findings

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•
•
•

NRC had one full-time dentist, one 20-hour part-time dentist, two full-time assistants,
and a full-time dental hygienist.
One dentist was employed by the IDOC and the rest of the dental staff were Wexford
employees.
CPR training was current on all staff, and all necessary licensing was on file.

Current Findings
We concur First Court Expert that CPR training was current and necessary licensing was on file;
however, we identified current and additional findings as follows. Staffing has decreased since
2014; there is one full-time dentist and dental assistant who are both Wexford employees.88
The dentist who was present when the First Court Expert visited NRC was replaced
approximately three years ago. There is no dental hygienist.89 Moreover, the part-time dentist
who assists with intake exams is at NRC approximately one-half day, rather than the 20 hours
per week in the First Court Expert Report. However, the true staffing is difficult to ascertain
because of the free flow of dental personnel between NRC and SCC.
A dentist from SCC assists with intake exams at NRC on Thursday afternoons when it is
expected that substantially more examinations will be performed. CPR training is current for
dental staff and all necessary licensing is on file; however, the dentist’s DEA number is not on
file.90
There are several impediments to evaluating the adequacy of NRC dental staffing. First, there is
no clear delineation of how many hours SCC dental personnel spend at NRC. Even assuming the
current staffing is adequate, the one dentist and one dental assistant officially assigned to NRC
understates the actual staffing, which cannot be determined until we have an accurate
accounting of the hours SCC dental personnel spend supporting NRC.
Second, since NRC has only one dentist assigned, when that dentist is ill or is on vacation, is
there adequate coverage? The reports provided to us suggest that there was a lapse in
coverage in the four-month period for which we reviewed sick call logs (“no Dr. in clinic
8/31/17-9/8/17”).91 Not only did inmates with painful dental conditions have to wait as many
as eight days; but given the eight-day backlog, treatment was likely delayed afterwards until the
dentist caught up.
According to the NRC Staffing Spreadsheet, there is a vacant dental assistant position.
Unless the mission of the dental program has changed markedly since the First Court Expert Report, it is difficult to
understand why NRC needed a full-time dental hygienist, since only the small number of MSU inmates are eligible for
comprehensive care (that generally includes a cleaning). While the First Court Expert Report noted that there was a full-time
dental hygienist at NRC, the position is absent in the current NRC staffing. Oral prophylaxes (cleanings) are performed by the
dentist on the small number of MSU prisoners who request them. The dental hygienist said that she does not treat NRC
patients but does assist in the intake examination process. Moreover, she stated that she does not provide oral hygiene
instruction to inmates at intake.
90 “N/A” rather than a DEA registration recorded (Training Records NRC – Stateville, p. 10). Since this information was not made
available, we did not have the opportunity to find out whether the dentist has a DEA number that is not on file or has no DEA
number.
91 The first entry in the sick call logs provided to us for a request received 9/6/17.
88
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Finally, it is difficult to determine patient waiting time; that is, the time from making a request
to receiving care. This will be addressed in the section on Dental Sick Call.

Dental: Facility and Equipment

Methodology: Toured the dental clinic, radiology area, and dental intake area to assess
cleanliness, infection control procedures, and equipment functionality. Reviewed the quality of
x-rays and compliance with radiologic health regulations. Observed clinical care.
First Court Expert Findings
• The clinic consists of a single chair and unit which is over 20 years old and showing wear
and tear. Free movement around each unit is acceptable. Provider and assistant have
adequate room to work. There are two closet-sized rooms adjacent to the clinic for
storage, the dental lab, and for sterilization. Some corrosion, fading, and rust is evident.
Cabinetry is similarly old and worn. The compressor is in good condition. Hand
instruments are in good condition and adequate. The x-ray unit is old but in good repair.
Hand pieces are old, and many are not functioning.
• Overall, the clinic was well enough equipped and the dentist felt all equipment was in
good shape and functional. She expressed some difficulty in getting equipment repaired
due to a lack of funds and administrative support.
• The Panelipse [panoramic] x-ray units are old but functional.
Current Findings
Facilities and equipment have deteriorated since the First Court Expert’s Report, particularly
the two inadequate panoramic radiograph units in the intake processing area that will be
discussed infra. However, we identified current and additional findings as follows.
The dental clinic consists of a single chair and unit, and intraoral x-ray device that are
approximately 20 years old.92 All equipment is in working order except for the film processor,
which was out of service for at least three years.93 The dentist stated that it had been repaired
recently but necessary chemicals were not on hand. Hand instruments are in good condition
and hand pieces are old but functional. The counters are intact and can be disinfected
adequately. There is no equipment replacement plan. This is particularly important for the
panoramic x-ray devices, which are subject to heavy use due to the high volume of initial
exams.
The First Court Expert noted that the equipment was old but serviceable, although many hand
pieces were not functioning. Several years after those findings, a dentist reported that repairs
were needed on the dental drill (“[w]e are working with 2 right now”).94 At the next meeting,
he reported, “[n]eed repairs on drill and equipment. ASR is done. Referred to Ken Harris office
We asked for documentation of the age of all dental capital equipment that has yet to be provided.
The dentist did not feel that the lack of an intraoral film processor was a major problem, since in his opinion a panoramic xray is sufficient for diagnosing dental decay. This is highly problematic and will be addressed later in this report.
94 August 15, 2017 NRC Quality Improvement Meeting Minutes, p. 1.
92
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now. Need 2 new and 1 repaired. If all can be repaired, we don't need new.”95 The next month,
he reported, “[n]o repairs on drill and equipment. Paperwork redone last Tuesday. It is over
$500, so @Springfield level to approve (not Doug or Warden}. Joe making call to Ken Harris to
update dental ASR. Less hands involved with ASR' s is needed.”96
The dentist said that equipment maintenance was currently not a problem and that all his hand
pieces had been repaired; however, given the recent problems with untimely repairs, there
appears to be a systemic problem.
The two rooms adjacent to the dental treatment area are small and cluttered. There is an
unserviceable autoclave on the floor under a counter in the sterilization room. We were
informed that it will be disposed of when the appropriate approvals are obtained.
A panoramic x-ray unit is in the radiology area and is operated by the dental assistant. There
was a lead apron in the radiology area; however, the dental assistant took a panoramic x-ray on
patients who were not wearing an apron. 97
While protective eyewear is available for patients, it is not used consistently because the
dentist felt it was not necessary. 98,99 There is no sphygmomanometer or stethoscope in the
clinic.

Dental: Sanitation, Safety, and Sterilization

Methodology: Reviewed Dental Administrative Directives, toured the dental clinic and dental
intake exam area, observed dental treatment room disinfection, interviewed dental staff, and
observed initial examinations and patient treatment.
First Court Expert Findings
• Appropriate surface disinfection was performed between each patient.
September 19, 2017 NRC Quality Improvement Meeting Minutes, p. 2.
October 24, 2017 NRC Quality Improvement Meeting Minutes, p. 2.
97 Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure. American Dental
Association and Food and Drug Administration (2012), p. 14. (While radiation exposure from dental radiographs is low, it is the
dentist’s responsibility to follow the ALARA Principle (As Low as Reasonably Achievable) to minimize the patient’s exposure.
Dentists should follow good radiologic practice and (inter alia), use protective aprons and thyroid collars.)
98 Guidelines for Infection Control in Dental Health-Care Settings ---2003. MMWR, December 19, 2003/ 52(RR17):1:16; pp. 1718. (“PPE [personal protective equipment] is designed to protect the skin and the mucous membranes of the eyes, nose, and
mouth of DHCP [dental health care provider] from exposure to blood or OPIM [other potentially infectious materials]. Use of
rotary dental and surgical instruments (e.g., handpieces or ultrasonic scalers) and air-water syringes creates a visible spray that
contains primarily large-particle droplets of water, saliva, blood, microorganisms, and other debris. This spatter travels only a
short distance and settles out quickly, landing on the floor, nearby operatory surfaces, DHCP, or the patient. The spray also
might contain certain aerosols (i.e., particles of respirable size, <10 µm). Aerosols can remain airborne for extended periods and
can be inhaled” and “Primary PPE used in oral health-care settings includes gloves, surgical masks, protective eyewear, face
shields, and protective clothing (e.g., gowns and jackets). All PPE should be removed before DHCP leave patient-care areas (13).
Reusable PPE (e.g., clinician or patient protective eyewear and face shields) […]”). Emphasis added. Moreover, protective
eyewear provides protection against objects or liquids accidentally dropped by the provider.
99 Why we Take Infection Control Seriously. UIC College of Dentistry. Viewed at https://dentistry.uic.edu/patients/dentalinfection-control, viewed February 2, 2018 (“We use personal protective equipment […] as well as provide eye protection to
patients for all dental procedures.”} Emphasis added.
95
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•
•

•

Protective covers were utilized on many of the surfaces and most instruments in
cabinets were properly bagged and sterilized. The intake examination mirrors were
bagged and sterilized in bulk. All hand pieces were sterilized and in bags.
The sterilization area is in a small closet-like room that is unkempt and cluttered,
adjacent to the dental clinic. It has inadequate work space to maintain proper
sterilization flow from dirty to sterilized to storage. The ultrasonic cleaner sits between
the sink and the autoclave. There was not a biohazard label posted in the sterilization
area.100
Safety glasses were not always worn by patients and warning signs were not posted
where x-rays were being taken to warn pregnant women of possible radiation hazards.

Current Findings
Dental sanitation, safety, and sterilization have deteriorated since the First Expert’s Report,
primarily due to inadequate hand and surface sanitation by the dentist in the intake area
(discussed infra). We concur with the findings in the First Court Expert’s report. However, we
identified current and additional findings as follows.
The dental treatment room was disinfected appropriately between patients and protective
covers were used on all surfaces. Instruments were properly bagged and sterilized. All hand
pieces were sterilized in bags.
The sterilization area is in a small cluttered room contiguous with the dental clinic. Because the
room has inadequate counter space, it is difficult to configure the area to accommodate
sterilization flow from dirty to sterilized to storage (as noted by the First Expert). The ultrasonic
cleaner sits between the sink and the autoclave. As noted by the First Court Expert, safety
glasses were not always worn by patients, and warning signs were not posted where x-rays
were being taken. 101

Dental: Review Autoclave Log

Methodology: Reviewed the last two years of entries in autoclave log, interviewed dental staff,
and toured the sterilization area.
First Court Expert Findings
• Spore testing was performed weekly and was documented. No negative results were
recorded.
Current Findings

CFR 1901.145(e)(4). “The biological hazard warning shall be used to signify the actual or potential presence of a biohazard
and to identify equipment, containers, rooms, materials, experimental animals, or combinations thereof, which contain, or are
contaminated with, viable hazardous agents.”)
101 Occupational Safety and Health Standards – Toxic and Hazardous substances. 29 CFR 1910.1096(e)(3)(i). “Each radiation area
shall be conspicuously posted with a sign or signs bearing the radiation caution symbol and the words, CAUTION RADIATION
AREA”. Emphasis in original.
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Autoclave log maintenance had improved since the First Expert’s Report and is adequate. The
sterilization log for the past two years was in order. Testing was performed weekly and
documented. No negative results were recorded.

Dental: Comprehensive Care

Methodology: Interviewed dental staff, reviewed randomly selected dental charts of an
inmates who received non-urgent care from Daily Dental Reports. Comprehensive, or routine
care102 is non-urgent treatment that should be based on a health history, a thorough intraoral
and extraoral examination, a periodontal examination, and a visual and radiographic
examination.103 A sequenced plan (treatment plan) should be generated that maps out the
patient’s treatment.
First Court Expert Findings
• Because of the rapid turnover of inmates, most of the records reviewed were very
recent from the transient, short-term population.
• Inmates who received non-urgent care received neither a comprehensive examination
(to include examination of the soft tissues, a periodontal assessment, and bitewing or
periapical x-rays). Nor was a treatment plan documented and they do not receive oral
hygiene care as part of the treatment.
• Oral hygiene instructions were never documented. Restorations were provided from the
information from the panoramic radiograph, which is not diagnostic for caries.
• There were many record entries that pain medication and/or antibiotics were provided
with no documented examination or diagnosis. Many record entries also were “n/s” (no
show) and/or reschedule.104
Current Findings
Comprehensive care is unchanged from the First Court Expert’s Report and remains
inadequate; and we concur with the First Court Expert. Moreover, we identified current and
additional findings as follows.
While most of NRC inmates are assigned for classification and will be transferred to other
facilities within several weeks, approximately 188 in the MSU who are housed at SCC and work
at NRC are candidates for comprehensive care at NRC. However, the MSU inmates do not stay
long; so, at any given time, there are relatively few dental charts of inmates who have received
comprehensive care. Since NRC does not have an electronic health record, identifying inmates
who have had comprehensive care was challenging and only one105 such chart was located.

Category III as defined in Administrative Directive 04.03.102.
Stefanac SJ. Information Gathering and Diagnosis Development. In Treatment Planning in Dentistry [electronic resource].
Stefanac SJ and Nesbit SP, eds. Edinburgh; Elsevier Mosby, 2nd Ed. 2007, pp. 12-15, passim.
104 This will be addressed in the discussion of failed appointments in a later section.
105 Patient #1 had a composite restoration placed based solely on a panoramic x-ray and without a periodontal assessment or a
treatment plan. Furthermore, the chart entry was not legible.
102
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Most of the dentist’s time is spent doing intake exams, which are scheduled for Monday,
Tuesday, Thursday, and Friday, with the remainder of the dentist’s time spent providing urgent
care for the newly arrived inmates. A small amount of routine care (principally fillings) is
provided to the MSU inmates.
Daily Dental Reports from October 2017 through January 18, 2018 document all dental
procedures performed and show that most of the procedures were exams and palliative
treatments related to urgent care.106
Dr. Gambla said that he did not perform a comprehensive examination and produce a
treatment plan before providing routine care to MSU inmates because, in his opinion, that is
not the mission of his clinic. He said that he bases his routine treatment on the panoramic x-ray
from the initial exam and feels that it is sufficient for identifying the problems he treats.107 In
fact, he could not take intraoral radiographs, since the film processor in the clinic was
inoperative for three years.
Just as he does not base routine treatment on intraoral x-rays, he stated that does not perform
periodontal probing on patients for whom he provides routine care, although there are
periodontal probes in the clinic.108 Failing to perform a periodontal screening using probing is
below accepted professional standards and can lead to under diagnosis of periodontal disease,
delayed treatment, and preventable tooth loss.109
While the primary mission of the NRC dental program is performing intake exams and providing
urgent care to a transient population, inmates who receive routine treatment should receive
the same standard of care that they would receive at any other IDOC facility. That they do not is
highly problematic and subjects these patients to risk of harm.110

The Daily Dental Report summarizes the treatment provided to each inmate. It records the procedure (exam, filling,
extraction, cleaning), as well as whether the procedure was palliative. Moreover, it records whether an analgesic or antibiotic
was dispensed.
107 Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure. American
Dental Association and U.S. Food and Drug Administration, 2012. Table 1, pp. 5-6. (Dentate or partially dentate adults who are
new patients receive an “[i]ndividualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior
bitewings and selected periapical images.” Furthermore, recall patients should receive posterior bitewing x-rays every 12 to 36
months based on individualized risk for dental caries. With respect to periodontal disease, “[i]maging may consist of, but is not
limited to, selected bitewing and/or periapical images of areas where periodontal disease (other than nonspecific gingivitis) can
be demonstrated clinically.”)
108 Stefanac SJ. (A panoramic radiograph has insufficient resolution for diagnosing caries and periodontal disease. Intraoral
radiographs (e.g., bitewings) and periodontal probing are necessary), p. 17. Also, (Periodontal Screening and Recording (PSR),
an early detection system for periodontal disease, advocated by the ADA and the American Academy of Periodontology since
1992, is an accepted professional standard.), pp. 12-14. See American Dental Hygiene Association. Standards for Clinical Dental
Hygiene Practice Revised 2016, pp. 6-9. (Periodontal probing is also a standard of practice for dental hygiene).
109 Makrides, N. S., Costa, J. N., Hickey, D. J., Woods, P. D., & Bajuscak, R. (2006). Correctional Dental Services. In M. Puisis (Ed.),
Clinical practice in Correctional Medicine (2nd ed., pp. 556-564). Philadelphia, PA: Mosby Elsevier, p. 560 (Early diagnosis of
periodontal disease is important since the disease is often painless and the prevalence of moderate to severe periodontal
disease in correctional populations is high and often not associated with pain).
110 It is possible that the inadequate comprehensive care reflects insufficient dentist staffing. This should be considered when
NRC dental staffing is revisited.
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Dental: Intake (Initial) Examination111

Methodology: Observed the initial examination process; reviewed 20 dental records of inmates
that have been screened recently; reviewed Dental Administrative Directive; and reviewed NRC
CQI Reports.
The “Initial Examination” is governed by Administrative Directive 04.03.102 (¶II F 2), which
states (inter alia) that
Within ten working days after admission to a reception and classification center
or to a facility designated by the Director to accept offenders with disabilities for
a reception and classification center, each offender shall receive a complete
dental examination by a dentist.112
First Court Expert Findings
• The dental screening [initial] examination is a cursory mirror and direct view
examination of the intra-oral structures, a Panelipse [panoramic] radiograph, and a very
sketchy health history. The teeth are charted for pathology from the direct examination
and from the Panelipse x-ray. One dentist was there to screen over 70 inmates.
• The inmate was standing while being examined. The examiner’s hands never entered
the oral cavity. The exam was very quickly done, taking about 15 seconds. Lighting was
poor. Mirrors came from a bulk package of sterilized mirrors from the NRC dental clinic.
The Panelipse x-rays are taken two at a time in the same small room.
• The inmates wear no lead apron protection, nor are there any signs warning of radiation
hazard. The radiographs are taken and developed by inmates from the MSU, a satellite
of NRC.113 They also reload the cassettes that hold the film. The films are developed,
dated, and labeled with inmate information.
Current Findings
While aspects of the intake examination have improved marginally since the First Court Expert’s
Report, the improvement is more than outweighed by the dentist’s inadequate hand sanitation
and surface disinfection. Our findings with respect to the inadequacy of the intake examination
are consistent with those of the First Court Expert; however, we observed patients examined
while seated114 using improved illumination rather than standing using poor lighting – only a
marginal improvement. Unlike the First Court Expert, we did not observe radiographs taken by
inmates; however, we did observe that panoramic x-rays were taken on inmates who were not

The First Court Expert Report describes the examination performed at intake screening as a “Screening Examination;”
however, Administrative Directive 04.03.102 describes it as a “complete dental examination.” We use the terminology of the
Administrative Directive and refer to the intake or initial dental examination as a complete dental examination.
113 We did not observe an inmate taking the x-rays. Inmates taking x-rays would be in violation of the Illinois Dental Practice
Act.
113 We did not observe an inmate taking the x-rays. Inmates taking x-rays would be in violation of the Illinois Dental Practice
Act.
114 Dr. Orenstein, an SCC dentist who performs initial examinations, said that both he and the patient stand “because there is
not enough time to seat the patient.” A hurried dental examination performed on a standing patient is inadequate on its face
and below accepted professional standards.
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wearing a lead apron with a thyroid collar.115 The intake examination has not changed
materially and remains inadequate. Moreover, we identified current and additional findings as
described below.
In 2017, NRC performed intake processing on 15,942 inmates. All inmates have a panoramic xray taken and receive a cursory direct-view oral examination that includes a taking scanty
health history.116
The dental examination area is a small room with two panoramic x-ray devices set
approximately four feet apart and two rooms that have non-functional dental chairs and
working dental lamps. Neither room has a sink. Patients sit on straight-backed chairs or stand
when they are examined.
Of 20 panoramic x-rays from initial exams performed January 23, 2018, nine (45%) were
clinically inadequate,117 characterized by poor contrast (washed out) or the presence of
artifacts that interfered with interpretation.118 The NRC dentist did not see this as an area of
concern, since he felt that the films were adequate for his purposes (i.e., the initial exam) and if
a film is not adequate, he has it retaken. The inconsistent quality was due to a combination of a
failing x-ray unit and film processor, and inadequate operator technique.119 There was no
signage in the radiograph area warning of radiation hazard. 120
Although Administrative Directive 04.03.102 requires that dentists chart the oral cavity, none of
the intake records we reviewed contained such a charting.121 Furthermore, the diagram for the
charting is too small for the charting to be legible and should it be expanded substantially.
We observed Dr. Gambla perform initial examinations. Both he and the patient were seated;
with the patient seated in a straight-backed chair. He worked without a dental assistant and did
his own recording.122
Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure. American
Dental Association and Food and Drug Administration (2012), p. 14. (While radiation exposure from dental radiographs is low, it
is the dentist’s responsibility to follow the ALARA Principle (As Low as Reasonably Achievable) to minimize the patient’s
exposure. Dentists should follow good radiologic practice and (inter alia), use protective aprons and thyroid collars.)
116 The health history taken at the exam (Appendix 3, Fig. 1) is inadequate because it is too abbreviated and omits information
necessary for safe dental care.
117 Dental: Intake (Initial) Examination Patients #1, 2, 3, 8, 9, 11, 12, 14, and 20.
118 Our findings were confirmed by an SCC Quality Improvement Study in which intake examination charting was compared with
the results of clinical examinations performed on the same patients. Of the 21 NRC charts, 62% had no charting of pathology
(e.g., “abscessed teeth, teeth that needed extraction, [and] periodontal disease, (+3) mobility in teeth, grossly decayed teeth,
impacted wisdom teeth in the maxillary sinus, and numerous visible dental caries”), with the remainder having only a partial
charting. Furthermore, “in all the patients reviewed, visible heavy tartar [calculus] was never charted or indicated. The
periodontal needs were never indicated” and “the dental radiographs from NRC varied in diagnostic quality”). Stateville Annual
CQI 2016-2017_2, p. 32.
119 We asked to see documentation that the panoramic x-ray devices had been calibrated or inspected by a therapeutic
radiological physicist; however, none was produced.
120 Each radiation area shall be conspicuously posted with a sign or signs bearing the radiation caution symbol and the words,
“CAUTION RADIATION AREA”. Occupational Safety and Health Standards – Toxic and Hazardous substances. 29 CFR
1910.1096(e)(3)(i). Emphasis in original.
121 ¶II F (2(b).
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He donned gloves, selected mouth mirrors from a bag of sterile mirrors that he opened and
placed on a bracket table before the first exam. A standard dental light illuminated the patient’s
mouth. He reviewed the panoramic x-ray and took a cursory health history. He used one or two
mirrors to reflect the cheeks and adjusted the light for optimal illumination. While his gloved
hands did not always touch the patient, in approximately half the exams we observed, they
touched the patient’s face, lips, or mouth. He did not change gloves between patients
consistently. In fact, there were several instances where he examined a patient wearing the
gloves he used to touch a previous patient’s mouth or face. He did not wash hands between
patients because the exam room had no sink. 123
Even when he changed gloves between patients, he used the same (unsheathed) pen to
perform his recording; a source of cross-contamination. Similarly, the handles used to position
the dental light had no disposable covers and were a source of cross-contamination. Finally,
when he reached into the pile of mirrors wearing gloves worn for a previous exam, he ran the
risk of contaminating the other mirrors. The dentist performed initial exams the following day,
examining at least seven patients without changing gloves.
The dentist did not perform a thorough soft tissue examination.124 For example, he did not
visualize the lateral and posterior regions of the tongue, a potential site of squamous cell
carcinoma.125 Performing a thorough soft tissue examination is critical at the initial exam, since
unless the inmate requests care, his next exam will be biennial.126
Our nursing expert observed the dentist perform initial exams on 2/1/18 and reported that he
did not change gloves between patients. In fact, he did not have a box of gloves in the room.
All dental charts of inmates who receive an initial examination have a stamp that indicates that
oral hygiene instructions were provided; however, this did not occur in the examinations we
observed.127 Moreover, the dental program reported 12,477 hygienist contacts at intake in
The exam has improved somewhat since the First Court Expert Report: now the lighting comes from a dental operatory light;
however, the exam is still grossly inadequate.
123 Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations
for Safe Care. Atlanta, GA: Centers for Disease Control and Prevention, US Dept. of Health and Human Services; October 2016,
p.7.
124 Stefanac SJ. (“Evaluation of head and neck structures for evidence of tissue abnormalities or lesions constitutes an important
part of a comprehensive examination.”), p. 12. See also Shulman JD, Gonzales CK. Epidemiology/Biology of Oral Cancer. In
Cappelli DP, Mosley C, eds. Prevention in Clinical Oral Health Care. Elsevier (2008) (“Regular, thorough intraoral and extraoral
examination by a dental professional is the most effective technique for early detection and prevention of most oral cancers.
[…]”) p. 41.
125 This is generally done by holding the anterior portion of the tongue with 2x2 gauze and reflecting the tongue with a mouth
mirror. This is a professional standard for an oral examination. National Institute of Dental and Craniofacial Research. Detecting
Oral Cancer. A Guide for Health Care Professionals.
126 This deficiency is compounded by the fact that dentists do not document soft tissue examinations at biennial exams. See
section on Comprehensive Care, supra.
127 The ‘uniform record system’ sponsored by the American Dental Association is the Code on Dental Procedures and
Nomenclature. “In August 2000 the CDT Code was designated by the federal government as the national terminology for
reporting dental services on claims submitted to third-party payers.” Oral hygiene instructions (Dental Procedure Code D1330)
“may include instructions for home care. Examples include tooth brushing technique, flossing, the use of special oral hygiene
aids.” See Dental Procedure Codes, 2015, American Dental Association Dental Procedure Codes, 2015, pp. 1, 16.
122

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2016-2017.128 The SCC hygienist stated that she assists with the intake exams by charting from
the panoramic x-ray or taking x-rays; however, she does not provide oral hygiene instruction.
Furthermore, adequate oral hygiene instructions cannot be performed in the time allotted to
the initial exam.

Dental: Extractions

Methodology: We reviewed records of inmates that have had extractions, reviewed Daily
Dental Reports October 2017 through January 2018, and interviewed the dentist.
First Court Expert Findings
• Documentation was poor. For example, none of the records examined had a diagnosis
or reason for extraction included as part of the dental record entry.
• Antibiotics were provided to every patient post-operatively who had a dental extraction,
even if not indicated.
Current Findings
Dental extraction care has not improved materially since the First Court Expert’s Report and
remains inadequate. Our findings with respect to inadequate documentation are consistent
with those of the First Court Expert; however, we note that none of the patients had postoperative antibiotics prescribed. Moreover, we identified current and additional findings as
follows.
Only seven patients had teeth extracted between October 2017 and January 18, 2018 as
documented in the Daily Dental Reports for that period. Of five records of patients who had
extractions, the quality of documentation was poor. None of the records documented the
diagnosis of the tooth that was extracted.129 All extractions were accompanied by a signed
consent form that listed the tooth number; however, there was no diagnosis. For consent to be
informed, the reason for the procedure must be clearly stated. None had post-operative
antibiotics prescribed or dispensed. All patients had recent preoperative x-rays; however,
patients #4 and #5 had teeth extracted based on panoramic x-rays that were clinically
inadequate because they did not provide a clear view of the entire tooth. 130

Dental: Removable Prosthetics

Methodology: Reviewed Daily Dental Reports from October 2017 through January 18, 2018 and
interviewed dental staff.

The dental program consistently includes “hygienist contacts” or “hygienist contacts/intake.” See, for example, NRC Annual
CQI Report, 2016-2017, 2 (12,477), NRC Monthly Continuous Quality Improvement Meeting, January 16, 2018, 3 (870).
129 Dr. Gambla said that he knows what the SOAP format is but does not use it.
130 Extracting a tooth without an adequate preoperative radiograph deprives dentists of the ability to (1) determine that the
case is beyond their skill level or unsuitable given the equipment limitations of the clinic, so the patient can be referred to an
oral surgeon; (2) assess a potentially difficult procedure so they can adjust the surgical approach accordingly; and (3) ensure
that the necessary equipment is available. Furthermore, an adequate pre-operative radiograph can serve as evidence of a
potentially life-threatening condition such as a hemangioma.
128

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First Court Expert Findings
• A comprehensive examination and treatment plan was never part of the treatment
process.
• Periodontal assessment and treatment was not provided in any of the records. Because
there is no comprehensive examination, or any treatment plans developed and
documented in any of the records, it is almost impossible to ascertain if all necessary
care, including operative and/or oral surgery treatment, is completed prior to
fabrication of removable partial dentures.
Current Findings
We did not locate any records that documented the fabrication of complete or partial dentures.
In fact, no dentures were fabricated between October 2017 and January 18, 2018 per the Daily
Dental Reports for that period.

Dental: Sick Call/Treatment Provision

Methodology: We interviewed dental staff; reviewed and randomly selected charts of patients
listed in the Dental Sick Call Log from 10/3/17 through 1/22/18, reviewed Daily Dental Reports
from 10/3/17 through 1/17/18, reviewed records of seven inmates who were seen on sick call,
and reviewed recent intake examination records.131
First Court Expert Findings
• Inmate requests are logged into a large bound ledger indicating complaint, date of
request and date of appointment. In none of the progress notes reviewed was mention
made of the inmate complaint; the only entry was the provided treatment.
• The average appointment date was seven days from the date of the request. A review of
several records revealed that they were often seen later than that due to the high noshow and reschedule rate. Many of the inmates had transferred out of NRC by the time
of their appointment.
• Often the treatment was prescribing pain medication or an antibiotic with no
documentation as to why they were prescribed. Approximately 50% of requests are
complaints of pain, swelling, or toothaches.
• Routine care is accessed from the request form and the inmates are seen within 14 days
and treatment started. There is no waiting list and reschedules are seen within 14 days.
Current Findings
Our findings are consistent with those of the First Court Expert and we noted no material
improvement in dental sick call, which remains inadequate. Moreover, we identified current
and additional findings as follows.
Inmates who want to see the dentist (or other health care provider) communicate the request
on a piece of piece of paper which they pass through cracks in the cell door since no standard
131

Dental Bates, pp. 40-46.

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health care request forms are available.132 These slips are typically picked up by officers or
health care staff or given to nurses at medication pass. Once collected, inmate health requests
are transported to the medical clinic and placed in an open bin in the main medical clinic. A
more detailed description of the process is in the Sick Call section, supra.
Per dental staff, requests for dental care are placed in a basket on a counter across from the
dental clinic and are recorded in a log kept in the dental clinic.133 While the log records the date
of request and the date the inmate was scheduled, it does not capture the date the inmate was
treated. Consequently, waiting time for treatment cannot be determined without reviewing
individual dental charts.
The Dental Sick Call Log from 10/3/17 through 1/22/18 contained 228 entries, approximately 90
percent of which stated pain or conditions that more likely than not were associated with pain.
The median time from request to scheduled appointment134 was two days. Requests received
Monday through Wednesday had a median schedule time of two days while those received
Thursday and Friday had a median of four days.
Median Time for a Dental Sick Call Appointment
Day Request Received N
Median Wait
Time (days)
Monday
84
2
Tuesday
35
2
Wednesday
41
2
Thursday
46
4
Friday
22
3
Monday-Wednesday
160
2
Thursday-Friday
68
4
All Days
228
2
Among inmates whose request suggested a painful condition, one waited eight days, two
waited seven days, seven waited six days, and nine waited five days to be scheduled. This is not
time to treatment, which cannot be determined from the available data and is likely to be
longer if patients are rescheduled.
There is no triage process, with routine care provided to inmates other than those in the MSU,
who will be transferred shortly. Many inmates who are scheduled do not appear for their
appointments.

See discussion of Nursing Sick Call earlier in this report.
The First Court Expert noted that the dental sick call requests were recorded in the Offender Request Log; however, this is
not done consistently. The dental clinic keeps its own log which contains the inmate’s name ID, nature of the request, date
received by the dental clinic, and date the patient was scheduled.
134 Since appointments were often rescheduled, the actual wait time for treatment for those inmates was longer.
132
133

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There is no process for nurses, when the dentist is not available, to perform a face-to-face
examination on a dental patient who states they have pain to identify pain and infection, and
provide analgesics and referral to a mid-level or advanced level provider if immediate
treatment is necessary.
Dr. Gambla said that when he sees patients with an urgent care need at intake screening, he
tells them to submit a request for an appointment and will occasionally dispense antibiotics for
patients with a dental abscess.135 Of five records of these patients, all had inadequate
documentation as to the diagnosis for which the antibiotic was dispensed.136

Dental: Orientation Handbook

Methodology: Reviewed the Orientation Handbook.
First Court Expert Findings
• The NRC is included in the Stateville Offender Orientation Manual. It addresses the
orientation screening exam, but in little detail. It states only that the inmate will receive
one as soon as possible.
• It explains how to access emergency care but does not explain the requests form system
for accessing urgent and routine care. It describes the hours of operation, partial
dentures, appointments and cleanings.
Current Findings
Inmate orientation to dental care has improved marginally since the First Court Expert’s Report.
NRC now has its own orientation handbook, so the First Court Expert’s findings are moot.
However, we identified current and additional findings as follows.
NRC now has its own Orientation Handbook; however, it erroneously states that every
reception offender will receive a complete dental exam at NRC.137 As discussed supra, the initial
examination performed at NRC is in no way a complete exam. Moreover, there is no
explanation of the process for accessing urgent and routine dental care.

Dental: Policies and Procedures

Methodology: Reviewed Administrative Directives that deal with the dental program,
interviewed dental staff, reviewed dental charts, toured dental clinical areas, and reviewed NRC
organizational chart.
First Court Expert Findings: None.
Current Findings
The dental clinic has limited stock of antibiotics and non-narcotic analgesics.
Progress note mentioned that the Patient #3 did not want the problematic tooth extracted, but there is no refusal in the
record.
137 NRC Offender Handbook, April 19, 2017, ¶IV B.
135
136

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The IDOC dental programs are governed by Administrative Directive 04.03.102 (effective 2012).
While the First Court Expert did not include this in the findings (although it was available for
review), we nonetheless find that dental policies and procedures are inadequate for reasons
stated below.
The NRC dental program is governed by Administrative Directive 04.03.102, amended
1/1/2012. It specifies that within 10 working days after admission to a reception and
classification center, offenders shall receive “a complete dental examination by a dentist”
(¶F2; emphasis added).138 In addition, the dentist should chart the oral cavity.139 The priorities
are Category I (emergency),140 Category II (urgent care),141 Category III (comprehensive/routine
care),142 and Category IV (low-priority care).143
While Administrative Directive 04.03.102 mandates a charting of the oral cavity, the tooth
diagram on the chart used for charting restorations and missing teeth (Appendix 3, Fig. 4) is too
small. Furthermore, in none of the records reviewed was there evidence of its having been
used.
The dentist did not have a thorough understanding of the classification priorities and did not
have the Administrative Directive in the clinic. He said that he was “oriented to the
Administrative Directive by Wexford.” To illustrate this, Patient #15 had a tooth that was noted
as IIa144 (see Appendix 3, Fig. 2), yet no disposition was indicated (Appendix 3, Fig. 3).145 The
dentist should either treat the tooth at NRC or indicate on Figure 3 that it should be treated
immediately at the receiving institution.

Dental: Failed Appointments

Methodology: Reviewed the Dental Sick Call Log, interviewed dental staff, and reviewed Daily
Dental Reports.
First Court Expert Findings

Administrative Directive notwithstanding, in actual practice, the dentist at NRC performs a screening, not a complete
examination (see discussion of comprehensive care supra). The NRC initial dental examination we observed contravenes the
Administrative Directive. Either this was not noticed or was noticed and ignored in the semi-annual internal audits of the dental
program per ¶C. Note that this error is also reflected in the ¶IV B of the NRC Offender Handbook.
139 And document it in the dental chart (Appendix 3, Fig 4). The dental hygienist said that when she does a charting, it is not
based on examining the patient’s mouth but from the panoramic x-ray.
140 Bleeding, pain, and acute infection.
141 A condition, if left untreated, that would cause bleeding or pain in the immediate future (IIa); an oral infection or oral
condition which, if left untreated (IIb), a condition that results in difficulty in chewing (IIc).
142 A medium to large non-painful carious lesion (IIIa), localized gingival involvement (IIIb), tooth fractures (IIIc), deteriorated
temporary, sedative, or intermediate restorations that have deteriorated extensively (IIId) and a broken or ill-fitting prosthetic
device (IIIe).
143 Small carious lesions (IVa), costly restorative procedure (IVb), severe non-functional bite and malocclusion (IVd).
144 “An oral condition, if left untreated, that would cause bleeding or pain in the immediate future.” Administrative Directive,
Attachment A.
145 There are three choices: 1) schedule immediately at R&C, 2) schedule routine exam at receiving institution, and 3) schedule
immediately at receiving institution.
138

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•
•

For a randomly selected 23-day period, there were 409 scheduled appointments, of
which 165 patients were seen, which is only 40% of those who were scheduled. The
remainder were rescheduled, transferred, or no-showed.
Of the patients who could have been seen (scheduled minus transferred), 43% failed
their appointment. The 20% who were transferred reflect the time from when they
were logged into the appointment book to when they were scheduled and the
understandable high and rapid turnover rate at the NRC.

Current Findings
The failed appointment issue has not improved since the First Expert’s Report. We concur with
the First Court Expert’s findings. However, we identified current and additional findings as
follows.
The findings in the dental sick call section confirm that failed appointments are a problem;
however, because of the disorganized sick call system and inadequate record keeping, it is not
possible to accurately determine an actual failed appointment rate. This appears not to be a
priority at NRC. For example, while the Dental Report in the January 16, 2018 QI minutes list
refusals, no information about failed appointments is provided. Similarly, while the number of
refusals is reported in the Dental Department Annual Summary, there is no mention of failed
appointments.146

Dental: Care of Medically Compromised Patients

Methodology: Reviewed health history form and records from recent initial exams, observed
the dentist taking health history at the initial exam, and interviewed the dentist.
First Court Expert Findings
• There is no system to identify medically compromised patients and red flag those that
may need medical consultation prior to dental procedures. The health history review is
cursory from the NRC screening examination.
• The dentist does not routinely take blood pressures on patients with a history of
hypertension.
Current Findings
Documentation of the health history of medically compromised patients has not changed
materially since the First Court Expert’s Report and remains inadequate. We concur with the
findings in the First Court Expert’s report. Moreover, we identified current and additional
findings as follows.
The health history (Appendix 3, Figure 1) is too limited and omits conditions relevant to dental
care, for example, anticoagulant therapy. There is insufficient room on the form for adding
information and the dentist does not routinely update the medical history. Blood pressure is
not routinely taken on patients who have a history of hypertension.
146

NCR CQI 2016-2017 Annual Report, part 3, pp. 24-30.

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Dental: Specialists

Methodology: Interviewed dental staff.
First Court Expert Findings
An oral surgeon is utilized by the NRC for oral surgery services. The inmates are scheduled and
managed from SCC. More complicated cases, such as facial fractures and those requiring
general anesthesia, are referred to Joliet Oral Surgeons, a local group. The information is
maintained at SCC.
Current Findings
We concur with the findings in the First Court Expert’s report. Moreover, we identified current
and additional findings as follows. The dentist refers patients who require complex extractions
to SCC, which schedules them for oral surgery. Since the details are not maintained at NRC, this
issue will be pursued at the SCC visit and will withhold opinions as to the program’s adequacy.

Dental: CQI

Methodology: We reviewed CQI minutes and reports and interviewed dental staff.
First Court Expert Findings
• The dental program contributes monthly statistics to the CQI committee. The NRC
participates with the SCC CQI Committee meetings, as part of the entire dental program.
These minutes are maintained at SCC.
• No studies were in place for the NRC at the time of this visit. In light of the number of
program weaknesses, this is unacceptable.
Current Findings
The NRC dental CQI program has not improved materially since the First Court Expert’s Report.
We concur with the findings in the First Court Expert’s report about the inadequacy of CQI
studies and note that NRC now has an independent CQI committee. We were not provided with
any CQI studies related to the dental program when we were at NRC.147 With the many
deficiencies identified by the First Court Expert and corroborated by this report, the dental
program provides a fertile field for studies.

Internal Monitoring and Quality Improvement
Methodology: Interview facility health care leadership and staff involved in quality
improvement activities. Review the internal monitoring and quality improvement meeting
minutes for the past 12 months.
First Court Expert Findings

147 The NRC 2016-2017 CQI Calendar indicated that there was a dental study planned for January 2017. We were subsequently
provided with reports of two studies at our SCC visit.

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The First Court Expert found that the NRC and SCC quality improvement meetings were
conducted as a single meeting, but that there were no NRC QI studies. Because there were no
logs (reception, sick call, urgent care, emergency send-out log, and offsite specialty log) there
was no data available to examine whether there was a problem. The First Court Expert
recommended that the quality improvement program must be re-energized with
knowledgeable leadership that has been provided specific training regarding quality
improvement philosophy and methodology. The First Court Expert also recommended that the
leadership of the continuous quality improvement program must be retrained regarding quality
improvement philosophy and methodology, along with study design and data collection.
Current Findings
We agree with all findings of the First Court Expert. NRC now has its own CQI program with
separate meetings, which is an improvement. The CQI program, however, remains ineffective.
The remaining findings of the First Court Expert remain unresolved.
We identified new findings which include the following:
• The “Traveling Medical Director” provides no leadership for the CQI effort.
• No one in NRC leadership is familiar with current CQI methodology, study design, or
data collection. The method of improving CQI at NRC as proposed by IDOC has not been
effective.148
• The CQI coordinator has no training in CQI, does not understand how to perform or lead
CQI work, and is so busy that CQI work is a low priority.
• The NRC CQI plan is generic and does not detail a year-ahead view of their CQI work.
This is not a plan. The NRC and SCC CQI plans and Medical Director’s reports are
identical, indicating that these facilities are not yet performing their own quality
improvement.
• NRC is not compliant with multiple requirements of their CQI AD, including:
o NRC does not maintain a CQI manual onsite.
o NRC does not monitor whether Wexford performs primary source verification of
its physicians working at NRC.
o NRC does not monitor offsite medical care for quality.
o NRC does not perform the number of studies in accordance with requirements of
the CQI AD.
o There are no studies that review the quality of medical care.
• NRC fails to use data in a manner that identifies problems.
• Data presented in several studies appeared unreliable.
• The CQI report presents statistical data which has little value from a quality perspective.
• Half of the six studies NRC chose to perform were in areas where there were no
problems, thus yielding 100% audit results. While it is useful to know areas that are
working well, there were so many problem areas that attention should be given to
problem prone areas.
148

Page 5 in IDOC comments regarding First Court Expert’s report in a letter to Dr. Shansky from William Barnes on 11/3/14.

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•
•

The annual CQI report repeatedly documents errors in medication administration yet
there was no attempt to discover why this was occurring.
Wexford’s physician and physician assistant peer review differs significantly in
comparison with our record reviews. We question its reliability.

The leadership at NRC has not effectively initiated a CQI program. The HCUA started nine
months ago and inherited a facility that had not had a full-time and effective HCUA for years.
The Medical Director position was vacant for a year before being filled for two months and then
vacated again. The current Traveling Medical Director does not provide strong leadership. The
HCUA told us that the DON position was vacant for years before being filled in September of
2017. Additionally, because quality improvement work was not being done when the HCUA
arrived, she had to start from the beginning. While no quality improvement work was being
done at the time of the First Court Expert’s report, there has been some progress, but the CQI
program is not yet operational or effective.
The IDOC AD requirement is that each facility develops a CQI program that provides
“systematic, on-going objective monitoring and evaluation of the quality and appropriateness
of offender care.”149 This is not being done. The Chief Administrative Officer is required by the
IDOC AD to designate a CQI coordinator to lead that effort. The Warden is the Chief
Administrative Officer. The person the Warden designated to be the CQI coordinator was the
Director of Medical Records. That person left service sometime last year and the CQI position
was vacant. Two months ago, the Warden appointed the newly hired Director of Medical
Records to be the CQI coordinator. This person has undergraduate and master’s degrees in
Health Information Management, but she has no experience or specific training in quality
improvement. The lack of knowledgeable leadership recommended in the First Court Expert’s
report is still not in place. It appears to us that this position is assigned to medical records staff
because of the need to have someone organize the paperwork requirements of the CQI
committee, including the mandated studies and the meeting minutes. While secretarial and
organizational work is important, the main requisite of a CQI coordinator is someone who has
the leadership capacity, skill, and expertise to identify problems and provide the leadership to
solve the identified problems, and to ensure that the various disciplines are trained and
enabled to perform quality improvement work. That is not a skill or expertise of the current CQI
coordinator. This coordinator would not be able to train any staff on how to engage in CQI
work. She is very well qualified to manage a medical record program but not a CQI program.
Except for attending CQI meetings, the new coordinator has not spent time performing or
leading any CQI studies. The time she dedicates to CQI is a few hours a month reviewing data
obtained for the CQI reports. Moreover, because the medical records program is in disarray,
this person will not be able to dedicate much time to CQI work. She has not read the CQI AD yet
and could not answer any questions with respect to the responsibilities of CQI. She did not have
a plan of action and was not able to answer questions about how CQI was performed at NRC or
how she might lead the CQI effort. The HCUA sat in on the interview with the CQI coordinator
149

Administrative Directive 04.03.125 Quality Improvement Program policy statement.

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on CQI activity and the HCUA responded to the questions, as the CQI coordinator did not know
the answers.
The IDOC AD requires that the Agency Medical Director develop and maintain a CQI manual
which the HCUA is to maintain locally. The HCUA did not have this manual onsite. The AD
requires a CQI plan. The NRC CQI plan is present in the annual CQI report. The CQI plan has no
specifics and lists only general goals such as improve quality, update programs, maintain
standards, ensure patient rights, and work toward complying with NCCHC standards. These
general goals do not constitute a CQI plan of action for the upcoming year. The plan does not
state what it attempts to study over the upcoming year or discuss the main problems at the
facility and how their CQI work will address those problems. The NRC plan is ineffective. It could
be recycled year after year without modification and gives no indication of how the CQI
program will be engaged in the upcoming year. We also note that the NRC and SCC CQI plans
are identical. These are separate facilities and should have different plans. The Medical Director
report for NRC is also identical to the SCC report, with the exception that the SCC report
includes a sentence about accreditation.
Multiple requirements of the IDOC AD on the quality improvement program were not being
accomplished at NRC. The AD requires a one-time primary source verification of credentials of
licensed staff. NRC could provide no verification that this has occurred for their NRC physician.
The annual CQI report verifies license and current DEA license, but this was done in 2016-17
and at that time the physicians listed were different from the current physician. In any case, this
is not primary source verification of their credentials. Primary source verification is discussed in
detail in the section on physician staffing in the section on Leadership, Staffing and Custody
functions.
The IDOC AD requires that there is a monthly 100% review of appropriateness and quality of
offsite medical care. Quality of care is not investigated at all based on CQI reports. Statistics
about the number of referrals offsite is given, but there is no analysis or review with respect to
quality. We were told by the HCUA that the Medical Director evaluates all hospitalizations and
determines if they are appropriate. The HCUA or DON also send an email to the IDOC regional
coordinator notifying them that a patient is going to be hospitalized. When the regional
coordinator believes it is necessary, he/she may call the Agency Medical Director to determine
whether the admission is appropriate. This process only evaluates hospital necessity. It does
not evaluate, for example, the quality of care at NRC to determine if with adequate care the
offsite or hospitalization could have been prevented. A mere statistical listing of
hospitalizations and offsite consults fails to satisfy, in our opinion, the AD requirement to
evaluate quality of care.
CQI studies are summarized in an annual CQI report. Studies performed in the CQI program are
organized according to a schedule that is defined in the AD for CQI, which at NRC are
memorialized in a calendar such that certain studies are done in certain months. NRC
performed six studies in only four of the seven medical program areas required by the AD to be

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studied on an annual basis. In the 2017 annual CQI minutes dated September 26, 2017, the
studies (excluding mental health and injuries) performed to satisfy the AD included:
1. An outcome study that all laboratory results are received from UIC within 72 hours.
2. An outcome study on sick call that sick call slips are reviewed within 24 hours and
treatment protocols are used.
3. A process study of chronic illness clinics that laboratory reports are received, signed, and
dated within 24 hours and subsequently filed in the medical record correctly.
4. A process study of non-formulary medication that from the request to delivery of
medication be less than four days.
5. An outcome study of whether the baseline clinic for a chronic illness problem is done
within 30 days of arrival for all patients.
6. An outcome study of sick call that patients are evaluated at RN sick call and referred as
per the AD.
None of the outcome studies performed included an acceptable clinical outcome. Clinical
outcomes are end point measures of health status. These might be, for example, mortality,
hospitalization, an HbA1C level of 7 or less, or normal blood pressure. An outcome study
measures interventions that may affect the studied outcome. An example would be to study
the effect of colorectal cancer screening on mortality or the effect of increasing the interval of
chronic clinic visits on obtaining a normal blood pressure. The studies performed at NRC were
not based on a clinical outcome but on performance measures. This demonstrates a lack of
understanding of the meaning of outcome studies.
NRC should be credited with having started the CQI process. It is a step forward to have
performed these studies. However, study choice and design is not meant to merely obtain a
good audit result but is meant to identify problem prone areas, study them and attempt to
improve quality of care. Also, this is a health care organization and there were no studies of
clinical outcomes or quality of care. These studies have not yet reached that standard. We also
note that one of the First Court Expert’s findings is that because of the lack of adequate logs
which track services, there is a lack of data available to understand whether a problem existed
in any area of service. We agree with that finding. Limited data is available at NRC for use by
the CQI program. The CQI studies did not appear to rely on adequate data needed to draw a
conclusion with respect to the quality of service.
For studies 1, 3, and 4 listed above, it does not appear that these studies are problems at this
facility. It is not unexpected that the results were all 100% or at goal. The First Court Expert
report documented, for example, that labs were consistently drawn prior to chronic care. Yet
one of the few studies done was to assess whether the lab reports were signed before a chronic
care clinic. Notably this was 100%. With many known problems at the facility, why choose items
which are known to not be problematic?
Study 2 was a study on whether sick call slips were reviewed within 24 hours and whether
protocols were completed. We note in the section on nursing sick call that sick call slips have
been destroyed and that sick call slips are not all retained. We question the reliability of data
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used in this study based on our findings on the sick call process. Also, item 2 studies only
whether a protocol was used, not whether the right protocol was chosen or whether the
quality of nursing care was adequate. This study fails to critically address this process. Its value
as a CQI study is limited. We could not evaluate item 6 because the methodology and data were
not included in the annual CQI report.
Study 5 involved an issue that was brought up in the First Court Expert report and we agree
with the concept of this study, which is a study of whether newly arrived patients with chronic
illnesses are evaluated in a chronic illness clinic within 30 days. As described in the section on
chronic illness, NRC fails to enroll all inmates with chronic illness and places only approximately
10% of chronic illness patients on their chronic illness roster. This study was listed as an
outcome study, which it is not. Enrollment of persons in chronic illness clinic is a process. Since
only 10% of persons with chronic illness are identified at intake, only 10% of patients with
chronic illness were assessed as to whether they were seen within 30 days. The 90% of patients
not on the chronic care roster are more likely to not have chronic care follow up as required by
the AD. These factors were not identified. Also, the study merely studies whether a doctor saw
the patient but does not monitor if the quality of care of the chronic clinic was adequate. As we
note in multiple medical chart reviews in this report, it is our opinion that the quality of chronic
care evaluations is poor. This study would have been improved if it had studied the process of
enrollment into chronic care, including how patients are identified as having chronic illness,
how they are enrolled in the clinic program, and where patients get missed.
There was an absence of review of quality of clinical care of nurses, physicians, and mid-level
providers. It is a requirement of the contract with Wexford that peer review is regularly
done.150 We asked for but did not receive Wexford’s peer reviews until a month after our tour.
The quality of care in all areas of our record reviews showed quality problems. Yet the peer
reviews failed to demonstrate quality issues or, when quality issues were identified, there was
no apparent corrective action and the results were not reported to the CQI committee.
The peer review of the Traveling Medical Director at NRC was performed by the Medical
Director at SCC. The Traveling Medical Director is a nuclear radiologist performing primary care.
He was noted by the First Court Expert to have “clinical concerns” and is on a final written
warning by Wexford for clinical performance. We also noted significant clinical problems for
this physician. Yet this doctor had a peer review performed by a surgeon who was clinically
inadequate based on our record reviews including mortality reviews of preventable deaths. The
peer review included reviewing 25 intake records. Ninety-six percent of questions reviewed
were adequate and the remaining 4% were not applicable. This doctor, for whom we identified
multiple problems, was scored as 100% adequate in this review. It is our opinion that this is
ineffective peer review.

Contract between Illinois Department of Healthcare and Family Services and IDOC and Wexford Health Services; Item
2.2.2.19 Participate in physician peer review program and any audit/peer review conducted by an outside review source to
ensure compliance with accepted professional standards of performance, which includes, but not limited to, chart reviews; p. 6
of contract.
150

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The nuclear radiologist Traveling Medical Director reviewed physician assistants at NRC. Sixtyfive episodes of care were reviewed, 673 questions were answered, 193 questions were not
applicable. Of the remaining 480 questions reviewed, 67 questions (13.9%) were found
inadequate. Nevertheless, all 65 episodes of care reviewed were found adequate without
further explanation. Two reviews stood out. In one review the doctor documented that six
questions were not applicable. Four items were found to be inadequate, including:
• Does the plan of care logically follow the history and physical?
• Does the provider account for all positive responses noted on this screening history?
• Are all fill-in areas completed with appropriate responses?
• Is the signature with professional designation legible?
Only two items were found adequate, including:
• Is the problem list complete with medication allergies?
• Is the handwriting legible?
Yet this episode of care was found adequate. One questions how the signature was illegible but
the handwriting legible. More important, based on only having a problem list and legible
handwriting, the intake assessment was found adequate. This is a defective review.
In another review, the intake physical examination was deemed adequate because the problem
list was complete, the provider accounted for positive responses on the history, and the
handwriting was legible. On the same record, the reviewer found that the care plan did not
follow the history and physical, the intake form was incompletely filled out, a digital rectal
examination was not completed based on patient age, and “yes” responses on the history were
not explained. These peer reviews appeared to be done only to provide evidence that a peer
review occurred. Based on our record reviews of intake assessments and sick call visits in
comparison to results of these peer reviews, we find these peer reviews are not identifying
important deficiencies of clinical care.
The First Court Expert opined that lack of leadership was a key factor in a lack of CQI activity.
The new leadership group has not yet developed a CQI philosophy or sense of purpose in its CQI
work. It is our opinion that the lack of understanding on how to perform CQI work is resulting in
supervisory staff appearing to blame staff for bad results when the bad result is a systemic
problem unrelated to individual employees. This is a failure of leadership to know how to
analyze or correct a problem. We note two comments in CQI minutes:
• “Were 18 med errors last month. Corrective action training was held. AW [name
deleted] questioned ‘at what point do we take nurses’ license? There is a progressive
pattern and adverse patient reaction.’”151
• With respect to medication errors, a comment was made that “Nurses are responsible
for accuracy. No excuses.”152

151
152

August 15, 2017 Quality Improvement minutes.
September 19, 2017 Quality Improvement minutes.

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These two comments were related to failure of nurses to adequately document on the MAR
and failure to appropriately administer medications. These types of medication errors were
reported almost every month, as recorded in the annual CQI report. Despite statistically
describing the problem, there were no studies or analyses to determine a root cause of why so
many errors are being made. This is poor CQI, because employees were held responsible for
systemic problems that were likely related to staffing or other process problems that are the
responsibility of management. We note, for example, that when nurses administer medication,
there is often no support officer. Management has the responsibility to uncover the root cause
of the errors and to develop corrective actions to address the systemic issue. Blaming
individuals for systemic problems is misguided in our opinion.
We reviewed the last annual CQI meeting report of September 26, 2017. This report consists
largely of a report of activity statistics which do not provide useful quality metrics. Tables list
the number of provider and nursing encounters without any other variables that would
measure the effectiveness or quality of the program. These lists have some usefulness for
managers to project staffing needs, but their utility of CQI is limited. NRC does not have
performance measures that give an indication of the effectiveness of their programs. Examples
of such measures might be:
• Percent of hospital and specialty consultant reports or hospital discharge summaries
that are present in the medical record after a consultation or hospitalization.
• The numbers of patients who actually show up for their clinical appointments and the
reasons why they do not show up.
• Percent of records sent to destination IDOC facilities which are not properly complete
and organized.
• The percent of patients identified with a chronic illness at reception who are found on
the chronic care roster.
These types of statistical measures give the program a performance benchmark. We do not see
these types of useful measures embedded in the NRC CQI reports.
Another example is the medication report in the annual CQI report of September 19, 2017. This
provides a list of the numbers of medication prescriptions for certain types of medications. This
type of report is useful for financial management purposes, but it is not useful to assess
whether the processes of the pharmacy and medication programs are effective. For example,
studies that measure the effectiveness of the medication program might include:
• The number of persons receiving their first dose of medication within 24 hours of a
prescription.
• The percent of doses of ordered medication that a patient actually received.
• The number of patients who had disruption of long term medication.
The annual CQI report contains two useful pharmacy studies. One is a monthly audit of the
medication rooms. While we did not verify the accuracy or effectiveness of this study, we do

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agree with the concept of this study and believe that such audits do promote regular
monitoring of the program.
The pharmacy also performs a monthly audit of 20 medication administration records (MAR) in
order to assess four items:
1. Whether the start and stop dates are present on the MAR.
2. Whether the drugs in the cart match the MAR.
3. Whether allergies are listed on the MAR.
4. Whether there is documentation of all doses given.
This is a useful audit. We have several comments. Systems that have an electronic medical
record can audit 100% of item 4 and perform the audit electronically and more accurately than
can be done with paper records. We note that in the annual CQI report, over the course of the
year, there was a persistent problem with documentation on the MAR. This persistent problem
continued into 2018. Despite this continued identification of this problem, there was no effort
in the CQI program to discover why this persistent problem continued. This routine audit
continued to identify a problem yet there was no attempt to resolve it.
We also noted in the pharmacy section of this report that many patients do not have a MAR
initiated even when they have ordered medication. These significant patient safety problems
should be studied in CQI to determine the root cause in order to eliminate the patient safety
concern.
Mortality review is part of the CQI program. There were 11 deaths in 2015-16 and only one
death in 2016-17. The one death in 2017 included only a death summary and did not include an
analysis of the death. This, in our opinion, does not constitute mortality review.
The IDOC requires internal and external reviews of the medical program. We have asked for but
have not received the internal and external reviews for NRC.
With respect to the First Court Expert’s findings, there is now a CQI program at NRC that is
independent of SCC, which is an improvement from the First Expert’s report. However, the CQI
program is not yet effective and is not performing in a manner that can identify and correct
system problems. In part this is a result of not having a CQI leader who understands how to
start and maintain a CQI program. The lack of a CQI leader was also a finding of the First Court
Expert. Also, though the leadership staff, with the exception of the Medical Director, is eager to
learn, they do not have a strong foundation in quality improvement and it will take
considerable effort to overcome that deficiency. We believe that the First Court Expert’s
recommendation to have a full-time quality improvement coordinator is one option to address
this problem. Also, we agree with the First Court Expert’s finding that without accurate logs and
other “structural elements,” self-monitoring is impossible to perform. We expand on that
finding to state that there is an absence of data useful in self-monitoring. Data used to self-

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monitor must be accurate and intentionally maintained for purposes of self-monitoring. The
NRC leadership has not yet identified what data is needed and how to use that data to monitor.
In his report, the First Court Expert recommended a full-time quality improvement coordinator
at each site. The IDOC stated in its response to this recommendation that the IDOC was
committed to improving the CQI process but questioned the need for a full-time CQI
coordinator. Since so little has been done to improve CQI and since staffing levels are so low, it
is unlikely that staff with other responsibilities are likely to be able to effectively lead the CQI
program. Under the circumstances at this facility, we would agree with the recommendation of
having a qualified full-time CQI coordinator.

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Recommendations
Leadership, Staffing, and Custody Functions
First Court Expert Recommendations
1. We agree with the First Court Expert’s recommendation to have its own leadership team.
The IDOC has now included a HCUA, Medical Director, and DON in NRC’s budget
allocation.
2. We agree with the First Court Expert’s recommendation that NRC should have its own
staffing grid that precludes use of shared staff. NRC should have sufficient staff to meet
its staffing needs. We would add to that recommendation the following:
a. A staffing needs analysis be completed that would be based on current need and
to include a relief factor.
b. The analysis needs to be based on realistic workload evaluations that ensure
adequate quality of care, including for physician and physician assistants.
c. The staffing at NRC needs to include sufficient clerical staff, a qualified nurse to
manage infection control functions, and a qualified quality improvement leader.
Additional Recommendations
3. The Medical Director should be permanently filled with a board certified primary care
physician.
4. The use of “Traveling Medical Directors” should not be permitted to contractually fill a
Medical Director position. Failure to have a permanent Medical Director should incur
contractual penalties. Coverage physicians should be used as necessary but coverage
physicians should not constitute a filled Medical Director position.
5. Senior staff at the facility (HCUA, DON, and Medical Director), the IDOC Regional
Coordinator, and Agency Medical Director should participate in development of
reasonable schedule E and state medical employee staffing documents.
6. A correctional officer staffing analysis should be completed to determine if there are
sufficient custody staff to ensure that patients are timely brought for scheduled
appointments and that nurses are timely and safely escorted during medication
administration.
7. The Wexford Regional Manager should have training in a medical discipline or in medical
administration. This should be a contract requirement.
8. An orientation for new health care leadership should be provided so that they are
familiar with requirements and responsibilities of their assignments.
9. The facility must have a current staffing document listing all staff.
10. The span of control of the IDOC Regional Coordinator is too large to effectively manage.
The span of control should be reduced to increase the onsite time at each facility.
11. Sharing of staff between NRC and SCC should stop.
12. Staffing loads for providers must be reduced so that reasonable time is given to
complete a reasonable evaluation of all patients.

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13. The physician at this site should not be permitted to provide primary care medical care,
as he is a nuclear radiologist, appears unfamiliar with primary care clinical management,
and shows repeated clinical concerns. His privileges should be confined to areas for
which he has training.

Clinic Space, Sanitation, Laboratory, and Support Services
First Court Expert Recommendations
1. There should be a designated exam room in each housing unit appropriately equipped
for conducting sick call. We agree with this recommendation.
Additional Recommendations
2. All space used for clinical care must provide privacy, confidentiality, equipment (exam
table, oto-ophthalmoscope, handwashing, access to record, light, paper barrier, sanitary
equipment, tongue depressors, gloves, and minor equipment), adequate space, and
waiting space. This should include segregation areas.
3. There need to be sufficient clinical examination rooms for the number of simultaneous
staff (providers, nurses, psychologists, psychiatrists) who need them by shift. There
needs to be clinic space for nurses to perform sick call in segregation and in all other
areas of service.
4. Clinic examination areas including intake need to be cleaned and sanitized on a regular
basis. A sanitation schedule needs to be developed to ensure that this happens.
5. There needs to be an inventory of equipment and a replacement schedule for
equipment based on expected life of the equipment.
6. The scheduling system must support the needs of clinical care.
7. Adequate supplies must be available to support the functions of the clinical areas. A
standardized system of re-supply must be put into place.
8. There need to be routine environmental rounds.
9. Environmental rounds should include the date, names of participants, findings, and
actions taken. The findings should be tracked and monitored by the quality
improvement committee.
10. The nurse sick calls rooms on the housing units should be included on the sanitation
schedule and equipped with exam tables, desks, chairs, and hand washing and drying
supplies.
11. Exam tables in the clinic should have adjustable foot and head sections.
12. Paper memos and announcements currently taped on the walls in the clinical areas
should be enclosed in plastic sheaths or removed as a fire safety precaution.
13. Broken clinical and office equipment should be expeditiously repaired or replaced.

Medical Records
First Court Expert Recommendations
1. The medical records of patients at NRC who remain beyond two weeks or who are
housed at the minimum security unit must be managed in exactly the same manner as

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patients at any permanent institution. We disagree with the First Court Expert’s
recommendation that a medical record can be initiated after a two-week period. We
agree with the IDOC AD and contemporary medical record standards that a permanent
medical record be initiated upon arrival at NRC.
2. Medical records staffing must be adequate to insure that records of patients who stay
more than two weeks or who are housed in MSU are maintained in the same manner
per DOC policy as records at permanent institutions. We agree with the First Court
Expert’s recommendation that medical records staffing be adequate.
Additional Recommendations
3. Mental health and dental records need to be incorporated into the record when the
record is first initiated, which should be on the day of arrival. A medical record jacket
should be completed at the conclusion of intake screening.
4. Medical records should be maintained in accordance with the IDOC AD on medical
records 04.03.100 and in accordance with Illinois Department of Human Services
guidelines.
5. The medical record room must be enlarged to accommodate the number of staff and
records in use at this facility. The room must be made secure. Unauthorized persons
must not be allowed to enter, pull, or re-file medical records.
6. A system needs to be put into place of identifying that a medical record has been pulled
and who has the record.
7. Given the disorganization of the medical record and inability to provide access to
clinicians to a complete and organized medical record, we strongly recommend that an
electronic medical record be installed.
8. Consultation reports and offsite hospital reports must be obtained and filed in the
medical record within the time period specified in the IDOC AD on Medical Records.
Lacking a consultation report, the providers must promptly communicate with the
consultant to identify the result of the consultation, recommended therapeutic plans,
new diagnoses, and updated status of the patient.

Medical Reception
First Court Expert Recommendations
1. The policy approach to NRC is inconsistent with the reality of service demands. The
assumption that patients have their medical intake completed within a week and then
are transferred out is not applicable to a substantial number of patients. Therefore, this
philosophy must be changed. This is especially true for patients with chronic diseases or
who need scheduled offsite services.
2. The intake assessment by an advanced level clinician must include questions regarding
current symptoms and include the development of a problem list and relevant plan.
3. Sufficient resources should be available such that the physical exams can be completed
within one week of arrival.

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4. NRC must begin conscientiously using logbooks, either paper or electronic, for intake
processing.
We agree with the First Court Expert findings regarding the medical reception process. The
exception is that with respect to receiving electronic data from Cook County Jail, we find that
printed medical transfer summaries are adequate.
Additional Recommendations
5. Health care leadership should develop and implement a medical reception tracking log
that documents completion of all medical reception/intrasystem transfer activities.
6. IDOC should amend medical reception forms to include a comprehensive review of
systems (ROS) to identify serious medical conditions.
7. At medical reception, a station should be established so that at the completion of the
process, medical records staff initiates a green jacketed medical record for each patient,
with documents filed under the correct tab.
8. Examination rooms should be adequately equipped and supplied, including paper for
examination tables to provide infection control barriers between patients. Furniture
that is torn or in disrepair should be replaced.
9. Staff should change gloves and wash their hands between patients.
10. Perform HIV testing via opt-out methodology, not opt-in methodology, with written
consent.
11. Weight scales should be periodically calibrated (e.g., weekly).
12. Nurses should measure uncorrected and corrected visual acuity in each eye and
document results in the medical record. If large Snellen charts are used, the nurse
should ensure the patient stands the correct distance away from the chart. Consider
smaller hand-held Snellen charts.
13. Nurses should correctly read tuberculin skin tests via palpation and measurement of
induration. This should be done in a medical setting.153
14. Given problems with tuberculin skin testing and inability to track results, TB screening
should utilize interferon gamma blood testing as the primary screening test for
tuberculosis. The Mantoux skin test is logistically complicated, and its interpretation is
prone to human error. Conditions at this facility make it impossible to adequately read
the Mantoux skin test.
15. Nurses should timely document tuberculin skin test results in the medical record (e.g.,
within 24 hours).
16. Providers should document review of medical transfer information sent by county jails.
17. Providers should perform pertinent review of systems and medical history for each
chronic disease and/or significant illness.
18. Providers should order CIWA and/or COWS monitoring in accordance with current
guidelines for patients withdrawing from alcohol, opiates, or other drugs.
19. Providers should provide continuity of medications unless there is a clinical indication
for changing medication regimens (e.g., glargine to NPH insulin, etc.).
We give recommendations for the existing program of using Mantoux skin testing but make a strong recommendation to
move to interferon gamma blood testing which, in our opinion, would significantly improve the process of screening.
153

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20. Providers should document all significant medical conditions onto the patient’s problem
list.
21. Nurses should transcribe all medication orders (i.e., KOP and nurse administered) onto a
MAR at medical reception and document administration of KOP medications at the time
they are administered to the patient.
22. Health care leadership should develop systems to ensure that all physician orders are
timely implemented (e.g., EKG, blood pressure monitoring, etc.).
23. Providers should timely follow-up on all abnormal labs.
24. Providers should use a chronic disease form when seeing patients for the first chronic
disease appointment within 30 days.
25. Health care leadership should revise medical reception policies and procedures to
provide sufficient operational detail to staff to adequately complete each step of the
process.
26. Health care leadership should develop and monitor quality indicators related to each
step of the medical reception process.

Intrasystem Transfer
First Court Expert Recommendations
1. The intrasystem transfer process must be designed to insure continuity of care for
identified problems. We agree with this recommendation.
Additional Recommendations
2. IDOC should revise its Administrative Directives to create a statewide policy and
procedure regarding intrasystem transfers consistent with NCCHC standards.
3. IDOC should include requirements for an Intrasystem Transfer Tracking log to enable
staff to track the provision of required services, such as enrollment into the chronic
disease program, medication continuity, tuberculin skin testing, and periodic physical
examinations.

Nursing Sick Call
First Court Expert Recommendations
1. Officers must be eliminated from the procedures that enable inmates to request health
care services; thus, inmates must either place the requests in a lockbox or give them to
health care staff.
2. There must be ongoing professional performance review of both nurse sick call and
advanced level clinician sick call, which includes feedback on individual cases in order to
improve professional performance.
3. NRC must begin conscientiously using logbooks, either paper or electronic, for sick call.
We agree with these recommendations.
Additional Recommendations

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4. Health care staff should ensure that inmates have daily access to medical request forms
and writing implements to submit their health requests.
5. Lockable health request form boxes that are accessed only by health care staff should
be installed in each inmate housing unit.
6. Inmates must be permitted out of their cells on a daily basis to confidentially submit
their health requests into the health request boxes.
7. Health care staff should collect health care request forms seven days per week.
8. Health care staff should legibly date and time receipt of health requests.
9. A registered nurse should triage health requests and document a disposition on the
form (e.g., urgent, routine). Nurses should legibly date, time, and sign the form,
including credentials.
10. Each health request should be entered onto the sick call log, including the urgency of
the disposition.
11. Health requests should be filed chronologically in the medical record.
12. A nurse should schedule patients to be seen in accordance with the urgency of their
complaint.
13. Nursing sick call should be conducted in adequately lighted, equipped and supplied
rooms with access to a sink for handwashing. This includes a desk and chairs so the
nurse and patient can be seated and an examination table, otoscope, scale, etc.
Consider installing lockable cabinets to store supplies (e.g., nurse protocol forms, gauze,
tape, tongue blades, etc.).
14. Nurses should have the medical record available at the time of the sick call encounter.
15. A registered nurse should perform and document an assessment of each patient in
accordance with treatment protocol forms and/or sound nursing judgment.
16. Nurses should refer patients to providers in accordance with the treatment protocol and
in accordance with sound nursing judgment.
17. Health care leadership should develop and monitor quality indicators associated with
each step of the sick call process.
18. IDOC/Health care leadership should revise policies and procedures to provide sufficient
operational detail regarding the sick call process.

Chronic Care
First Court Expert Recommendations
1. The policy regarding chronic diseases must be that patients who remain beyond two
weeks must have their initial chronic care visit at NRC before a total of 30 days have
passed. This is clearly the case routinely for higher security inmates. We agree with the
First Court Expert’s recommendation with a comment. It is our opinion that the initial
intake evaluation should identify all chronic illnesses and establish an initial therapeutic
plan for each patient with chronic illness. Waiting 30 days for this to occur will result in
patients not receiving adequate continuity of care. It is our opinion that the initial intake
evaluation needs to adequately identify and initiate an adequate therapeutic plan for all
patients with chronic illness. We find this does not now occur. We agree that a follow up
chronic illness visit should occur within 30 days.
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2. NRC must begin conscientiously using logbooks, either paper or electronic, for the
chronic disease program. We agree with this recommendation. The chronic disease
program must have an accurate roster of persons with chronic illness. Our opinion is that
this can be most effectively accomplished with an electronic medical record.
Additional Recommendations
3. Patients should be seen in accordance with the degree of control of their diseases, with
more poorly controlled patients seen more frequently and well controlled patients seen
less frequently.
4. TB screening should utilize interferon gamma blood testing as the primary screening test
for tuberculosis. The Mantoux skin test is logistically complicated, and its interpretation
is prone to human error. Conditions at this facility make it impossible to adequately read
the Mantoux skin test.
5. All NRC admissions with chronic illness should have laboratory tests performed at intake
that are typically used to monitor the status of the patient’s illness. As an example,
persons with diabetes should have HbA1C drawn during the intake reception process.
6. Repeated failures to receive ordered medication due to refusal or other error need to
result in intervention, to include, as necessary, a person to person evaluation by a
provider. The timeline of referral to the provider must be dictated by the importance of
the medication. For example, failure to take anti-rejection medication should result in a
same day referral. Refusal to take insulin should result in a two or three day referral.
Timelines for referral should be clear to providers and nurses and delineated in policy.
7. Health care leadership and the quality improvement committee should develop,
monitor, and report quality indicators that measure and track the quality of care
provided to patients with chronic diseases.
8. The provider progress notes should indicate the clinical status of the patient’s condition
and the rationale for any modification of treatment.
9. The current use of good and fair ratings of status on the chronic care form should be
changed to well controlled, moderately controlled, poorly controlled, or undetermined.
10. The care of diabetes and adherence to existing guidelines should be a focus of the
Quality Improvement Committee.

Urgent/Emergent Care
First Court Expert Recommendations
1. NRC must begin conscientiously using logbooks, either paper or electronic, for
urgent/emergent care. We agree with this recommendation.
Additional Recommendations
2. Health care leadership should implement an urgent/emergent care tracking log and
monitor it to ensure that it is contemporaneously maintained.
3. The treatment room should be terminally cleaned and disinfected. Equipment in
disrepair (e.g., torn stretchers) should be replaced.

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4. Emergency equipment, including disaster and emergency response bags, AEDs, oxygen,
etc., should be stored together in the main medical clinic.
5. Emergency response bags should be standardized with respect to equipment, supplies
and medications. The bag should be secured with a plastic lock. When used, designated
staff should replace all used supplies and replace the lock.
6. If emergency response bags contain medications (e.g., glucagon), a sheet is attached to
the outside of the bag that notes medications and their expiration dates.
7. Emergency equipment should be checked each shift and noted on the SCC-NRC
Machine/Equipment Check Log Sheet.
a. When checking AEDs, ensure that electrode pads are not expired.
b. When checking oxygen tanks, record how much oxygen is left and when tanks
need to be replaced.
c. Ensure that oxygen tanks have oxygen tubing and masks readily available.
d. Ensure that EKG machines have paper.
8. Emergency response drills should be conducted and critiqued quarterly. Scenarios and
critiques should be meaningful and identify areas for improvement. Corrective action
plans should be implemented and monitored for effectiveness.

Specialty Consultations
First Court Expert Recommendations
1. Patients whose problems require scheduled offsite services who are a higher level of
security must have those scheduled while at NRC. We agree in part with the First Court
Expert’s recommendation. We believe this recommendation should apply to all patients
undergoing specialty care but only for higher level care that requires offsite referrals.
Patients with other less critical specialty care appointments (podiatry, optometry, etc.)
can have their appointment scheduled prior to transfer so that there is continuity of
care.
2. NRC must begin conscientiously using logbooks, either paper or electronic, for
scheduled offsite services. We agree with the First Court Expert’s recommendation but
have an addition to this recommendation. The IDOC, not Wexford, should develop a
standardized offsite tracking log on an Excel spreadsheet that should be used at all sites.
This tracking log should be used to report timeliness of referrals, collegial reviews,
approvals, and appointments to the QI committee.
Additional Recommendations
3. Wexford must begin placing specialty care documents, including referrals, verification of
collegial review, and approvals into the medical record. Referrals for offsite care should
be considered a physician order. The original referral form should be filed in the medical
record on the date it was initiated by the provider. This should be done prior to the
collegial review. Copies of this form can be used by the scheduler to manage scheduling.
4. The collegial review process should be abandoned. Medical providers should be
permitted to send patients to offsite consultants without going through the collegial

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5.
6.

7.
8.

9.

review process on the basis of patient safety and inability to timely and effectively
arrange ordered consultation care when using the collegial process.
Any denial of care needs to be documented in the medical record using documentation
of the person who denied care.
At follow up provider visits after consultations, the provider should be required to
document the results of the consultation, update the status of the patient, and update
the treatment plan based on the consultation. If consultant reports are unavailable, the
provider should use other communication efforts to discuss with the consultant what
occurred at the consultation and document this discussion in the medical record.
An IDOC physician should review all denials of care, not the IDOC HCUA, who is a nurse.
Medical rounds or a “huddle” on offsite visits should occur every day. This huddle
should consist of a meeting including the scheduling clerk with the providers as a group
to discuss every patient who went offsite, where the report is, when the report will be
obtained, what occurred, what follow up is indicated, and to schedule the patient to see
the provider timely. These huddles should include review of the referral form that
accompanies the patient which has consultant comments on the form. These huddles
can be expanded at a later date to include other aspects of managing critical patients.
It is critical that consultation reports are all obtained and placed in the medical record
within three days, consistent with the requirements of the IDOC AD on Offender
Medical Records 04.03.100.

Infirmary Care
First Court Expert Recommendations
The First Court Expert had no recommendations on infirmary care in the NRC report.
Current Recommendations
1. Health care leadership and the quality improvement committee should develop,
monitor, and report quality indicators that measure and track provider and nurse
adherence to the infirmary policy and the quality of the acute and chronic care provided
to infirmary patients.
2. The provider progress notes should indicate the clinical status of the patient’s condition
and the rationale for any modification of treatment.
3. The quality and quantity of the bedding and linens should be monitored during the
sanitation and environmental rounds.

Pharmacy and Medication Administration
First Court Expert Recommendations
1. Medication administration must include a designated officer to escort the nurse and
ensure that patients appropriately identify themselves with their ID card, that they bring
water in a container so as to ingest the medication, and so that the officer can do a
mouth check after ingestion. We agree with this recommendation.

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Additional Recommendations
2. At reception, physicians should document all medication orders onto a physician order
form.
3. Nurses noting physician orders should transcribe all medication orders onto a
medication administration record (MAR). Nurses should document on the MAR the
administration of stock medications to the patient.
4. A schedule of sanitation and disinfection activities should be developed and
implemented in all medication rooms.
5. The nurses’ medication room must be kept clean and well-organized. Rusting shelves
should be replaced.
6. Nurses should not transfer properly labeled and dispensed medications from the
pharmacy into improperly labeled medication envelopes.
7. Medication carts should be clean, well-organized, and have adequate supplies to
properly administer medications, including medication cups and hand sanitizer.
8. Custody leadership should ensure that sufficient officer escorts are available to escort
and assist the nurse with medication administration.
9. Nurses should maintain standards of nursing practice with respect to medication
administration, including:
a. Using two identifiers to identify patients (e.g., ID card and date of birth, etc.).
b. Washing hands prior to medication administration and using hand-sanitizer
between patients.
c. Comparing the medication blister pack against the medication administration
record at the time of medication administration.
d. Placing medications into disposable medication cups.
e. Ensuring inmates have access to a cup and water to take medications.
f. Observing inmates take medications, having the patient step aside and an officer
performing oral cavity checks using a small penlight.
g. Documenting administration of medications onto the MAR at the time of
administration.
h. If inmates are not in the housing unit at the time of medication administration,
nurses should arrange for administration of the medication later in the shift.
9. In order for nurses to perform medication administration in accordance with standards
of nursing practice as described above, conditions of confinement must permit inmates
to come out of their cells to receive administration of medications.
10. The cutoff date for BosWell to print MARs for the following month should be later in the
month (e.g., 27th or 28th) to reduce the number of MARs that nurses must transcribe at
the end of the month.
11. Health care leadership should develop a system for timely renewal of chronic disease
and other essential medications.
12. Health care leadership should revise the policy and procedure for medication
administration to provide sufficient operational guidance to administer medications in
accordance with accepted standards of nursing practice.
13. Health care leadership should develop, implement, and monitor quality indicators
related to pharmacy services and medication administration.
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14. Health care leadership should conduct a root cause analysis and develop a corrective
action plan with strategies targeting the causes of performance that fall below
expectations.

Infection Control
The First Court Expert Report contained no recommendations regarding infection control. We
include our recommendations below.
Current Recommendations
1. An infection control position should be established and budgeted.
2. Health care leadership should establish, implement, and monitor a schedule for
sanitation and disinfection activities in all areas of the institution.
3. An analysis should be performed of infectious/communicable disease statistics,
including prevalence of TB, HIV, and HCV infection among newly arriving inmates.
4. Track and report skin infections due to all pathogens, not just MRSA, including
infestations with scabies or body lice.
5. Medical providers should be educated on the evaluation, staging, and treatment of
syphilis infection.
6. Pending the hiring of an infection control nurse, document, monitor, and report to the
Quality Improvement Committee and facility leadership the training provided by
security to the inmate porters who clean and sanitize the clinical areas, including the
infirmary patient rooms.
7. Inmate porters are to change gloves and wash their hands after sanitizing infirmary
rooms and between sanitizing each patient’s bed. Porters are not to leave infirmary
rooms without removing gloves.
8. Protective clothing and gear are always to be worn by porters when cleaning body fluid
exposed surfaces and walls.
9. All torn and cracked outer protective coverings of infirmary beds, wheel chairs,
examination tables, and gurneys are to be repaired or disposed and replaced.

Dental Program
Dental: Staffing and Credentialing

The First Court Expert Report concluded that staffing was adequate and had no
recommendations with respect to personnel. We found staffing to be inadequate and will be
even more inadequate after necessary program changes have been made.
Current Recommendations
1. Perform a detailed analysis of the hours SCC dental personnel spend furthering NRC’s
mission and assign personnel to NRC accordingly.
2. Collect data on patient wait times and failed appointments to inform staffing schedule.

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3. While staffing appears to be adequate for current operations, staffing should be reevaluated if the intake screenings become more thorough and take more time (as we
believe they should).

Dental: Facility and Equipment

First Court Expert Recommendations
1. The chair and unit should be considered for replacement in the near future. Hand pieces
should be repaired. We add that there should be a replacement schedule for all dental
equipment to inform budget preparation.
2. The examination rooms for the screening exams should be better equipped. Patients
should be seated, and lighting should be adequate for the exam. We note that the lighting
has been improved since the First Court Expert Report.
We agree with these recommendations.
Additional Recommendations
3. Patients should routinely wear a lead apron with a thyroid collar when dental
radiographs are taken.
4. The approval process for repairing dental equipment should be streamlined.
5. All x-ray devices should be inspected periodically by a therapeutic radiological physicist
to ensure that patients are not subjected to unnecessary exposure to ionizing
radiation.154
6. The clinic equipment should include a sphygmomanometer and stethoscope.
7. The panoramic x-ray units should be replaced immediately.

Dental: Sanitation, Safety, and Sterilization

First Court Expert Recommendations
1. That the sterilization area be made neater and every attempt made to correct the
sterilization flow. It may mean reconfiguring the space and the storage utilization
therein.
2. That safety glasses be provided to patients while they are being treated.
3. That a biohazard warning sign be posted in the sterilization area.
4. A warning sign be posted in the x-ray area to warn of radiation hazards, especially
pregnant females.
We agree with these recommendations.
Additional Recommendations: None.

Dental: Review Autoclave Log

First Court Expert Recommendations: None.

32 Illinois Administrative Code 360 pdf, p. 47. Also, “[r]ecords of machine calibrations and quality assurance checks shall
include identification of the x-ray therapy system, radiation measurements, the date the measurements were performed and
the signature of the therapeutic radiological physicist who performed the measurements.” Id., p. 48.
154

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Additional Recommendations: None.

Dental: Comprehensive Care

First Court Expert Recommendations
1. Comprehensive “routine” care be provided only from a well-developed and documented
treatment plan.
2. The treatment plan be developed from a thorough, well-documented intra and extraoral examination, to include a periodontal assessment and detailed examination of all
soft tissues.
3. In all cases, appropriate bitewing or periapical x-rays be taken to diagnose caries.
4. Hygiene care be provided as part of the treatment process.
5. That care be provided sequentially, beginning with hygiene services and dental
prophylaxis.
6. That oral hygiene instructions be provided and documented.
7. Provide comprehensive, routine care only to the designated, long-term population.
We agree with these recommendations.
Additional Recommendations: None.

Dental: Intake (Initial) Examination

First Court Expert Recommendations
1. Provide a thorough soft tissue examination. This is the most important part of the
screening exam and should include intra-oral palpation and a well-lighted examination
of all soft tissue surfaces. We note that this will require that dentists allocate more time
to each screening.
2. Note pathology seen on the Panelipse radiograph. Do not diagnose small carious lesions
from this radiograph.
3. Do not provide comprehensive routine care from this examination. This is a screening
examination.
4. Do not take the Panelipse radiograph simultaneously with inmates standing next to each
other. This is a direct violation of radiation safety. Provide protective lead apron
coverage to the inmate receiving the x-ray. We add that the apron should have a thyroid
collar.
5. Place signage in the radiograph area warning of radiation hazard.
6. Individually bag and sterilize the mouth mirrors or use disposable mirrors.
7. Wash hands and change gloves between patients. We agree that gloves should be
changed between patients but offer the alternative of using an alcohol-based hand rub
before donning gloves.
8. Take a more thorough health history and “red flag” health issues that require medical
attention prior to dental treatment.
We agree with these recommendations.
Additional Recommendations

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9. The health history should be expanded and printed on a separate form.
10. The IDOC should ensure that dentists perform the charting required by Administrative
Directive 04.03.102.
11. The portion of the form for charting is too small and should be increased substantially.
12. The panoramic x-ray units should be replaced immediately.
13. Infection control barriers be used on the light and changed between patients.
14. If the dentist does not have an assistant to record, an infection control barrier (i.e., a
disposable pen sleeve) should be used on his/her pen.
15. Valid oral hygiene instructions should be provided and if they are not, the dental chart
should not record that they have been provided.

Dental: Extractions

First Court Expert Recommendations
1. A diagnosis or a reason for the extraction be included as part of the record entry. This is
best accomplished using the SOAP note form at, especially for sick call entries. It would
provide much detail that is lacking in most dental entries observed. Too often, the
dental record includes only the treatment provided with no evidence as to why that
treatment was provided.
2. Provide antibiotics appropriately from a diagnosis and only when indicated.
We agree with these recommendations.
Additional Recommendations
3. Clinically inadequate preoperative x-rays should not be used for tooth extractions.
4. Consent forms should document the tooth number to be extracted as well as the reason
for the extraction.
5. All treatment refusals should be documented to include the reason for the
recommended procedure and the consequences of declining the procedure.

Dental: Removable Prosthetics

First Court Expert Recommendations
A comprehensive examination and well developed and documented treatment plan, including
bitewing and/or periapical radiographs and periodontal assessment, precede all comprehensive
dental care, including removable prosthodontics.
1. That periodontal assessment and treatment be part of the treatment process and that
the periodontium be stable before proceeding with impressions.
2. That all operative dentistry and oral surgery as documented in the treatment plan be
completed before proceeding with impressions.
We agree with these recommendations which represent the accepted professional standard for
diagnosis and treatment planning.155
Additional Recommendations: None.

155

See, for example, Stefanac SJ. pp. 11-15, passim.

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Dental: Sick Call/Treatment Provision

First Court Expert Recommendations
1. Implement the use of the SOAP format for sick call entries.
2. Develop a request/sick call system that insures that inmates complaining of
pain/swelling/toothaches are seen by a provider and evaluated within 24-48 hours from
receipt of the request.
3. Develop a system such that urgent care complaints (pain, swelling, toothaches) are seen
in person for evaluation and triage by the next working day, and that care be provided
expeditiously. Otherwise, these inmates are transferred and gone if too much time
elapses. This should be a primary mission at NRC.
4. Provide routine comprehensive care to the designated MSU population only.
We agree with these recommendations.
Additional Recommendations
5. When the dental clinic is closed, or the dentist will not be available for 24 hours, a midlevel provider should perform a face-to-face examination for all inmates submitting a
request that states or implies the existence of dental pain within 24 hours.
6. NRC should develop a standard health care request form that is available to all inmates.
7. All health care requests should be time-stamped and logged, and a record of when the
inmate was seen by a provider and the disposition should be maintained.

Dental: Orientation Handbook

First Court Expert Recommendations
1. Ensure that the orientation manual describes fully and accurately how inmates can
access both urgent and routine care via the inmate request form system. We agree with
this recommendation.
Additional Recommendations
2. Modify Administrative Directive 04.03.102, ¶IV B to reflect the fact that every offender
at NRC receives a screening exam, and not a “complete dental exam.”156

Dental: Policies and Procedures

First Court Expert Recommendations: None.
Current Recommendations
1. The initial examination performed at intake should be in accordance with Administrative
Directive 04.03.102 (¶F2), or the Administrative Directive be rewritten to reflect what
IDOC decides should be done.
2. All Administrative Directives, policies, and protocols relevant to the dental program
should be maintained in the dental clinic and the HCUA should ensure that dental
personnel review them initially and after any changes.
In most prison systems with which we are familiar, dental screenings are performed at intake and comprehensive
examinations are performed typically within 30 days of arrival at the assigned prison.
156

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3. Dental findings classified as Class II at the intake screening exam should be addressed at
the NRC or immediately at the receiving institution.

Dental: Failed Appointments

First Court Expert Recommendations
1. Every effort should be made to see inmates complaining of pain or swelling in a timely
manner, within 24-48 hours. These inmates need not be scheduled for operative
[routine] dentistry. Only palliative care need be provided.
2. A sick call system should be established that can accomplish this goal. Administration
should be involved in this project and in assisting the dental program in getting inmates
to the clinic or their appointment. The inmate handbook should make it clear who is
eligible for routine care.
We agree with these recommendations.
Additional Recommendations
3. The failed appointment rate should be collected and reported as part of the CQI
program with other dental program data.
4. Failed appointments should be a priority emphasis of the CQI program.

Dental: Care of Medically Compromised Patients

First Court Expert Recommendations
1. The medical history section of the dental record be kept up to date and that medical
conditions that require special precautions be red flagged to catch the immediate
attention of the provider.
2. That blood pressure readings be routinely taken of patients with a history of
hypertension, especially prior to any surgical procedure.
3. The health history be addressed and updated on every patient and that consultation
with medical be provided and documented when indicated. This issue is serious and
needs to be corrected immediately.
We agree with these recommendations.
Additional Recommendations
4. The health history should be expanded and printed on a separate form.
5. There is not enough room on the chart to accommodate the tooth diagram used for
charting restorations and missing teeth. The diagram should be substantially larger.

Dental: Specialists

No recommendations.

Dental: CQI

First Court Expert Recommendations
1. The CQI process should be used extensively and continuously to assist in correcting the
deficiencies noted in the body of this report. A good starting point would be to focus on
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addressing urgent care needs in a timely and efficient manner. We agree with this
recommendation.
Additional Recommendations
2. The dental CQI program (as well as all other components of the dental program) lacks
guidance from a dentist with experience in corrections. This expertise should reside
centrally at IDOC and not depend on a Wexford employee or contractor.

Internal Monitoring and Quality Improvement
First Court Expert Recommendations
1. The quality improvement program must be reenergized with knowledgeable leadership
that has been provided specific training regarding quality improvement philosophy and
methodology.
2. The leadership of the CQI program must be retrained regarding quality improvement
philosophy and methodology, along with study design and data collection.
3. Training should include how to study outliers to develop targeted improvement
strategies.
We agree with these recommendations.
Additional Recommendations
4. The NRC quality improvement plan must be a practical year-ahead work plan for the
upcoming year to work on and improve identified problems on a priority basis.
5. NRC must develop an effective methodology to review for quality of clinical care at all
levels, including nursing and physicians.
6. NRC needs to re-evaluate its use of data. Data must be reliable and must measure
processes determined to be essential services.
7. The CQI program at SCC must be separate from the CQI program at NRC. Annual reports
must be uniquely developed. Reports used for NRC should not be used for SCC.
8. The Quality Improvement Committee should adhere to AD requirements including:
a. Review primary source verification of physicians.
b. Review 100% of offsite clinical events for quality and appropriateness. The
review of quality should include whether the quality of care prior to and after
the appointment was adequate and appropriate.
c. Review of 100% of critical incidents including mortality, new or delayed
diagnosis, use of isolation, IDPH reportable cases, and all staff evaluations for
occupational exposures. This review should not consist of merely listing the
number of these events but should be a critical review.
9. Sentinel event reviews and peer review on any non-primary care provider should be
conducted by a non-Wexford physician.
10. NRC needs to develop a method of identifying problems with their processes of care.

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Appendix A
Staff Type

NRC Staffing157
Positions

Vacant

Supervising
Authority

HCUA

1

0

NRC HCUA

DON

1

0

NRC HCUA

Nurse Supervisor

2

0

NRC HCUA

Med Room assistant

1

0

Wexford

Office Assistant

1

0

NRC HCUA

Medical Supply

1

0

NRC HCUA

Radiology Technician

1

0

NRC HCUA

CMT (shared SCC and NRC)*

17

11

SCC HCUA

RN

21

5

NRC HCUA

Certified Nurse Assistant

6

5

Wexford

Medical Records Director

1

0

Wexford

Dentist

1

0

Wexford

Dental Assistant

1

0

Wexford

Dental Technician

1

1

Wexford

Medical Director

1

1

Wexford

Staff physician

1

0

Wexford

Physician Assistant

2

0

Wexford

Medical Records staff**

9

6

Wexford

69

29

Total

*Five shared CMT staff out of 11 are on Leave of Absence and not working and are considered effectively vacant. These
positions are shared between NRC and SCC and have been listed on both NRC and SCC’s staffing tables.
**An adjusted service request (ASR) for five additional medical record clerks was just filed but these staff are not yet hired and
therefore not listed on the grid provided by the Regional Coordinator.

157

Based on a staffing grid provided by the IDOC Regional Coordinator via email to Expert on January 30, 2018.

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Appendix B
Review of Specialty Care158
Type of referral

Rheumatology
Patient 1 Specialty
Care (SC)
Rheumatology
Patient 1 SC
Hospitalization
Patient 1 SC

ERCP procedure
Patient 2 SC
Urology Patient 3
SC
Ultrasound Patient
3 SC
Oncology Patient 3
SC
CT scan Patient 4
SC

158

Referral Collegial Approval Formal
present present present
report
in
record
0

0

0

1

1

0

0

1

Days to
see Pt
after
consult

# of consultant
Recommendations of Consultant not
recommendations carried out
not carried out

12

2

Check labs and refer to nephrology

1

3

Refer to nephrology, GI, and monitor labs

6

Recommended Renal biopsy, transrectal
ultrasound, repeat CT scan of abdomen,
cystoscopy with bilateral pyelograms, nephrology
consult, urology follow up. There no meaningful
review of these recommendations and referrals
made for nephrology and urology but no collegial
review or approval was present. There were no
referrals to any of the other investigations.
Follow up cytology results, FU in GI clinic the
following week

1

0

1

1

3

2

0

0

0

1

19

0

1

0

0

0

9

0

0

0

1

0

5

2

Vascular surgery, urology

1

1

0

0

10

0

CT scan not reviewed

This data comes from review of patients 1 through 7.

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Oncology Patient 4
SC

0

0

0

0

3

Oncology Appt.
with immediate
hospitalization
Patient 4 SC
Corneal clinic
Patient 5 SC

1

0

0

0

15

1

0

1

0

1

Contact lens clinic
Patient 5 SC

1

0

1

0

6

Corneal surgery
Patient 5 SC
Corneal clinic
Patient 5 SC
Corneal clinic
Patient 5 SC
Corneal clinic
Patient 5 SC
Corneal clinic
Patient 5 SC

1

0

1

0

4

0

0

0

0

3

1

0

0

1

2

1

0

1

1

1

1

0

1

0

1

Orthopedic Patient
6 SC
Outpatient surgery
Patient 6 SC
Transplant Center
Patient 7 SC

1

1

1

1

1

1

1

1

1

1

0

0

0

0

4

Burn Patient 7 SC

0

0

0

0

4

Transplant Center
Patient 7 Sc

1

0

0

0

12

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1

No evidence of an ultrasound done as
recommended.
Because there were no reports it was unclear if
recommendations were made.

1

Comments by the consultant on the referral form
recommend contact lens clinic ASAP and surgery
on the cornea.
Return to contact lens clinic was recommended
on the referral form

1

This patient's three month follow up was delayed
and occurred only after the patient developed a
complication. There was no evidence of a one
week follow up at that clinic.

1

This consultation documented as having occurred
in the medical record. Consultants recommended
a hepatology consultation. There was a referral
and approval for this but this consultation did not
occur.
This consultation documented as having occurred
in the medical record.
There was documentation in the record that the
patient had a transplant clinic visit on 11/6/17

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Transplant Center
Patient 7 SC

Totals

0

0

0

0

14

3

9

8

January 29 - February 1, 2018

and there was a referral for a transplant follow up
but there was no other information as to what
occurred in the record. If there were
recommendations, these were not present.
There was patient after-care paperwork for a
12/18/17 visit to Rush Presbyterian but there was
no other information. If there were
recommendations, these were not present. There
was no provider follow up of this presumed visit.

Not seen

Northern Reception and Classification Center

19

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Appendix C

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Stateville Correctional Center
2nd Court Appointed Expert Report
Lippert v. Godinez

Visit Date: February 26, 2018 – March 1, 2018

Prepared by the Medical Investigation Team
Mike Puisis, DO
Jack Raba, MD
Catherine M. Knox RN, MN, CCHP-RN
Jay Shulman, DMD, MSPH

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Table of Contents
Overview ............................................................................................................2
Executive Summary ............................................................................................2
Findings ..............................................................................................................6
Leadership, Staffing, and Custody Functions.............................................................................. 6
Clinic Space, Sanitation, Laboratory, and Support Services ....................................................... 9
Medical Records........................................................................................................................ 16
Intrasystem Transfer ................................................................................................................. 17
Nursing Sick Call ........................................................................................................................ 19
Chronic Care .............................................................................................................................. 24
Urgent/Emergent Care.............................................................................................................. 38
Specialty Consultations ............................................................................................................. 48
Infirmary Care ........................................................................................................................... 50
Pharmacy and Medication Administration ............................................................................... 55
Infection Control ....................................................................................................................... 59
Dental Program ......................................................................................................................... 62
Internal Monitoring and Quality Improvement ........................................................................ 75

Recommendations ............................................................................................ 82
Leadership, Staffing, and Custody Functions............................................................................ 82
Clinic Space, Sanitation, Laboratory, and Support Services ..................................................... 83
Medical Records........................................................................................................................ 83
Intrasystem Transfer ................................................................................................................. 84
Nursing Sick Call ........................................................................................................................ 84
Chronic Care .............................................................................................................................. 85
Urgent/Emergent Care.............................................................................................................. 87
Specialty Consultations ............................................................................................................. 87
Infirmary Care ........................................................................................................................... 88
Pharmacy and Medication Administration ............................................................................... 88
Infection Control ....................................................................................................................... 89
Dental Program ......................................................................................................................... 90
Internal Monitoring and Quality Improvement ........................................................................ 95

Appendix A ....................................................................................................... 97
Appendix B ....................................................................................................... 99

February 26 - March 1, 2018

Stateville Correctional Center

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Overview
From February 26 to March 1, 2018, the Medical Investigation Team visited the Stateville
Correctional Center (SCC) in Joliet, Illinois. This report describes our findings and
recommendations. During this visit, we:
•
•
•
•
•

Met with leadership of custody and medical
Toured the medical services area
Talked with health care staff
Reviewed health records and other documents
Interviewed inmates

We thank the Warden and staff for their assistance and cooperation in conducting the review.
The SCC facility is one of three maximum security prisons in the IDOC. The Warden of SCC is
also the Warden at the Northern Reception Center (NRC), a separate facility with a very
different mission and needs. SCC opened in 1925 and is plagued by aging infrastructure. There
have been attempts to close this aging facility, but political pressure kept the facility open.1 In
2016, the “Roundhouse,” a maximum security complex within SCC, was closed. In our
introductory meeting, the Warden told us that several additional units have been closed.
SCC is located on a 2200-acre campus with 33-foot walls surrounding the perimeter. It has a
population of 1183. SCC has three galleries on unit X for segregation housing with a capacity of
48. SCC has an infirmary unit of 32 beds. Units B, C, D, and E occupy a structure that is 420 feet
long and 52 feet high. Each of these units has five floors, each with a housing “gallery.” Inmates
on these units are separated by levels of aggression. Dialysis patients are housed in Unit C. Unit
E houses inmates with moderate to high aggression. This type of structure, in combination with
maximum security classification, makes administration of medication and attendance for
medical appointments exceedingly difficult.
The IDOC Agency Medical Director and IDOC Regional Coordinator were present for this tour.
The Wexford Regional Manager and Regional Medical Director were not present for our tour.

Executive Summary
Based on a comparison of conditions as identified in the First Court Expert’s report, we find that
some conditions appear to have improved by virtue of hiring a permanent Health Care Unit
Administrator (HCUA) and improving access to sick call. Most other areas have either not
improved or have deteriorated. We find that SCC is not providing adequate medical care to
Stateville to Stay Open; Pontiac Prison to Close; Paul Meincke ABC Eyewitness News 5/5/08 as found at
http://abc7chicago.com/archive/6123448/.

1

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patients, and that there are systemic issues that present ongoing serious risk of harm to
patients that result in preventable morbidity and mortality. The deficiencies that form the basis
of this opinion are provided below.
The HCUA position is now filled with a capable full-time administrator. But the Medical Director
position is now vacant and the Director of Nurses (DON) is new to the position. All supervisory
nurse positions are vacant, resulting in the DON and HCUA having to perform direct line nursing
supervision, which detracts from their ability to manage. Staff are still shared with Northern
Reception Center (NRC) and the vacancy rate is high (32% including those on leave of absence),
resulting in an apparent lack of staffing. A staffing analysis needs to be done and SCC needs its
own staff that is not shared with NRC. The prior Medical Director was a surgeon and not
appropriately trained in primary care medicine, likely accounting for the preventable morbidity
and mortality we identified in record reviews. The lack of appropriately trained physicians was
the single most important contributor to preventable morbidity and mortality in our opinion
and must be corrected.
Clinic examination rooms were generally clean and appropriately equipped. There were some
items in these areas that need to be addressed. Infirmary beds need repair or replacement. All
rooms on the infirmary need to be sanitized uniformly and this unit needs pest control to
remove cockroaches, flies, and gnats. Negative pressure rooms need to be repaired so they are
fully functional and need to be regularly cleaned and inspected. The hemodialysis unit was in
deplorable condition from a sanitation and physical plant perspective. This unit should be
refurbished and properly sanitized. The inmate kitchen and dining area had birds living in the
unit who deposited droppings in the area where inmates eat. This poses a health risk and these
birds should be removed from inside the kitchen. The monthly environmental rounds now
being performed are an improvement, but these should include the infirmary and hemodialysis
unit.
Except for hospital and consultant reports, most documents are filed timely into the medical
record. Offsite consultations and hospital records are often unavailable, which adversely affects
clinical care. Confidentiality is a problem to a lesser degree than at NRC, but the medical
records area needs to be continuously secured. We continue to find problems with use of the
excessively large medical records. The problems with the use of the paper record and the
clinical problems it causes prompt us to strongly recommend implementation of an electronic
medical record.
We found that the intrasystem transfer process has improved since the First Court Expert’s
report. However, we did find that for approximately 30% of inmates transferring into SCC, their
transfer information was incomplete or prescribed care was not continued. We do, however,
agree with the First Court Expert’s recommendation to initiate quality improvement monitoring
of this area of service.
Access to care has significantly improved since the First Court Expert’s report and problems
identified in that report related to access to care have been resolved. We note, however, that
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quality of care of nurses performing nursing sick call exhibit deficiencies that are not currently
being monitored by the Continuous Quality Improvement (CQI) program or by nurse
supervisory staff. In addition, Licensed Practical Nurses (LPN) continue to perform sick call when
this task exceeds the scope of their license.
The chronic care program appears to have deteriorated since the First Court Expert’s report
based on chart reviews. Physicians appear to be ignorant of currently accepted care guidelines
for a number of common medical conditions that adversely affected patients. It is our opinion
that this ignorance is related to the defective hiring, credentialing, and privileging process of
Wexford. Physicians do not consistently take adequate histories, perform adequate physical
examinations, derive adequate assessments, or form appropriate therapeutic treatment plans.
The structure of the chronic care management program as described by the First Court Expert
contributes to fragmentation of care and this has not been corrected. Evidence of poor chronic
illness management is present in record reviews for chronic illness, hospitalization, and
mortality reviews. Evidence showed preventable morbidity and mortality that is significant.
With respect to urgent, emergent, and hospital care, first responder bags are not standardized
and are inconsistently inspected and maintained. Many ER visits and hospitalizations were
preventable and due to inadequate primary care management. With respect to
hospitalizations, we identified a preventable stroke and heart attack. We also noted that a
metastatic colon cancer may have been prevented or have been identified much earlier with a
better result than the metastatic cancer that was identified because of a year delay in
performing diagnostic studies. We found these significant problems having reviewed only six
records.
Specialty care has not improved compared to the First Court Expert’s report. Care at University
of Illinois Chicago (UIC) is not timely, yet for patients whose consultative care is delayed,
consultation with an alternate service provider is not obtained. We find that this has caused
morbidity. Tracking of consultation services is extremely poor and appears inaccurate. We
found, for example, that 70% of completed consultations in January of 2017 were dated as
completed before the referral for the consultation was documented as submitted. It is our
opinion that the Wexford collegial review utilization process is a barrier to timely care and
should be abandoned. This program has become a patient safety issue.
Medication administration services appear to have deteriorated as compared with the First
Expert’s report. The current system of medication administration is unsafe and does not ensure
that patients receive medication as ordered. Nurses administer medications in an unhygienic
manner and fail to document administration at the time medication is administered. There are
many errors related to medication administration that the SCC program is aware of. Yet there
has been no effort through its CQI program to correct these systemic problems. Also, contract
monitoring documents have documented continual violations concerning controlled substance
medications, yet no penalties or corrective actions have been taken.

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The First Court Expert had no concerns or findings with respect to infection control. We
identified multiple findings. These include vermin in patient rooms on the infirmary unit,
serious infection control and sanitation issues in the dialysis unit, and birds in the inmate dining
room, all of which can promote disease transmission. Negative pressure units on the infirmary
used for respiratory isolation in cases of active tuberculosis or other illnesses were not fully
functional, cleaned, or regularly serviced. Tuberculosis monitoring was poor. Nurses were not
accurately reading Mantoux skin tests. Because the infection control responsibilities were
dispersed among several nurses, it is our opinion that a dedicated infection control nurse would
be beneficial. This was also a recommendation of the First Court Expert.
The dental program has not changed materially since the First Court Expert Report. Routine
treatment is timely; however, it often occurs without a comprehensive oral examination (i.e.,
intraoral x-rays, a periodontal assessment, and a treatment plan); placing patients at risk of
preventable pain and tooth loss. Clinical notes are inadequate and often illegible. Antibiotics
and analgesics were often dispensed without a diagnosis having been recorded and postextraction antibiotics were prescribed without documented evidence of infection. The dental
sick call process is disorganized, and it is not possible to determine how long patients wait to be
treated, or the failed appointment rate. There is no process for mid-level providers to triage
and palliate patients whose sick call request suggests pain or infection. The treatment provided
to IDOC inmates remains substantially below accepted professional standards and is not
minimally adequate.
While the First Court Expert found the quality improvement program “non-functioning,” we
found that the HCUA and his staff have initiated CQI activity, although it is nascent and not yet
effectively functioning. The annual CQI plan and annual Medical Director Report at SCC are
identical to the NRC CQI plan and Medical Director Report. Several requirements of the IDOC
administrative directives (AD) are not performed by the CQI committee, including primary
source verification of physician credentials and evaluation of 100% of offsite consultations and
hospitalizations for quality and appropriateness. The CQI program does no evaluation of the
quality of physician or nursing clinical care. Wexford peer reviews do not appear to identify or
correct provider’s unacceptable care. The CQI committee does not perform sentinel event or
mortality reviews even though there was preventable morbidity and mortality that we
uncovered in record reviews.
We have several recommendations at the end of this report and address the recommendations
of the First Court Expert, most of which we are in agreement with.

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Findings
Leadership, Staffing, and Custody Functions
Methodology: We interviewed leadership of the health program and the Assistant Warden of
Programs. We evaluated staffing documents and discussed these with the leadership. We
reviewed other selected documents.
First Court Expert Findings
The First Court Expert found that staffing between NRC and SCC was combined and shared,
making adequacy of staffing difficult to assess. Because all staff at SCC are assigned to NRC for
part of their work hours, staffing at SCC is unreliable, making SCC out of compliance with policy
requirements. Staffing schedules do not account for sickness and vacancies. Management must
prioritize staff based on critical needs. Leave of absences and vacancies of state employees
were significant. These vacancies are filled by Adjusted Staffing Requests (ASRs), accounting for
40 RN and LPN positions. A single HCUA manages both SCC and NRC and that position was
functionally vacant due to prolonged medical leave. The SCC Medical Director was a surgeon
who did not provide clinical management of the program.
The First Court Expert recommended that SCC have its own HCUA and staffing allocation, that
only primary care trained physicians provide care, and that these physicians be board certified,
and that all providers have access to electronic medical references.
Current Findings
We agree with the First Court Expert’s findings, although there have been several changes at
SCC. We found additional problems.
• Newly appointed SCC leadership has not had an orientation to their positions and are
learning on the job.
• There are no nursing supervisors, so the HCUA and DON act as supervisory nurses,
making them less effective in their assigned positions.
• Staffing vacancies and sharing staff with NRC contribute to a perceived lack of staffing.
Actual staffing needs have not been determined by way of a staffing plan. A staffing
plan, including for providers, should be developed.
• Lack of physician credentialing and granting privileges to physicians to perform care in
areas in which they have no training has resulted in preventable morbidity and
mortality.
• Contract monitoring fails to adequately monitor for vendor quality of care and overall
performance.
There have been some changes since the First Court Expert’s report, but we agree with the
main conclusions of his findings. SCC now has a dedicated HCUA, which was a recommendation
of the First Court Expert. This is an improvement. However, this improvement is negated by the
lack of a Medical Director. The Medical Director recently died and was replaced about two
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months ago by the recently appointed NRC Medical Director. Two weeks after our visit,
however, this physician resigned, leaving SCC without a Medical Director. Staffing is still shared
between the two facilities and all staff from SCC goes to NRC on occasion to assist in the
reception area on busy days. There has been a very recent increase in staffing at NRC which will
reduce the need to send staff from SCC to NRC. However, the degree of staff sharing is not
known but is still substantial. We did not find that staff vacancies are filled by ASR positions.
The leadership staff at SCC are all recently appointed. The HCUA has been in his position for
about a year. The Director of Nursing (DON) has been in her position for about five months and
was a staff nurse at SCC for about five years before taking the DON position. The HCUA and
DON were both staff nurses prior to their current positions. The Medical Director was in his
position for about two months before he resigned shortly after our visit. He had been with
Wexford for two years and over those two years had been a Traveling Medical Director or
Medical Director at five different facilities. According to a Wexford document, he was listed as
Medical Director simultaneously at both NRC and Sheridan between 2/19/17 to 8/12/17.2
Overall, this leadership group lacks management experience and is now lacking a Medical
Director. However, the HCUA and DON are energetic and willing to learn their assignments.
The IDOC Regional Coordinator for this facility covers 10 facilities, which is a span of control too
large to effectively supervise. He and the IDOC Agency Medical Director were present for part
of our tour. Neither the Wexford Regional Medical Director nor the Wexford Regional Manager
was present for our tour. The Wexford Regional Manager is an ex-warden and we have
concerns that a person with criminal justice training will have the skills necessary to manage a
clinical medical program.
None of the key leaders indicated receiving specific training for their new roles. All three
inherited positions that were vacated and they have been learning on the job. In the case of the
HCUA, his predecessor, as described in the First Expert report, was chronically absent and was
not performing. He inherited a poorly functioning program. The Director of Nursing inherited
the program from a nurse who had performed well. However, the prior DON did not have time
before her departure for an orientation for the new DON. The Medical Director had just started
in the position as Medical Director when he resigned.
Nursing supervision is significantly deficient. There are two nurse supervisor positions. One
supervisor is on leave of absence and the other recently left service, making both positions
effectively vacant. The DON and HCUA provide supervision during daytime hours, in addition to
their management responsibilities, but there is no evening or night supervision. Having staff
work without supervision is not an acceptable situation. The staff is a mixed IDOC/Wexford
staff. Dialysis staff is supervised by Naphcare, the dialysis vendor. As with NRC, there are some
supervision issues with respect to assignment and discipline when an IDOC employee assigns or
supervises a Wexford nurse, or when the Wexford DON assigns or supervises an IDOC
employee.
2

Document 42P5643 – IDOC Position History 7-1-2015 to 11-22-2017 Bates #520-548 (Requests 1 & 2).

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All three key leaders believe that staffing shortages are their number one problem. All staff at
SCC can be shared with NRC. The amount of time SCC staff work at NRC is determined on an ad
hoc basis by negotiation and discussion between the NRC and SCC HCUAs. Based on a
discussion with the HCUA, the staffing at SCC includes 98 positions with 24 (24%) vacant
positions and nine on leave of absence or injured. 3 The effective vacancies total 33 (34%). This
extraordinarily high vacancy rate is made worse by having to share staff with NRC, which results
in prioritizing assignments to avoid crises as opposed to ensuring that all needed work is done.
Despite these staffing deficiencies, there is no staffing plan that addresses actual needs at SCC.
The current official Schedule E is not up to date. None of the existing leadership staff has
participated in developing the Schedule E or existing staffing pattern at this facility.
Almost all provider notes lack adequate history, physical examination, assessments, and
therapeutic plans. We could not determine whether this deficiency was due to practice issues
or lack of staffing. The Medical Director’s opinion was that an additional physician is needed.
The Medical Director has clinical responsibilities in addition to management responsibilities.
The annual CQI report for 2016-17 states that providers see approximately 20-30 patients
daily. 4 The Medical Director’s report in the 2016-17 annual CQI report notes that “Depositions
and court appearances for pending litigation are continuing to increase. Due to this, provider’s
time is divided between depositions and patient care.” We add that when NRC intake physicals
are backlogged, providers from SCC are sent to NRC to assist. The statistics in the most recent
annual CQI 2016-17 report list 14,321 provider contacts, which yields about 18 patients a day
per provider without infirmary visits, assistance to NRC, or time needed for litigation concerns,
which the prior Medical Director deemed significant. The Medical Director also told us that he
has asked for extra time to see patients because the medical record documentation is so poor
that it is difficult to determine what the patient’s problems are. In a well-functioning prison
program with 1200 inmates, three providers are typically adequate. Under current
circumstances, particularly with the sharing of staff with NRC, it is not certain whether
budgeted staffing is adequate. A staffing analysis is necessary.
Based on record reviews, the quality of physician care, particularly care provided by the
recently deceased Medical Director, was substandard. This was a serious problem at this
facility. We noted multiple cases of morbidity and harm that occurred as a result of poor care.
Two death charts reviewed showed preventable mortality. This, in our opinion, is related to use
of physicians without primary care training. The recently departed Medical Director was a
surgeon who did not appear to know how to manage many primary care problems, resulting in
harm to patients. The credentialing and privileging of physicians is inadequate and places
inmates at risk of harm. The prior Medical Director had the worst performance on peer review
of all providers at this facility (two of whom were nurse practitioners), yet he was assigned the
most complex patients and oversaw clinical care. We were told that assignments of Medical
Directors are made by the Wexford Director of Operations, Regional Manager, with input from
the Regional Medical Director. The recently resigned SCC Medical Director stated that he
3
4

Appendix A at the end of this report has the staffing grid for this facility.
Medical Director Annual Summary, Medical Director section of annual 2016-17 CQI presentation.

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received his assignment by the Director of Operations. Lay persons do not have the ability to
review the qualifications of physicians. Assignment of physicians not trained in primary care to
be in charge of primary care at a facility places inmates at risk of harm.
The Assistant Warden of Programs covers both NRC and SCC. According to the HCUA, there are
monthly meetings conducted by the Assistant Warden of Programs at which custody
impediments can be discussed.
The HCUA monitors the contract by use of a standardized contract monitoring spreadsheet.
NRC and SCC are reported as a single facility with respect to contract monitoring. There are
three main functions with respect to contract monitoring: bills being paid on time, staffing
hours filled, and performance monitoring. With respect to the total number of hours filled, the
HCUA lists any hours in excess of the Schedule E that the vendor provides. This is subtracted
from the total hours not filled based on the Schedule E. This yields the hours not provided or
the total excess hours provided by the vendor in excess of the Schedule E. For the seven
months from June 2017 to December 2017, there were 17,681.15 unfilled hours or about 2526
unfilled hours a month or about 14 positions. This accelerated beginning in October 2017,
presumably due to the addition of new staff positions which have yet to be filled. Nevertheless,
this is a significant amount of unfilled positions.
Performance contract monitoring consists of adherence with both contract requirements and
compliance with administrative directives. With respect to administrative directives, the HCUA
lists each item of the administrative directives which are not being followed by the vendor.
However, this is subjective and does not appear thorough. For the June of 2017 contract
monitoring report, as an example, the only medical performance deficiencies reported for SCC
were two items related to distribution and documentation of controlled substances. Many ADs
do not appear to be followed. As examples, we noted several administrative directives that
were not being followed including:
• Failure to file hospital reports in the medical records in three days
• Failure to assess appropriateness and quality of 100% of offsite medical care services
• Failure to perform a one-time primary source verification of physician credentials.
The contract monitoring, in our opinion, fails to identify key failures of the vendor, especially
regarding quality of provider care, for which there appears to be virtually no effective
monitoring.

Clinic Space, Sanitation, Laboratory, and Support Services
Methodology: Accompanied by a correctional officer and the IDOC Medical Director, the IDOC
Regional Coordinator, and the Health Care Unit Supervisor, we inspected the nurse sick call
rooms on the housing units, the infirmary, and the main outpatient clinical area which housed
medical exams rooms, nurse work areas, an urgent care center, physical therapy, hemodialysis
unit, dental clinic, telehealth room, mental health interview rooms, nurse medication

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preparation room, medical records department, health care administrative offices, conference
room, the inmate cafeteria and dining areas, and the kitchen.
First Court Expert Findings
The First Court Expert found the clinical areas at SCC clean, well maintained, and
environmentally comfortable. He recommended that designated exam rooms should be made
available with appropriate equipment in cell houses B, E, and F to allow sick call to occur with
reduced movement demands.
Current Findings
We had some different findings with respect to sanitation and equipment maintenance. Our
findings included:
• The nurse sick call rooms in the housing units (B, C, D, E, X) are adequately sized and
properly equipped. Their location in the housing units maximizes the patient-inmates’
access to sick call.
• Five of the nurse sick call rooms in the housing unit have sinks with hot and cold water
with hand washing supplies. Housing unit B’s nurse room does not have a sink but has
sanitizing gel.
• The first aid kits in the correctional officer rooms on the housing units are not regularly
inspected and re-supplied. Two kits were inspected; the seal was broken on both and
there were no gauze or bandages in the kit.
• The infirmary beds were in unacceptable condition. All of them need to be properly
repaired or replaced. The low level of the beds makes it difficult and unsafe for the
clinical team to properly examine and transfer patients.
• The cleaning and sanitation of the infirmary rooms must be uniformly done and should
not vary based on the ability of the patient to assist the cleaning. Pest control must
continue to be addressed in the infirmary.
• The negative pressure units in the infirmary are not regularly inspected or cleaned. The
units were not fully functional. These units should have documented inspections on a
weekly basis (daily if the room is occupied by a patient in respiratory isolation) and the
filters changed on a monthly basis or as needed. The unit should be regularly checked
during the environmental rounds and the condition noted in the monthly Medical Safety
and Sanitation Report.
• The infirmary porters were verified to have received blood borne disease training and
hepatitis A and B vaccinations.
• The physical plant, cleanliness, safety, and sanitation of the hemodialysis unit were
unacceptable. The deficiencies and concerns noted in this section and the Infection
Control sections must be immediately addressed.
• All medical equipment must be inspected and calibrated no less than annually by a
bioengineering team. Only the AED and the UIC lab centrifuges had labels documenting
inspections within the previous 12 months.

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The main housing unit is a long rectangular building that has been subdivided into four quads,
B, C, D, and E. Each of the quads houses approximately 260 inmates (capacity was reported to
be 277). Each cell on these quads has two single beds with a toilet and a sink. The doors are
barred. Large open showers are located on the second floor. The shower in Quad E was in good
repair with no obvious mold. There was a plastic shower chair for use by patient-inmates with
ambulation issues. There are no elevators in the housing units. All inmates with ambulation
issues are housed on the entry level.
The nurse sick call rooms in Quads B, C, D, E, and in the X (disciplinary segregation and
protective custody) building were inspected. The location of the nurse sick call rooms in the
housing areas enhances the inmates’ access to health care services. The sick call rooms have
adequate space. Each has an exam table with disposable paper coverage, a blood pressure and
vital sign unit, a temperature taking device, a medication cart, a wall mounted otoophthalmoscope, a privacy barrier, and a scale. Four of the five nurse sick call rooms had a sink
for hand washing and paper towels. Quad B did not have a sink, but there were sanitizing wipes
and gel for hand washing. The ophthalmoscopes in two of the sick call rooms (D, E) were not
functional. The medication cart in one room was inspected; it was locked and sealed. The
medication cart check list/log with a pill count was properly maintained. Although the floor in B
was dirty and the sink in D was crusted with mineral deposits, the nurse sick call rooms were
generally clean and organized. In a few rooms there were unprotected paper memos taped on
the wall; this is considered a potential fire safety hazard.
The first aid kits in the correctional officers’ rooms on Quad D and B were not sealed and did
not have any gauze or bandages for emergency use. This was reported to the correctional
supervisor.
Although there are locked boxes for sick call requests on the housing areas, inmates reported
that they use a signup list on the first floor to request a nurse sick call visit. They are asked not
to write their medical concerns on the list. All inmates interviewed stated that they are, almost
always, seen by the sick call nurse within 24 hours. In the X facility, inmates have to tell the
correctional officer or med nurse to sign them up; they also stated that they were seen on the
next day. If the nurse referred them to a physician/physician assistant, there was a two to three
day wait unless the problem was deemed urgent.
The infirmary has 32 beds; 26 were occupied during this visit. One of the wings has two beds
per room and the other is predominantly single beds. Mentally ill individuals in crisis are housed
in a single bed room. Nearly 70% of the current infirmary patients were chronically ill (postCVA, dementia, encephalopathy, ataxia, paraplegia, difficulty with ambulation etc.), with most
needing some level of assistance with activities of daily living.
Almost all of the beds in the infirmary need to be replaced. The infirmary beds are low to the
floor and cannot be raised. The head of the beds cannot be elevated. Most of the beds had
broken or non-functional railings. There were no electrical beds in the infirmary. One patient
with dementia was noted in his bed with nearly half of his body hanging over the edge of the
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bed. This is a significant safety risk. The condition of the infirmary beds creates a notable safety
risk for staff and patient-inmates. There is no replacement plan for the infirmary beds. The
mattresses were generally in good condition; the impervious covers were also either intact or
taped. Only one mattress had a tear (across the entire end of the covering). The rooms on the
two-bed wing had nurse call devices; a review of four rooms verified that the devices were
functional. There are no call devices on the single bed wing.
The infirmary had two negative pressure rooms (124 and 126). Room 124 has two HEPA units;
the filters in both units were caked with dust. One unit had 1/12/2016 written in magic marker
on its surface; presumably this was the last date of inspection. The second unit was undated,
had dusty and dirty intake and outflow vents, and when turned on moved a very limited
amount of air. In addition, the ceiling air vent was taped over. There was a single HEPA unit in
room 126; there were no dates of inspection on this unit. The filter was covered with dust. The
nurses demonstrated how they test the negative pressure in these rooms by placing a sheet of
toilet paper over the chuck hole to see if the paper is drawn into the room. The test failed in
room 124 and had limited draw in room 126. The experts requested the inspection reports for
the HEPA units but the reports, if they exist, were not provided. The facility management staff
changed the filters that evening, and the tissue paper test demonstrated the presence of
negative pressure on the following day.
Inmate porters sweep and mop the floors of the infirmary rooms two to three times a week.
They report that they spray and clean the toilets, sinks, and showers on a regular basis. No
printed cleaning schedule was provided. Two infirmary porters were interviewed. 5 They both
stated that they had received formal training about their duties and had been vaccinated
against hepatitis A and B. The Director of Nursing provided copies of their training curriculum,
post-training test and vaccination records that confirmed the information provided by the
porters. We did, however, note cockroaches, flies, and gnats on the infirmary unit. The patient
rooms in the infirmary varied in degree of cleanliness and sanitation. Rooms in which the
occupant participated or primarily did their own cleaning were reasonably clean. Infirmary
room 124 was occupied by an individual with dementia; his room was filthy, with debris on the
floor. His shower had not been recently cleaned. There were 20 small flies on the wall of the
shower. He reportedly would tell the porters not to clean his room. The condition of this room
created infection control and health hazards for the entire infirmary. Porters were directed to
come in and sanitize this room.
The infirmary tub room in the wing with the two-bed rooms was virtually unusable, having no
safety bars and large gaps and cracks in the floor tile. The floor drain does not fully drain. The
adjacent shower room was clean with surrounding safety grab bars; however, the ceiling vent
and wall towel hooks were completely rusted and thus impossible to sanitize.
The infirmary nurse station was centrally located between the two wings, with access to both
hallways. The nurse station was adequately sized and clean. All the chairs in the nurse station
5

Infirmary Patients #5 & 6.

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were deteriorating, with torn fabric and cushions; these need to be replaced. There was a single
box on an upper shelf that was less than 18 inches from the ceiling and this is considered a fire
safety hazard.
The health care unit/clinic’s exam rooms, nurse work rooms/offices, urgent care room, physical
therapy room, telehealth rooms, mental health interview rooms, and phlebotomy/lab prep
room were organized and clean. The large elevated exercise mat in physical therapy, a number
of examination tables, and the optometry chair had tears in their outer protective surfaces. One
of the provider exam rooms had numerous paperback reference books cluttering the desk and
a file cabinet.
A large space next to the urgent care area had six rooms. There were two provider exam rooms,
each with an exam table, sink, paper towels, desk, and two chairs. The exam tables were
adjustable; both tables had tears in the upholstery. Only one table had a paper barrier. The
room used by the physician assistant was cluttered with 20-25 paper backed reference texts,
some outdated, and food sitting on ice was noted in the sink. Two other rooms with
correctional computers were used by nurses to track inmate locations for medication passage.
One of the nursing rooms was a former exam room with an exam table with untorn impervious
upholstery. The fifth room was the phlebotomy/lab prep room. Two centrifuges owned by
University of Illinois (UIC) had been inspected in December 2017. There was a taped biohazard
box in the lab that had not yet been moved to the nearby biohazard waste room. The
optometrist (two days/week) uses the sixth room; it has an optometry chair with a small tear,
optometry equipment that is aging but was reported to be fully functional, a functioning
ophthalmoscope, and a desk with a chair. The optometry room was clean, neat, and organized.
The urgent care room had two gurneys with intact mattresses and paper barriers. This room
had a functional Gomco suction unit, Automatic External Defibrillator (AED), EKG machine,
oxygen tanks, nebulizer units, ambu bag, and oto-ophthalmoscopes. The equipment was
verified to have been checked daily on the 11 p.m. to 7 a.m. shift. On every shift, the urgent
care nurses count and log the narcotics, sharps, and suture quantities. With the exception of
the AED, none of the equipment had been recently inspected by a bioengineering vendor. The
last bioengineering inspection of the nebulizer was dated 2005. SCC does not have a crash cart;
the institution performs basic CPR, applies the AED, and calls 911 for cardiac arrests. This is an
acceptable option for responding to codes/cardiac arrests. A plugged-in radio repaired with
duct tape was on the treatment counter in the urgent care room; the condition of the radio
rendered it unable to be sanitized. The staff was directed to remove the radio from the unit.
Hemodialysis is performed onsite via a contract with Naphcare, Inc. in a four-chair hemodialysis
unit. Hemodialysis treatments are performed Tuesday, Thursday, and Sunday on the evening
shifts but these sessions appear to continue into the night. A hemodialysis patient on a housing
unit told the experts that he is always moved to dialysis sessions. The chairs were in good
condition. The dialysis machines were clean but there were indelible stains (likely betadine) on
the top of the machines. During sessions when a hepatitis B infected patient is being dialyzed, a
hemodialysis chair is not used exclusively by hepatitis B infected patient(s) nor is a dedicated
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dialysis technician/RN assigned to these patients. This is not in accord with Center for Disease
Control standards. 6
The hemodialysis room was in deplorable physical condition. The walls and paint were
deteriorating and peeling, the floor was dirty and had not been buffed for a lengthy period of
time, there was standing water in the water room, a number of unformed boxes were leaning
against a wall, and a large, half-filled garbage container lacked a cover. The water room was
cluttered and cramped. Half of the water room was used to store deionization tanks, eight of
which were unsecured, creating a safety hazard. The door of the refrigerator in the water room
was rusted and deteriorating and cannot be effectively sanitized. The storeroom in the
hemodialysis room had boxes on the floor and boxes stacked on shelves up to the ceiling.
Hemodialysis units have high risk for blood borne contamination. The hemodialysis unit at SCC
does not meet the community standards for hemodialysis centers. SCC maintenance staff, the
vendor Naphcare, and the correctional health vendor must jointly work to address the physical
plant, safety, and infection control issues in the hemodialysis unit.
The kitchen and dining areas were unsanitary and promoted infectious hazards. The inmate
dining halls had sparrows flying above the tables and even landing on the cafeteria line serving
counters. Bird droppings were noted on walls, the floor, and ceilings. There appeared to be a
nest high on a wall in one of the inmate dining areas. The presence of birds and their droppings
in the inmate dining and food serving areas exposes the inmates and staff to preventable risk of
infection by bacteria, viruses, fungi, and ectoparasites that are known to be associated with
birds, their droppings, and their nests.7 Birds and their droppings in the SCC inmate dining and
food serving areas is a health risk for the inmates and staff. The birds must be removed from
the dining areas and the droppings cleaned using proper safety precautions. A registered
sanitarian must be hired to fully inspect the kitchen and correct these deficiencies.
The tray, utensil, pots, and pan-washing and sterilization machine had been broken for three
years. The meat freezer does not have rubber/plastic flaps at the entrance, allowing the
temperature to rise above freezing temperatures when meat is being brought in and removed
from the freezer. An environmental sanitarian should be brought in the fully inspect the
kitchen.
The dish cleaning unit in the main kitchen has been broken for three years. Trays, pots, and
pans are washed and dried by hand. It was reported that a new unit has been purchased and
will be installed in 2018. The meat freezer in the kitchen does not have rubber flaps at the
entrance, resulting in an unsafe rise in freezer temperatures above freezing (as noted on the
freezer temperature log) in the early morning when frozen meat is moved to the defrost room.
The current cleaning of the trays, pots, utensils, and pans is done manually.

Centers for Disease Control and Prevention, Recommendations for Preventing the Transmission of Infections Among Chronic
Dialysis Patients. MMWR, April 27, 2001/50 (RR05); pp. 1-43 as found at
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm.
7
We note that IDOC had a histoplasmosis outbreak at the Danville facility thought to be due to bird droppings.
6

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In summary, the First Court Expert made no specific recommendations concerning sanitation
and infection control. We have recommendations that are found at the end of this report.
Environmental Rounds
Methodology: The HCUA was interviewed and copies of the Monthly Safety & Sanitation
Reports (January-May, July-August 2017) and the Medical Safety and Sanitation Reports
(September 2017-February 2018) were provided and reviewed.
First Court Expert Findings
The First Court Expert did not report on environmental rounds at SCC.
Current Findings
• Safety & Sanitation Reports were filed monthly from January through August 2017 (July
was not provided). These reports were then replaced by the Monthly Medical Safety
and Sanitation Report.
• Monthly Medical Safety and Sanitation rounds are being performed and have been
reported from September 2017 through February 2018.
• The format of the Monthly Medical Safety and Sanitation report is notably improved.
This report includes: 1) Location, 2) Identification of Standards Not Met, 3)
Recommendations for Corrective Action, 4) Follow-up on Past and Present
Discrepancies.
• The Health Care Unit, hemodialysis unit, and the infirmary have been reported in the
monthly reports as having an ongoing pest control (insects, cockroaches, gnats) issues.
Exterminators have been contracted. An exterminator was seen entering the facility on
the first day of the experts’ visit to SCC.
• Cleaning issues in the infirmary and the health care unit were cited in the report,
including the cleaning of dirty vents.
• In January 2018 the hemodialysis unit was noted to be in compliance, but the February
2018 report cited water on the floor, cockroaches, and broken floor tiles that need to be
repaired in the hemodialysis unit.
• The Clinic Space, Sanitation, and Infection Control sections in this report noted far more
deficiencies in the health care unit, the hemodialysis room, and the infirmary than have
been reported in the Monthly Medical Safety and Sanitation Reports. The rounds did
note and repair mattresses in the infirmary that were in poor condition.
Monthly environmental rounds are being performed by the health care team at SCC. These
rounds have identified concerns, some of which appear to have been corrected or are being
addressed. The rounds must focus more attention on the beds in the infirmary, the cleaning
and sanitation of the infirmary rooms, the repair of impervious covers of exam tables, chairs
and patient mattresses, and the deplorable condition of the hemodialysis unit (water room,
floors, walls, safety, and infection control standards).

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In summary, the First Court Expert made no specific recommendations concerning sanitation
and infection control. We have included recommendations that are found at the end of this
report.

Medical Records
Methodology: We inspected the medical record room and interviewed staff. We also reviewed
many medical records and had an opportunity to assess the organization of the medical record
document.
First Court Expert Findings
The First Court Expert did not provide any findings with respect to medical records at SCC.
Current Findings
The medical records program has a Director of Medical Records who is a Registered Health
Information Technologist (RHIT), which is appropriate training for this position. There are three
IDOC employees and one Wexford employee working in medical records in addition to the
Director of Medical Records.
The medical records room appears orderly but is cluttered, with very old carpeting and
furnishings. There was insignificant backlog of filing. There is a procedure for filing records and
for use of out guides. But these procedures are not always followed. For the most part, medical
record staff pull and refile medical records. However, nurses pull some records and we were
told that medical records staff re-file only about 80% of medical records. Medical record staff
typically are to handle all medical record transactions, especially pulling records and refiling
records. This is done in order to ensure confidentiality of the medical record. The medical
record room is either occupied by medical record staff or is locked. During daytime hours, the
medical record staff does secure the files. Certain staff, during off hours, have keys to the
medical records room and can pull and refile records.
While there is no backlog of medical record documents to file, there are a significant number of
offsite consultation reports that are not available. Consultation reports from UIC are not filed
within three days of the consultation as required by the IDOC administrative directive on
medical records. It appears that most reports are filed within three weeks of the consultation.
This may account for the provider’s lack of knowledge of the clinical status of the patient as
represented in the medical record reviews. Some offsite consultants, including St. Joseph’s
Hospital, do not consistently provide a hospital discharge summary. Several records we
reviewed had no information about when a patient was sent offsite and this made it impossible
to determine the clinical course of care for these patients. In our discussion with the Medical
Director, he stated that he asks the patient what transpired at their consultation visit. This is
not a reliable method of understanding what the consultant found. Providers must have a
consultation report.

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For patients going for consultation at UIC, the program must get a patient release of
information for the medical consultation report. 8 This results in a delay of one to three weeks
before the consultation report is provided. Since the IDOC providers are required to evaluate
the patient within five days of a return from offsite encounters, the providers almost always
evaluate the patient without a consultation report. The referral form, which is available, usually
has limited comments by the consultant. However, in our review of records, the lack of
availability of the consultation report typically meant that the providers were uninformed with
respect to the status of the patient. This appeared to create poor continuity of care for
patients.
In using the paper records for our record reviews, we noted that many of the records are large
documents. When using the record, the plastic binder holding the chart together frequently
came apart. This happened repeatedly, and the current Medical Director expressed the same
concern. If paper records are to be used, a better system needs to be developed so that the
record is a functional and useable document. Records that come apart can result in misplaced
or lost documents.
SCC serves as a dialysis facility; however, the dialysis records are maintained separately from
the facility medical record. Medical records should be unified. Doctors at SCC are unaware of
nephrologist’s notes or recommendations or the status of the patient during dialysis because
the records are not kept in the medical record.
We found the paper records very difficult to use. It is not possible to evaluate current
medication records, as those are not placed in the record until several weeks after they are
completed. Because most charts are multiple volumes, key information about patients was
often in older volumes. Given the difficulties in using the paper record system, we strongly
recommend implementation of an electronic record. We note that in review of mortality
records from SCC we could not make a determination whether the death was preventable in
three of seven records reviewed because the medical record was missing documents. This
demonstrates a very broken system of maintaining medical records.

Intrasystem Transfer
Methodology: To evaluate the medical screening of inmates received at SCC as transfers from
other Illinois DOC facilities, we interviewed health care staff, toured the urgent care area where
transfer screening takes place, reviewed the IDOC health status form, the SCC Operations Policy
and Procedure P-118 Transfer Screening, and health records of inmates received at SCC.
First Court Expert Findings
Typically, when a physician refers a patient to a consultant, the consultant sends a report to the referring physician. Why this
does not occur in IDOC is not understandable. In our past experience, when situations like this arise, a discussion with the
hospital administrator and hospital medical director have resulted in obtaining records. We view this problem as a failure of the
Wexford leadership in conducting appropriate negotiations with the consultants.

8

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The previous Court Expert found in more than half the charts reviewed that the transfer
summary was incomplete or missing, inmates with chronic diseases were not referred for
chronic care clinic, and vital signs were not recorded or not followed up when abnormal.
Current Findings
Transfers to SCC most often take place on Wednesday and average less than 50 per month.
Inmates received on transfer are brought to urgent care in the health care area for screening
before placement in population. The sending facility documents information about the inmate’s
health status and treatment on the Health Status Summary Record. This form and the medical
record is reviewed by a nurse at SCC upon the inmate’s arrival. The nurse also inquires if the
inmate is currently receiving treatment or has any other immediate need for medical attention.
The nurse then schedules the inmate for subsequent health care (i.e., enrollment in a chronic
care clinic, initiation of medications, etc.) as needed. The nurse also provides a verbal
explanation and handout about how to access health care at the facility.
SCC does not keep a log, list, or other method to track inmates received on transfer. The
medical records department had filed the memos which listed the names of inmates to be
received on transfer. Using these memos, the charts of all inmates received in January and
February 2018 who were still at SCC as of the date of the site visit were reviewed. A sample of
12 records was obtained. Ten of these inmates had health care requirements that needed
continuation at SCC. The transfer process was complete in seven of the 10 charts reviewed of
inmates with ongoing health care needs. One transfer summary did not list psychotropic
medications that were prescribed, but these were identified by the nurse upon review of the
chart and continued.9 In another, there was no transfer summary for an inmate with diabetes
and hypertension. The nurse who reviewed the chart noted his medical history, enrolled him in
chronic care and ensured that his medications were continued. 10 In another chart reviewed, an
inmate on prescribed psychiatric medications was not scheduled to see a provider urgently and
no other attempt was made to continue medication upon his arrival at SCC. 11
Transfer screening at SCC has improved since 2014. However, the record review performed at
this site visit revealed transfer information that was incomplete, or care that was not continued
as prescribed for 30% of the inmates requiring continuity of care. Continuity of care upon
transfer needs to be more reliable.
The First Court Appointed Monitor recommended, “The intrasystem transfer process needs to
be appropriately addressed to effectively insure continuity of care for patients who enter with
prior diagnosed problems. This should be monitored by the QI program.” 12 CQI minutes and
related material from SCC that were provided from January 2017 through December 2017 were
reviewed. There were no reports monitoring the continuity of care after intrasystem transfers.

Intrasystem Transfer Patient #11.
Intrasystem Transfer Patient #12.
11 Intrasystem Transfer Patient #10.
12 Lippert Report, p. 38.
9

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We agree with the First Court Appointed Expert’s recommendation. SCC has not implemented
the recommendation made by the First Court Appointed Expert in 2014. Inmates are at
significant risk of discontinuity in their medical care and treatment resulting from incomplete or
inaccurate transfer screening. These deficiencies should be addressed in documented
corrective action plans and regular follow-up monitoring done until sustained improvement is
demonstrated. We have additional recommendations found at the end of this report.

Nursing Sick Call
Methodology: Nursing sick call was evaluated by reviewing SCC Institutional Directive
04.03.103K Offender Health Care Services, SCC Operations Policies and Procedure P 103 NonEmergency Health Care Requests and Services, IDOC Treatment Protocols, and the SCC
Offender Handbook. We also interviewed the Director of Nursing, nurses, and inmates;
observed nurses conducting sick call, inspected the rooms used for sick call, and reviewed
tracking logs and health records. The completed sick call log showing the reasons patients
requested health care attention for the month of February 2018 was used to select charts to
review. Seventeen sick call encounters were selected for chart review. 13
First Court Expert Findings
The First Court Appointed Expert found that sick call was available to inmates only a few days
each week based upon their housing location. The rooms used by nursing staff were not
equipped appropriately. There were delays in accessing sick call because it was not scheduled
frequently enough and, at times, because security staff would not escort inmates to the nurse
sick call room. Nurses failed to document the dates that sick call requests were received and
triaged. Nurses also did not adequately assess or document evaluation of inmate health
complaints. Inmates who were referred from nurse sick call were not seen or not seen timely by
providers. Providers failed to follow up at intended intervals and treatment orders were not
completed.14 Two recommendations were made:
1. Custody issues should not interfere with timely provision of health care.
2. There should be no such thing as a “no show.” Patients should be required to report to
health care when scheduled. They may refuse care but only to a health care
professional.15
Current Findings
Our review found that problems with daily access to sick call have been resolved. Since SCC has
implemented the sign-up log, patients are seen the next day. Documentation of timeliness and
disposition of sick call requests is evident from review of the sick call logs. The rooms used to
perform sick call are now adequately equipped. There was also no evidence of security staff
failing to escort inmates to sick call as described in the First Court Expert’s report.

Sick Call Patients #1-17. We selected patients whose requests were potentially serious (chest pain, abdominal pain, seizure,
vomiting, skin infection, diabetic complications, withdrawal, etc.).
14 Lippert Report, pp. 9-12.
15 Lippert Report, p. 38.
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Problems with sick call identified in the First Court Expert’s report that are still evidenced
include:
• Nurses do not adequately assess or document evaluation of inmate health complaints.
• Inmates who were referred from nurse sick call were not seen or not seen timely by
providers. Providers failed to follow up at intended intervals and treatment orders were
not completed.
In addition, we had several additional findings:
• LPNs continue to be assigned to conduct sick call even though the stated practice at SCC
is to assign RNs.
• Security practices in segregation do not provide sufficient privacy for patients during the
sick call encounter.
• Nurses do not refer patients to providers in accordance with IDOC Treatment Protocols
and do not document the urgency of the referral (e.g., urgent, routine).
When inmates arrive at SCC they are provided an orientation handout that states, “Inmate
patients needing to see healthcare must sign up on the sick call call-out logs located within each
housing unit. The day after you sign up, you will be called to the sick call room located within
each cell house.” 16 This information is consistent with SCC Operations Policies and Procedure P
103 Non-Emergency Health Care Requests and Services. 17 We observed this process in several
of the housing units. The log is prominently posted in the cell block. Inmates wanting to be seen
write their name on the sick call log. The sick call logs are collected at night or early in the
morning.
Inmates may also use the Medical Services Request form to request dental, eye and mental
health services that are not urgent. 18 The inmate puts the request into a clearly labeled box
mounted on the wall in each housing unit. Any requests in the box are picked up by CMTs daily
when they make rounds of the cell blocks. These requests are then forwarded to the respective
department (dental, mental health, optical, pharmacy) to address. Inmates may also use the
sick call sign up log for dental, mental health, optical, or any other issues, and are seen at
nursing sick call the next day.
The morning after the sick call lists are collected, nurses conduct sick call using the lists. Anyone
who has signed up on the sick call log is seen by a nurse that day. The medical service requests
are routed directly to the relevant department (dental, mental health, etc.) if the request is for
a routine service such as an exam, medication refill, or supply item.

16
Stateville Access to
Care Inmate Handout.

17
18

SCC Operations Policies and Procedures, pp. 4-5.
STA 0202 (Rev 4/2103).

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The day we observed sick call 19 each of the inmates seen had signed up on the sick call log the
day before.20 Of the 17 charts we reviewed, all documented sick call encounters with inmates
who had signed up on the log the day before.21 Five other inmates interviewed during the site
visit confirmed that when they signed up for sick call they were seen the next day. 22 Inmates
appear to be able to access nursing sick call within 24 hours of signing up. None of the inmates
interviewed or who agreed to be observed during sick call voiced complaints about the
timeliness or responsiveness of nursing sick call.
According to the Director of Nursing, only registered nurses (RNs) are assigned to perform sick
call on a regular basis. However, LPNs are assigned to sick call if there are not sufficient RNs
available. Review of the daily assignment roster for the week of February 12, 2018 showed that
RNs were assigned to sick call six of seven days. 23 According to the Director of Nursing, LPNs
were assigned sick call on six days in January 2018 and eight days in February 2018. Of 17 sick
call encounters reviewed in the chart review, five were completed by LPNs. 24 From these three
sources, we conclude that LPNs are relied upon to complete 20 to 30% of sick call encounters.
The Illinois scope of practice does not permit LPN’s to perform assessments independent of a
registered professional nurse or higher level professional, as is currently being done at SCC.25
There are insufficient RN positions at SCC to conduct sick call. LPNs are assigned to do the work
in lieu of available RNs but they are not qualified, and this assignment is not within their lawful
scope of practice.
Nurses see inmates in a sick call room that has been established in each of the cell houses. The
nurse brings the inmate’s medical record to use during the sick call encounter. The sick call
rooms are well lighted, generally clean, and capable of providing patient privacy. Each has an
exam table with paper and a wall mounted oto-ophthalmoscope. See the description of these
rooms in the section of this report on Clinic Space and Sanitation. The space, equipment, and
supplies available to conduct sick call are adequate.
We observed three nurses (all RNs) as they were conducting sick call on Monday February 26,
2018. A total of five patients were seen, three of these were in segregation.26 Each of the
nurses’ evaluation of the patients’ complaints was thorough and appropriate. Nurses correctly
used the IDOC treatment protocols and the plans derived for each patient were appropriate.
The nursing assessment was pertinent to the complaint in 11 of the 17 charts reviewed (64%
compliance). The plan of care was consistent with sound nursing judgement or that specified in
the nursing treatment protocol in 12 of 17 charts reviewed (71% compliance). Based upon the
Monday February 26, 2018.
Sick Call Patients #17-22.
21 Sick Call Patients #1-17.
22 Sick Call Patients #23-27.
19
20

23

Stateville RN Staffing
for Sick Call.PDF

Sick Call Patients #2, 4, 8, 9 & 12.
Illinois LPN Scope of Practice, Section 55-30.
26 Sick Call Patients #18-22.
24
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results of the chart review, nursing assessment and planning care could be improved. However,
the adequacy of nursing assessments and the plan of care are not monitored by nursing service
as part of the peer review or CQI. We recommend that the adequacy of nursing evaluation and
planning at sick call be an area of ongoing monitoring, training, and coaching.
The three patients we observed being seen in segregation were provided neither visual nor
auditory privacy during the sick call encounter. One, or sometimes two officers, were at the
doorway or just inside the room. They interacted with both the nurse and the inmate during
the encounter. The officers also interacted with each other and other traffic passing through
the corridor. In one case the officer helped the nurse obtain the patient’s weight. 27 In another
encounter, the officer resisted the nurse’s request to remove one patient’s arm from the
shackles to obtain vital signs. 28 This was finally accomplished when a more senior officer arrived
to assist. It is not possible to assess and evaluate inmate health concerns when custody staff
intrude and impede the encounter in these ways. Custody staff should stand at a distance from
the sick call room so that they can see the encounter but not hear the substance of the
interaction. Custody staff should be prepared and available to remove restraints as requested
by the nurse to complete the evaluation of a health complaint.
We were told by the Nursing Director that patients referred to the provider from sick call are to
be seen within 72 hours unless it is more urgent. Based upon the charts reviewed, nurses do
not document urgency when referring to a provider and there is no area on the nursing
treatment protocols to indicate urgency. From observation of the nurses conducting sick call it
was clear that they do make this determination, it just is not documented. The sick call
documentation forms should be revised to indicate if the referral is emergent, urgent, or
routine.
There were only two charts that documented an urgent referral from sick call; only one was
seen within 24 hours of the referral. There were 13 sick call encounters that were referred nonurgently to a provider. Of these, only three patients were seen within 72 hours of the referral
(23% compliance). Patients were not seen timely because either the appointment was
scheduled out longer than 72 hours or the appointment did not take place and was rescheduled
for a later date. CQI studies were completed to study timeliness of patients seen by providers
when referred from sick call in December 2016, and January, March, and June 2017.
Performance on this measure was less than 80% in four of five studies reported in the annual
CQI report. The actions taken as a result of these studies was to repeat the study four times
and, in June 2017, to educate the nurses on sick call procedures. Clearly, problems accessing
providers persist if only 23% of the 13 referrals from sick call encounters in February 2018 were
seen within 72 hours.
The following are examples from the chart review of problems found with sick call.

27
28

Sick Call Patient #22.
Sick Call Patient #21.

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•

The first patient was seen by an LPN in sick call on 2/13/2018 for a complaint of chronic
diarrhea. 29 The nurse did not document an adequate assessment of the patient or
develop a plan of care per the protocol for diarrhea. 30 From a review of the chart it was
clear that the patient had been discharged from the infirmary 19 days earlier after a
month long stay for treatment of salmonella. The nurse did not refer the patient to a
provider and should have done so urgently.

•

Another patient was seen at sick call on 2/8/2018 because he was experiencing
shortness of breath at night. 31 The nurse did not assess the patient per the treatment
protocol for shortness of breath. 32 The nurse provided no intervention and did not make
a referral to a provider for further evaluation. This is a symptom of potentially serious
cardiorespiratory disease that should have been more thoroughly assessed by the nurse.
The assessment would likely have prompted a provider referral.

•

Another patient was seen in sick call on 2/9/18 for a painful lump in his breast.33 The
nurse’s assessment prompted referral to a provider. The provider appointment was
scheduled to take place four days later but was subsequently cancelled. The
appointment was re-scheduled for 2/26/18 but did not take place. This was a delay in
care for evaluation of a potentially serious condition. After reviewing the chart, we
asked that he be seen, so an appointment was scheduled for 2/28/18.

•

Another patient was seen by an LPN on 2/13/18 for a skin rash.34 The nurse did not
assess the patient per the treatment protocol for rash. 35 There was no description of the
rash nor did the nurse acknowledge that he had been seen previously for the same
condition on 1/6/18 and 1/31/18. The nurse did refer the patient to a provider, but he
was not seen promptly. An appointment was originally scheduled for 2/15/18 but did
not take place until 2/21/18, or until eight days later.

•

Another patient was seen in sick call for a complaint of dizziness on 2/15/2018. 36 The
nurse referred the patient to a provider per the treatment protocol for dizziness. 37 The
provider appointment was scheduled to take place five days later, on 2/20/18, but he
was not seen. It was rescheduled to 3/2/18 or 14 days after the referral. The provider’s
evaluation of this patient’s serious symptom of dizziness was not timely.

Sick Call Patient #4.
IDOC Nursing Treatment Protocols, (March 2017), p. 39.
31 Sick Call Patient #6.
32 IDOC Nursing Treatment Protocols, (March 2017), pp. 75-76.
33 Sick Call Patient #7.
34 Sick Call Patient #9.
35 IDOC Nursing Treatment Protocols, (March 2017), p. 70.
36 Sick Call Patient #10.
37 IDOC Nursing Treatment Protocols, (March 2017), p. 40.
29
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•

Another patient complained of chest pain when seen on sick call 2/15/2018. 38 The nurse
did not assess for cardiac risk factors per the treatment protocol. 39 The patient’s blood
pressure was elevated, he was overweight, and being treated for hypertension. The
nurse did not confer with a provider per the instructions in the treatment protocol but
scheduled him for an appointment four days later. This appointment did not take place
until 2/22/2018, or seven days later. The provider documented that the patient had not
been taking his medication for hypertension. An EKG done at that appointment revealed
an abnormal cardiac rhythm. This patient should have been more thoroughly evaluated
by the nurse and the provider notified urgently.

•

Another patient was seen in sick call on 2/17/18 because of abdominal pain. 40 He gave a
history of GERD and chronic diarrhea. The nurse scheduled the patient to a pre-existing
appointment that was to take place 10 days later. It was poor nursing judgement to
schedule a patient with this history and symptom presentation to a pre-existing
appointment 10 days later.

•

Another patient was seen in sick call 2/2/18 for a complaint of chest pain.41 He was
referred to a provider urgently and seen that same day. The provider ordered the
patient’s blood pressure to be checked twice a day for three days and then he was to be
seen by the provider in follow up. None of the six expected blood pressure readings are
recorded in the chart. Twice there is documentation that the patient refused to have his
blood pressure taken. The other four times there is no documentation that his blood
pressure was taken. The patient also was not seen in follow up by the provider. In this
case, ordered care was not completed and the patient who was experiencing chest pain
was not followed up.

In summary, we concur with the First Court Appointed Expert’s recommendation that custody
issues should not interfere with timely provision of health care, especially as it pertains to
patient privacy in segregation. With the implementation of practices to see all inmates who sign
up for sick call the next day, the other recommendation that refusals be seen by health care
professionals has been accomplished. We have additional recommendations found at the end
of this report.

Chronic Care
Methodology: The medical records of 13 patients with chronic medical illnesses and conditions
were reviewed. There was limited opportunity to interview SCC providers due to restrictions
imposed by Wexford. The Office of Health Services Chronic Illness Treatment Guidelines dated
March 2016 were reviewed as needed.
Sick Call Patient #11.
IDOC Nursing Treatment Protocols, (March 2017), pp. 30-31.
40 Sick Call Patient #13.
41 Sick Call Patient #17.
38
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First Court Expert Findings
The previous court expert noted that chronic care patients should be scheduled in accord with
their degree of disease control, not at the fixed intervals that a specific chronic disease clinic is
scheduled. Diabetics’ meals should be served on a predictable schedule to facilitate the timely
coordination with insulin administration just prior to food consumption; Type 1 diabetics should
receive short-acting insulin prior to each meal, not just at breakfast and dinner; HIV patients
should also receive primary care provided by SCC providers; and the chronic care nurse should
do no less than monthly medication compliance checks with HIV patients.
Current Findings
We agree with the findings in the First Court Expert’s report. In addition, we identified
additional findings and confirmed some of the First Court Expert’s findings as follows:
• Problem lists occasionally are incomplete or inaccurate.
• Patients assigned to chronic care clinics are regularly seen in these disease specific clinic
sessions.
• The chronic clinic visits contain very limited clinical information, do not indicate that
appropriate examinations had been performed, do not document the rationale for
clinical decisions and therapy modifications, do not modify treatment to attain generally
accepted treatment goals, and do not document the patient’s treatment plan.
• Management of chronic illnesses is not in accord with either the Office of Health
Services Chronic Illness Treatment Guidelines or national standards of care.
• SCC fails to provide basic screening tests and vaccines that are recommended for
diabetics in the IDOC Diabetes treatment guidelines and in national standards of
diabetes care.
• Chronic care visits strictly focus on a single specific disease and do not address any other
associated clinical problems. As examples, abnormal blood pressure values were not
addressed in diabetic clinic. Elevated blood glucose was not addressed in hypertension
clinic. Neither one of these clinics addressed hyperlipidemia. Managing each chronic
care disease in a silo independent of the patient’s other illnesses contributes to delays in
modification or initiation of treatment for patients with multiple chronic illnesses and
can contribute to increased morbidity.
• All patients over 50 need to be screened at regular intervals for colon cancer. The
frequency of screening is based on patient characteristics and on the type of screening
method used. The charts of seven 50 years of age or older patients were reviewed; only
one had documentation in their medical record that they had been screened for colon
cancer. 42

Screening for Colorectal Cancer, US Preventive Services Task Force Recommendation Statement, JAMA June 21, 2016;
Volume 315, Number 23 as found at
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/colorectal-cancerscreening2?ds=1&s=colon%20cancer.
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•
•
•

Nationally recommended vaccinations for adults are not consistently administered.
Pneumococcal, meningococcal, and hepatitis A and B vaccinations were not offered or
given as recommended by national age and disease-based guideline.43
Uncontrolled chronic illnesses that appear to be beyond the expertise of the SCC
providers are not referred for specialty consultation.
The chronic care providers do not document any review of the MAR, the capillary blood
glucose tests (CBG), and the nursing and provider sick call notes and blood pressure
readings when they see patients in the disease-specific chronic care clinics.

Chronic disease visits are conducted separately for each disease. If a person has three diseases,
he will be seen in three separate clinics two or three times a year. This dramatically increases
the number of visits. SCC has chronic care clinics for asthma (January & July), diabetes (April,
August, & December), high risk (March & September), hypertension (March A-L, April M-Z,
September A-L, & October M-Z), seizure disorder (February & August), and tuberculosis
(January – December). Individuals with Human Immunodeficiency Virus (HIV) are referred to
and managed by the UIC Infectious Disease Telehealth Clinic. All other chronic diseases
including hepatitis C are managed by the general medicine clinic (May & November). One
physician is assigned to staff all the chronic care clinics with backup (vacation, sickness,
conference) by the other SCC providers.
The chronic care nurse manually prepares the provider’s log-in sheet, noting the reason for the
appointment (e.g. asthma clinic, MD sick call, or follow-up, etc.). Medical record staff types and
sends this list to all the housing units. This list is used by the correctional officers in the housing
units to move men to the health care unit. The chronic care RN hand writes on the list the time
in and time out of those seen and those who have to be rescheduled (no show, no provider,
refused).
There were 1,700 chronic care visits at SCC in 2015-2016; this number decreased to 1,384 in
2016-2017. There was a drop of 243 hypertension clinic visits. This reason for this drop in total
visits was not able to be determined.
In January 2018, the chronic care provider was scheduled for 19 sessions (8 a.m.-2 p.m.); he
only was able to staff 17 of these sessions. 400 patients (23.7/session) were scheduled for the
month. The 400 patients were not limited to chronic care patients but included provider sick
call appointments, add-ons, and 133 asthma chronic care appointments. 282 (71%) of the 400
scheduled patients were actually seen. The provider treated 17 patients per session or
approximately 4.7 per hour. Seeing patients every 12 minutes allows limited time for a provider
to evaluate chronically ill patients.

CDC Recommended Immunization Schedule for Adults 19 years or Older by Medical Conditions or other Indications, 2018 as
found at https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf.

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A review of the asthma chronic care clinic statistics for January 2018 showed:
Scheduled Visits
Patients seen
Patients Already Seen
Rescheduled
Other

133
65 (52%)
4 (3%)
32 (25%)
31 (22%)

This data indicates that approximately 55% of all asthma patients scheduled in January 2018
were actually seen on the scheduled visit day or had already been recently seen. It was unclear
what the reason for the “Other” category was or whether they were also eventually
rescheduled. Some may have refused, others may have been transferred or discharged. The
chronic care nurse was not interviewed.
The providers’ documentation in the medical record was extremely brief, commonly illegible,
and seldom contained pertinent clinical information needed to clarify and understand the state
of a patient’s chronic illness or justify a change in the treatment plan. The experts found it
extremely difficult to track the status of a patient’s chronic illness and to comprehend the
reasons for a modification of treatment. This lack of clinical documentation is a significant
barrier to the continuity and quality of care delivered to the SCC patient population. The
experts found no documentation that the chronic care providers had reviewed the MAR
(refusals, compliance with prescribed medications), the CBG tests, the nurse and provider sick
call notes, and the blood pressure readings taken in the sick call visits when they assessed
patients in the disease specific chronic care clinic visits. This failure to review the data and
information that had been gathered between chronic care visits contributed to flawed clinical
decisions and delays in providing needed care to SCC patient-inmates.
Most of the chronic care patients had completed problem lists. However, four (31%) of the 13
charts reviewed were found to be missing important diagnoses on the problem, list including
hypertension, hepatitis C, amputated thumb post human bite, and diabetic foot ulcer.
Incomplete problem lists contribute to the failure to adequately monitor and treatment known
chronic illnesses.
The care provided to diabetics and patients on chronic anticoagulation, hypertensives, asthma
medications, and anti-epileptics was problematic. Diabetics, hypertensives, and patients on
warfarin anticoagulation remain uncontrolled for lengthy periods of time, in part because their
treatment may only be evaluated in chronic care clinics (two to three times per year) and not as
frequently as their condition justifies. Diabetics are not routinely screened for urinary protein
and even if they are found to have elevated urine protein, the appropriate medical intervention
is not consistently prescribed. Detailed foot and lower extremity sensory exams are not
documented in the diabetes chronic care notes. Recommended vaccines are not universally
provided to patients whose age or disease warrants such vaccination. Compliance with
prescribed medication is important for all chronic illnesses, but the impact of not taking or
receiving diabetic, hypertension, anticoagulation, and seizure medications can result in rapid
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deterioration and morbidity. There was no documentation in the chronic care provider notes
that they were reviewing the MARs or nursing notes to assess compliance with medication and
initiating appropriate interventions as needed.
All 13 (100%) of the patient records had problems identified in the provision of care. The
following patient summaries highlight the concerns and the findings noted above:
•

This is a 42-year-old patient with a problem list noting asthma who was being treated
with Xopenex inhaler (beta-agonist), Singulair (Montelukast), and a Medrol Pack
(methylprednisolone tabs). 44 He was transferred to SCC from Menard Correctional
Center on 6/24/17. His database noted that he had received the pneumococcal-23
vaccine on 5/28/12. His asthma was not evaluated upon arrival at SCC. The RN
incorrectly noted that he was taking Albuterol, did not check a PEFR, and referred the
patient to the asthma chronic care clinic. Two months later, on 8/24/17, he was seen in
the asthma clinic; his PEFR was 500 L/min, he was assessed as stable, and was referred
to a January 2018 asthma clinic. Patient was seen again in the asthma clinic on 1/22/18,
and his PEFR was 450-500. Although he had a normal exam and his asthma was
controlled, the provider noted that he had bronchitis and ordered an oral antibiotic
(amoxicillin). At neither asthma clinic visit did the provider note how frequently the
patient was using his relief inhaler, or if was waking up at night with cough or whether
the patient still had the pack of methylprednisolone that could be immediately taken by
the patient in the case of an acute asthma attack. This patient is very stable, and he
likely could be taken off Montelukast. At each asthma clinic the provider should be
taking a more detailed history concerning any symptoms of bronchospasm and use of
inhaler consistent with generally accepted asthma standards of care. The use of
antibiotics to treat bronchitis in a stable asthmatic is against the national standard of
care and was not indicated in this patient.45 In summary, the failure to document an
adequate history of inhaler use and symptoms indicative of bronchospasm was not in
compliance with the Office of Health Services Chronic Disease Treatment Guidelines,
Asthma.

•

Another patient was a 62-year-old patient whose problem list noted insulin resistant
diabetes mellitus (IRDM), hypertension, hyperlipidemia, and aortic arteriosclerosis. 46 His
hepatitis C disease was not documented in the problem list. His database noted that he
had received the pneumococcal 23 vaccine on 5/23/16 and hepatitis A and B #1 vaccines
on 3/26/16. There is no documentation that he received, as required, hepatitis A
vaccine #2 or hepatitis B vaccines #2 and #3. During the last 11 months of 2017, he was
seen in hypertension clinic two times, in diabetes clinic three times, and semi-annual
clinic two times. He also was seen by the optometrist two times. Many of the medical

Office of Health Services, Chronic Illness Treatment Guidelines, Asthma, March 2016.
Chronic Care Patient #1.
46 Chronic Care Patient #2.
44
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provider notes were barely legible. The diabetes and hypertension chronic care notes
contained little clinical information and no rationale for modifying or not changing
treatment. Between February and December 2017, HbA1Cs were done monthly (in
chronological order) 8.7%, 7.9%, 7.8%, 7.8%, 8.1%, 8.2%, 8.2%, 8.2%; none reflected that
his diabetes was under control. NPH insulin was increased to 35UAM/20UPM (4/18/17
DM clinic) and again, eight months later at the next DM clinic to 50UAM/25U/PM
(12/4/17 DM clinic). If there were any additional modifications in the insulin dosage it
was not documented in the provider notes. Ten HbA1Cs were performed in 2017. The
national diabetic standards state the HbA1Cs should be tested every three to four
months; more frequent testing offers no valid clinical information to the care of
diabetes. The providers are not knowledgeable about the recommended frequency of
HbA1C testing and the value of this important diabetes test. There was no
documentation that this diabetic had a single foot or sensory neuropathy exam in 2017;
this does not meet the standard of diabetes care. Simvastatin 10mg was not increased
even though this hypertensive, diabetic, elderly male had a >20% 10-year risk of having
heart disease or stroke and should have been taking a high intensity statin drug per
national standards of care. 47 The SCC providers are not able to calculate this risk
because they are not allowed to bring in cell phones and do not have access to
electronic references. The statin dose was inadequate for this patient’s level of
cardiovascular risk. This patient was given a diagnosis of hepatitis C, yet there were no
tests done to support this diagnosis. This patient’s hepatitis C was not being monitored
in accord with national standards. At the two semi-annual clinic visits (6/5/17 and
12/19/17), the patient’s hepatitis C was evaluated; no organomegaly, edema, or icterus
were identified, and the elevated liver enzyme data were documented in the notes.
However, the plan was only to return to clinic in six months; there was no estimate of
fibrosis using laboratory tests and no order to do a liver ultrasound or a liver fibroscan
to evaluate the stage of fibrosis in order to determine if the patient was a candidate for
hepatitis C treatment. Episodes of difficulty breathing, propping his head up in bed to
breath, waking up suffocating in October-November 2017, were not being adequately
evaluated as of the end of January 2018. The initial provider assessment was sleep
apnea, but no additional diagnoses (congestive heart failure (CHF), cardiac arrhythmia,
COPD, asthma, coronary artery disease) were considered. There was no documented
examination of the patient’s heart or lungs and no additional tests were ordered (e.g.,
chest x-ray, echocardiography, CBC, BMP, EKG, pulmonary function test, sleep studies)
to evaluate these repeated symptoms of difficulty breathing. This patient was over 50
years old, but he was not offered a colon cancer screening test during 2017 even though
he had two semi-annual clinic visits.
In summary, this patient is not being properly monitored for complications of diabetes,
including foot ulcers and sensory neuropathy. HbA1Cs are being ordered at an
unjustifiably high frequency, indicating that the providers are not knowledgeable about
the utilization of this important diabetic test. His diabetes has not been fully controlled
47

ACC/AHA ASCVD Risk Calculator.

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for over a year. His hepatitis C has not been assessed to determine the presence of liver
fibrosis (cirrhosis) that would determine if he is a candidate for treatment. He is not
being prescribed the proper dosage of a statin that is warranted by his 10-year risk of
cardiovascular disease. The providers are not assessing 10-year cardiovascular risk in
elderly patients with diabetes, hypertension, and hyperlipidemia. He was prescribed an
antibiotic for the treatment of bronchitis. He has not been properly evaluated for his
recurrent episodes of difficulty breathing. He is not being screened for colon cancer. The
care provided to this patient is not in accord with national standards of care.
•

Another patient is a 65-year-old with diabetes mellitus (DM), hypertension, and
hyperlipidemia noted on his problem list. 48 The database noted that he had received
pneumococcal 23 vaccine on 7/23/16 and had negative PPD on 12/10/16. His
medications included NPH insulin 24U/10U, sliding scale regular insulin, Metformin
500mg/d, Lasix 40mg/d, Lisinopril, Simvastatin 40mg/d, Nifedipine 30mg/d, and ASA. He
was seen every six months in the diabetes and hypertension clinics. He was seen at UIC
Eye Clinic in July 2017 and did not have diabetic retinopathy. His blood pressure was
generally at goal. Multiple HbA1Cs between August 2016 and November 2017 indicated
excellent control, with all HbA1Cs under 6.0%. However, the CBG logs from October
2017 through January 2018 documented elevated glucose levels that were not
consistent with the control indicated by the HbA1Cs; this important clinical discrepancy
was not discussed at any of the diabetes clinics. This indicates that the diabetes chronic
care providers are not regularly, if at all, reviewing the CBG tests or the MARs during the
clinic sessions. Labs done on 3/21/17 reported a microalbumin/creatinine level of
60mg/L (normal range 0-30), but sick call and diabetes clinic providers did not comment
on this abnormality and did not order, as is indicated for all diabetics, an ACE inhibitor to
prevent further kidney damage. There was no documentation of a detailed foot or distal
extremity sensory exam in any of the diabetes clinic notes.
In summary, there are significant deficiencies (no detailed foot or sensory exam, failure
to initiate an ACE inhibitor for proteinuria, no endocrine consultation to evaluate the
discrepancy between the HbA1Cs and the finger stick blood glucoses 49) in the care and
screening of this elderly diabetic patient which do meet the ADA standard of care. This
65-year-old was not offered colon cancer screening during 2016-2017; this is not in
accord with national age-based standards of care.

•

This patient is a 69-year-old whose problem list noted hypertension and
hyperlipidemia. 50 His database noted PPD positive 37mm since 2007, and did not note
the administration of a pneumococcal vaccine in Volume II. His medications included
Lisinopril, Nifedipine, spironolactone, metoprolol, and pravastatin. This patient had

Chronic Care Patient #3.
The HbA1C test used at SCC is a point of care test (iSTAT). When there is a question of accuracy of test results, a comparison
of a same blood sample should be done at a known reliable laboratory comparing that test result with the iSTAT result. The
iSTAT equipment typically needs regular calibration and this may have been not properly done.
50 Chronic Care Patient #4.
48
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been treated in the past for a positive TB test. He had negative chest x-rays in 2016 and
2017. He is followed in the hypertension clinic, with two visits in 2017. The patient is
taking four antihypertensive medications, none of which were at maximum doses. Two
of his blood pressure medications retain potassium. It would be safer for this patient if
his diuretic was switched to one that did not have the risk of retaining potassium. There
was no comment in the provider notes that there was a clinical reason that
spironolactone was being prescribed. This hypertensive patient had markedly elevated
blood pressure readings at every provider sick call visit (five visits), but perfectly normal
blood pressures at the two hypertension clinics. At the 4/4/17 doctor sick call, the
provider noted a blood pressure 192/107 but did not comment on the markedly
elevated blood pressure and did not modify the blood pressure medication. The
hypertension clinic providers made no comment about the elevated blood pressures at
the sick call visits, did not document that they reviewed the blood pressures from other
visits, or were even knowledgeable of these elevated blood pressures. This 69-year-old
had no documentation in his record that he had been screened for colon cancer or had
received the pneumococcal 23 vaccine.
In summary, the experts are concerned that chronic care providers do not review the
findings or vital signs from other non-chronic care visits. The failure to utilize important
clinical information or data from other visits puts the health of patients with chronic
illnesses at risk. National age-based standards recommend that patients over 50 years
receive colon cancer screening and those over 65 years old be administered both
pneumococcal vaccines (13 and 23); there is no evidence that either of these screening
and preventive measures were offered to him. The experts are concerned that
prescribing of four antihypertensive medications with none at maximal dosage is putting
this individual at risk and is not in accord with national standards of care.
•

51

Another patient is 47-year-old whose problem list noted asthma, hypertension, and
bilateral knee pain. 51 His database indicated that he received the pneumococcal vaccine
on 1/17/16 and a flu shot on 11/30/17. His current medications include Xopenex
inhaler, Alvesco 160mg I puff BID, Montelukast 10mg/d, and hydrochlorothiazide
50mg/d. From January 2016 through January 2018 he was seen four times in the asthma
clinic, four times in hypertension clinic, and three times in the general medicine clinic.
His PEFRs recorded in the asthma clinic were 500 on 1/9/17 and 825 on 7/1/17 and
1/26/18, all reflecting excellent control. At some point Montelukast was properly
discontinued. The provider notes did not note any symptoms or any justification for the
continuation of the steroid inhaler (Alvesco). The patient had eight normal blood
pressure recordings from January 2017 to January 2018. He is taking
hydrochlorothiazide 50mg/day. Hydrochlorothiazide 50mg has been known for years
not to offer greater blood pressure control benefit than 25mg but has some greater risk
for dehydration and hypokalemia. He should be given the lower dosage of
hydrochlorothiazide. He had increased frequency of urination in June 2017 that was

Chronic Care Patient #5.

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clinically suspected to be benign prostatic hypertrophy (BPH), and he was placed on
Flomax. The higher dose of the hydrochlorothiazide diuretic may have been contributing
to his symptoms and, if decreased, might allow Flomax to be discontinued.
In summary, this patient has been regularly seen in three chronic care clinics. His asthma
and hypertension are under good control and he should be monitored to see if any of
his asthma medications can be decreased or discontinued. The providers should
decrease the blood pressure medication to 25mg for the safety of the patient. The
continued prescribing of hydrochlorothiazide 50mg has not been recommended for
treatment of blood pressure in the last 15-20 years.
•

52

Another patient is a 36-year-old whose problem list noted seizure disorder. 52 His
database was empty. His medication was phenytoin (Dilantin). He was seen in the
seizure chronic care clinic five times from February 2016 through February 2018. The
patient had a seizure reported on 1/30/16. At the 2/2/16 seizure clinic he was noted to
not have his seizure medications Keep-on-Person (KOP). On 4/26/16, he was reported to
have had another seizure; the physician wrote that the patient’s history was not
consistent with a seizure disorder and Dilantin was ordered to be tapered off. Another
seizure in his bed was noted by the RN on 7/17/16. On 7/29/16, the MD wrote “doubt
seizure;” again the Dilantin level was sub-therapeutic (2.5). The 8/9/16 seizure clinic
provider noted that the patient had seizures while sleeping and that the 7/29/16
Dilantin level was 2.5, but did not increase the dosage. The 2/7/17 seizure clinic wrongly
stated that the patient’s last seizure was on 1/6/16. A repeat Dilantin level was again
sub-therapeutic (2.5) and Dilantin dose was increased to 300mg/d. The Dilantin level
was again low (<2.5) on 2/23/17. Nursing noted on 3/17/17 that the patient was noncompliant with taking his seizure medications; there were three unused blister packs in
his cell. The RN wrote on 4/2/17 that she had the patient take his AM dose in front of
her and she recommended Watch-Take medications. Again on 5/18/17, the nurse stated
that the patient was not compliant with taking his antiepileptic medication. There were
no MD visits for the next two and a half months. The patient missed seizure clinic on
8/1/17 due to a security lockdown. He was seen in the seizure clinic on 8/12/17; the
provider did not comment on the repeated nursing concerns of non-compliance and
continued KOP Dilantin. A Dilantin level on 8/22/17 was for the fifth time in 20 months
sub-therapeutic (<2.5). At 8/24/17 physician sick call, it was noted that the patient had
another seizure “last night,” and Dilantin was finally changed to Watch-Take medication
administration; however, a loading dose was not given. This switch to Watch-Take
occurred over four months after nurses had documented his non-compliance with his
seizure medications. A repeat Dilantin level was 3.1, still sub-therapeutic, on 9/5/17. The
9/15/17 physician note was not legible. He was seen again in seizure clinic on 2/2/18.
The provider again erroneously noted that “no seizures since January 2016,” did not
comment on the recent sub-therapeutic level, but continued the Watch Take. This
provider clearly did not review the previous physician and nursing notes nor the recent

Chronic Care Patient #6.

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drug level; the Dilantin dose should have been increased or a new medication
prescribed.
In summary, this epileptic patient with uncontrolled seizures and multiple repeat subtherapeutic Dilantin levels was not being adequately treated. Physicians initially
doubted that he was having seizures, then failed to expeditiously switch him from KOP
to Watch-Take administration after repeated nursing notes documented noncompliance with his KOP medications. The four-month delay in changing the mode of
medication administration jeopardized this patient’s health. Even after Watch-Take
medications were finally initiated, the drug level was not therapeutic, but no clinical
action was taken (increased dose or new medication); this was not acceptable care. No
repeat Dilantin levels have been tested since the last sub-therapeutic level five months
ago. This patient with an unstable seizure disorder will not be followed up until August
2018. This is not acceptable and does not meet the community standard of care.
•

Another patient had a problem list noting asthma, Crohn’s disease, and hypertension. 53
The database noted a negative PPD on 8/20/17. His medications included
hydrochlorothiazide 25mg/d, verapamil 180mg 2 tabs/d, and Delzicol (mesalamine
equivalent) 400mg 2 tabs TID. He was seen in the hypertension clinic on 3/20/17 and
9/14/17; his blood pressures in the chronic care clinic and in a number of physician sick
calls were well controlled. He was evaluated twice (5/16/17 and 11/21/17) in general
medicine chronic care for his Crohn’s Disease. The provider stated at both visits that the
Crohn’s disease was “stable.” Labs performed four times during the last 12 months were
normal. At the 8/10/17 provider sick call, the patient stated that he not received his
Delzicol (Crohn’s medication) for a month, he was passing blood in his stool, and his
abdomen was benign. The assessment was acute flare-up of Crohn’s due to no
medications. The pharmacy was contacted, and the medications restarted. Patient was
seen again in the provider sick call on 10/31/17, complaining of blood in bowel
movement two times; a rectal exam was negative, CBC and FOBT was ordered. A
physician note on 12/19/17 was illegible. A referral to GI was approved on 12/27/17,
although there was no documentation in any notes that the patient was referred to GI.
At physician sick call on 1/9/18, patient again reported that he had occasional blood in
his stool and had occasional diarrhea. His abdomen was soft. The GI appointment had
been scheduled for 3/8/18. Review of the MAR verified that the patient received his
KOP supply of Delzicol in June 2017 and August 2017-January 2018, but not in the
month of July 2017.
In summary, the failure to deliver his Crohn’s medications in July 2017 triggered a flareup of his disease which persisted intermittently for the next six months. The presence of
blood in the stool can be caused by his inflammatory bowel disease and by other
conditions, including cancer of the colon. The patient reported passing blood on
8/10/17, 10/31/17, and 1/9/18. Even though he is at high risk for colon cancer, he was

53

Chronic Care Patient #7.

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not scheduled to see GI until seven months after his first reported episode and five
months after the second visit for blood in stool. This is an unacceptably long delay and
does not meet the community standard of care. He was noted in November 2017
chronic clinic as having “stable” Crohn’s disease even though he had had a recent
exacerbation in August 2017.
•

Another patient is a 51-year-old whose problem list included seizure disorder, hepatitis
C, hyperlipidemia, and bipolar disorder. 54 His medications are Procardia (nifedipine) and
Lopressor (metoprolol), both medications for hypertension, which is not on the problem
list, and Keppra (levetiracetam) 250/d. He is followed in the hypertension and seizure
chronic care clinics. He was seen in the seizure clinic four times and in the hypertension
clinic two times in the last 13 months. His blood pressure is generally well controlled. His
seizures were assessed as stable in 2017, but at his 2/21/18 seizure clinic it was noted
that he had a seizure three weeks prior to the visit. There was no comment on the type
of seizure or whether the patient was taking his seizure medications. The patient is
being administered his seizure medications as Watch-Take. In September-November
2017 and January 2018, the MARs documented that he received 100% of his doses, but
from December 17-30, 2017, he was documented as having received only four of the
expected 14 doses. This was not commented on during his 2/21/18 seizure clinic visit,
but may have been the reason that he had a seizure near the end of January 2018. By
just reading the medical record it was very difficult to identify whether the patient had
hepatitis C infection, had been treated for hepatitis C, or whether the disease was
active. He was not being followed in the general medicine clinic or in sick call for his
history of hepatitis C. The patient was interviewed, and he verified that he had been
successfully treated in 2006 with Interferon/Ribavirin while in IDOC. Lab tests showed
normal liver enzymes/liver studies but a low normal platelet count (125) was reported
on 7/17/17. An abdominal ultrasound exam to screen for hepatosplenomegaly, liver
fibrosis, and HCC was not performed in 2017. Patients with hepatitis C, especially those
with cirrhosis, which can cause low platelet counts, are at increased risk for
hepatocellular carcinoma. He was not being regularly screened with liver ultrasounds.
In summary, the problem list for this patient was incomplete, not noting the presence of
hypertension nor indicating that hepatitis C had been successfully treated. This placed
the patient at risk for disruption of his care and inadequate follow-up of these
conditions. It was very difficult to verify the patient’s history of hepatitis C, his previous
treatment, and his current status. The patient should have a liver ultrasound performed
to clarify the degree of liver fibrosis and to help determine whether he needs to be
regularly screened for HCC. The medical record does not address why the MAR indicates
that seizure medications were not consistently administered in December 2017 and
whether this contributed to a seizure that occurred in late January 2018.

54

Chronic Care Patient #8.

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•

Another patient is a 55-year-old whose problem list noted hepatitis C post-successful
treatment, hepatosplenomegaly, low platelets, BPH, and kidney stones.55 His
medications included lactulose, finasteride, Tamsulosin, and betablocker. He was
successfully treated (Harvoni) for hepatitis C at UIC Hepatology Clinic in 2014-2015.
Between October and December 2017, he had an abdominal US, colonoscopy and
esophagoscopy performed at UIC which did not identify liver masses/HCC, removed four
colon polyps (repeat colonoscopy in 10 years), and found small esophageal varices for
which a beta blocker medication was ordered. The liver ultrasound was repeated in
January 2018 and showed no masses. Multiple lab tests in 2016-2017 showed low
platelets, normal liver enzymes, normal INR, and intermittent mild elevations of total
bilirubin. He has received hepatitis A and B vaccines but there is no documentation in
the medical record that he has been administered/offered pneumococcal vaccinations.
There are no notes by the providers at SCC concerning his cirrhosis and portal
hypertension. The patient is not being followed in the SCC chronic care clinic. There are
no notes about his mental and cognitive status even though he is taking lactulose for the
treatment of hepatic encephalopathy.
In summary, this patient was successfully treated while in IDOC for hepatitis C. He also
has advanced cirrhosis. He is being followed by the Hepatology Service at UIC. It is not in
the best interest of the patient or the institution that this patient is not jointly
monitored in the chronic care clinic for his cirrhosis. SCC’s clinical team must be
continually aware of this patient’s baseline status so that they can expeditiously and
appropriately respond to any deterioration in his condition.

•

Another patient is a 52-year-old whose problem list notes HIV infection and s/p GSW
groin in 1986 with blood transfusions. 56 His database shows negative PPDs from 2010 to
2017. His medications include KOP Genvoya. There is no documentation that he has
been administered pneumococcal or meningococcal vaccinations or had been screened
for colon cancer. He has been seen twice by the UIC HIV telehealth specialists; the UIC
ID specialist’s notes are in the SCC medical record. On 3/20/17, UIC discontinued Atripla
and started Genvoya, and his VL was undetectable on 2/6/17. Repeat labs on 4/15/17
(VL undetectable, CD4 851), 5/4/17 (Cholesterol 153, Hct 39.9), and 6/12/17 (VL
undetectable, CD4 670) were good. The UIC HIV specialists assessed his HIV to be in
good control on 6/22/17. Repeat labs on 10/3/17 (VL undetectable, CD4 687) again
reflected good control. This patient is being regularly managed by the UIC telehealth HIV
specialists; his HIV is under good control. There are no notes by the SCC providers about
his HIV status or in regards to any of his age-based routine health maintenance needs.
In summary, this 52-year-old should have been screened for colon cancer, should have
documentation that pneumococcal and meningococcal vaccines had been provided, and
should have been considered for a statin for prevention of cardiovascular disease. None

55
56

Chronic Care Patient #9.
Chronic Care Patient #10.

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of these indicated interventions or screening have been done and all of these screening
and preventive measures are the responsibility of the SCC primary care medical team.
He has been at SCC for at least 11 months and he has not had an annual visit or a
chronic care visit. SCC must continue to provide the routine health maintenance needs
of all patients, even those with a condition that is closely monitored by offsite
specialists.
•

Another patient is 42-year-old whose problem list noted hypertension, seizure disorder,
hyperlipidemia, and HIV infection.57 His medications include Dulera
(mometasone/formoterol) inhaler, Albuterol inhaler, hydrochlorothiazide, Lisinopril
20mg/d, Genvoya, gabapentin, Keppra, atorvastatin, and ASA. He was seen in the
hypertension clinic one time, hypertension/seizure clinic one time, HIV Telehealth one
time, diabetes clinic one time, diabetes/seizure clinic one time, and asthma clinic one
time (refused one time) in 2017. His blood pressure is well controlled on his current
regimen. He had two HbA1Cs (6.1 and 6.6), consistent with pre-diabetes on the first test
and consistent with diabetes on the second test which was unrecognized. His glucoses
ranged between 89 and 132 in 2017. The diabetes care provider encouraged lifestyle
modifications to treat presumed pre-diabetes but failed to address the 2nd test which
was diagnostic of diabetes. His last seizure was reportedly in early 2017, with no further
seizures as of January 2018. He was assessed by the UIC HIV Telehealth Infectious
Disease specialists on 6/22/17; his VL was undetectable and CD4 617. Repeat VL
undetectable, CD4 624 on 10/3/17. His HIV is well controlled on Genvoya. In January
2018, the Genvoya was switched from DOT/Watch-Take to KOP, but the nursing staff
continued to give daily doses for the rest of January, even though the patient had
received a KOP supply of 30 tabs on 1/18/18. This created a potential risk for the patient
of double dosing. It is unclear why the DOT order in the MAR was not discontinued. At
the 7/1/17 asthma clinic, his PEFR was 325, and the patient refused to attend the 2/6/18
asthma session.
In summary, this patient’s multiple chronic conditions were managed in silos of five
separate chronic care or specialty clinics. This division of care has the potential of
disrupting this patient’s continuity and comprehensiveness of care. Excluding the UIC
HIV Telehealth Clinic, the chronic care notes are extremely brief and provide very
limited information on the patient’s status or ongoing health care plan. There is no
documentation anywhere in the asthma, diabetes, or HIV clinics that he had received or
been offered the indicated pneumococcal or meningococcal vaccines. Any one of these
three clinics could have provided the vaccine(s), but none of them did. There is no
comment or rationale for the prescribing of gabapentin in this patient. There was no
mention of peripheral neuropathy or nerve pain in the any of the provider notes. The
seizure clinic also did not contain any documentation that gabapentin was being used as
an epileptic medication in combination with Keppra. Gabapentin is not a benign
medication; the provider notes should clarify why this medication is being prescribed.

57

Chronic Care Patient #11.

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The patient appeared to have an A1c test diagnostic of diabetes which appeared
unrecognized.

58
59

•

Another patient is a 46-year-old whose problem list noted deep vein thrombosis (DVT)
secondary to GSW right leg (early 1990s) and hyperlipidemia. His database noted
negative PPD on 3/9/17.58 His medications include warfarin and Zocor (simvastatin). He
was followed in the chronic care clinic (5/1/17, 11/3/17) in 2017. From 12/20/16
through 2/22/18, 12 INRs were performed to assess the level of anticoagulation; only
one (11/8/17, 2.3) was in the therapeutic range. The providers did incrementally
increase the warfarin dose from 7.5mg/d to 10mg/d over these 15 months. The latest
increase was ordered on 10/1/17, but INRs have continued to be sub-therapeutic in
December 2017 and January-February 2018. The MARs revealed 100% patient
compliance with warfarin doses from November 2017 through January 2018. In
summary, the level of anticoagulation for this patient is suboptimal. The frequency of
INR testing and warfarin adjustment should have been accelerated. This patient is at risk
for another DVT or thromboembolism. The providers at SCC do not seem to understand
the urgency of achieving therapeutic levels of anticoagulation using warfarin. In this
clinical environment, the use of newer anticoagulants that do not require INR testing
and dose adjustments should be strongly considered. Also, DVT is typically treated for
three months. This patient was being treated for over a year. While selected patients
require long-term treatment, the rationale for long-term treatment needs to be
documented in the record. If the patient was being treated unnecessarily, it places him
at significant risk due to the potential adverse effects of warfarin.

•

Another patient is a 62-year-old whose problem list noted diabetes and hepatitis C. 59
His database documented pneumococcal 23 vaccination in 2003 and 2011, and hepatitis
A and B vaccinations in 2013. His medications include insulin 70/30, metformin
500mg/d, and gabapentin. He was seen in the diabetes clinic seven times and the
hepatitis C clinic three times from 12/13/15 and 12/12/17. Over the last two and a half
years, this patient’s diabetes was never under optimal control, his HbA1C ranged from
7.7-8.7 with a minimum goal of less than 7.0, as in IDOC DM guidelines. His 70/30 insulin
has remained at 50U/AM and 30U/PM for a number of months; it was unclear from the
notes why and when the insulin dose was decreased from 65U/30U to 58U/30U to
50U/30U. He also takes metformin 500mg/d and on 1/8/18, glipizide 5mg/d was added
to his regimen. Urine testing has demonstrated macroproteinuria since 2008 and high
microalbumin/creatinine level (1017 mg), yet there is no evidence in the medical record
that this patient had been prescribed an ACE inhibitor to minimize the risk of further
kidney damage. This diabetic’s cardiovascular 10-year risk was 20.2% but he has no
documentation in the chart that he is taking a statin medication to decrease his risk of
MI or CVA. His blood pressures have never been at goal of <140/90 as required in IDOC
guidelines, yet it appears that he is not taking anti-hypertensive medications. There is

Chronic Care Patient #12.
Chronic Care Patient #13.

February 26 - March 1, 2018

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no comment in the chronic care clinic notes that the patient is taking an ACE inhibitor, a
statin, or a hypertensive medication. This patient’s diabetes is being poorly managed.
The rationale for decreasing the insulin dosages was not documented in the progress
notes of diabetes clinic. Elevated liver enzymes have been noted at three of the four
hepatitis clinic visits. UIC did a liver fibroscan that revealed Stage 4 (advanced cirrhosis)
on 11/15/17. A hepatitis C RNA test on 5/31/17 was elevated to 2,775,804. It has been
determined that this patient is a candidate for hepatitis C treatment and a referral has
been recently made (2/6/18) to Wexford’s Dr. Paul for review and approval to treat.
In summary, this patient’s diabetes has never been controlled. The treatment plan is
unclear from the brief chronic care notes. This patient warrants a referral to
endocrinology to establish a plan to optimize the diabetes treatment. It is inexplicable
why this at-risk diabetic is not prescribed an ACE inhibitor, a HMG-CoA reductase
inhibitor (statin), and a hypertensive medication. This 62-year-old patient should be
screened for colon cancer and should have received a pneumococcal 23 vaccine, but
there is no documentation in the medical record that these screening and preventive
interventions have been done. We also note that referral for treatment for hepatitis C
occurred when this patient already had cirrhosis or late-stage disease. This means that
this patient will endure long-term risk of cirrhosis, including hepatocellular carcinoma,
when earlier treatment may have avoided this complication.

Urgent/Emergent Care
Methodology: We interviewed the Director of Nursing, toured the medical clinic, assessed the
availability and functionality of emergency equipment and supplies, reviewed emergency drills,
CQI reports, and medical records. Medical records were selected from the list of emergency
department (ED) visits in 2017 provided by SCC. This list includes the reason for the ED visit.
Records selected for review were those conditions sensitive to ambulatory care, such as
seizure, withdrawal, infection, diabetic complications, abdominal pain, chest pain, etc. A total of
eight records were reviewed.
First Court Expert Findings
ER reports were absent in all the medical records reviewed and the care of patients was found
to be problematic before the ED visit and after the patient’s return to SCC. The First Court
Appointed Expert recommended the QI program monitor and report results on the timeliness,
appropriateness, and continuity of care of patients sent to the ED.
Current Findings
SCC provides basic CPR and first aid. Emergency response equipment consists of first responder
bags that contain first aid supplies, stethoscope, blood pressure cuff, cervical splint, and a few
medications (i.e., glucagon). There are also two large duffel bags that are considered disaster
bags. These contain larger quantities of supplies and equipment needed to respond to multiple
injuries. The basic first responder bags and the disaster bags are not locked and there is no list

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of contents and their location as required by SCC Operations Policies and Procedure. 60 An
automatic external defibrillator (AED), ambu bag, portable oxygen, EKG machine, suction,
nebulizer, and oto-ophthalmoscopes are available in the urgent care room in the clinic at SCC.
The presence and functionality of the first aid equipment is checked daily by the night shift and
documented on a log. We checked the AED and oxygen tanks and found both to be functional.
First aid kits are in the offices on each of the cell blocks. These are not regularly inspected and
re-supplied as required by SCC Institutional Directive. 61 Two kits were inspected; the seal was
broken on both and there were no gauze or bandages in the kit.
Training records are maintained and nearly all health care staff are current in CPR. The few who
are not current are noted on the record; these are staff on leave. SCC’s Institutional Directive
and Operations Policy and Procedure require that emergency drills be conducted twice a year
on each shift. One of these is to be a mass casualty drill involving multiple people with injuries.
The annual CQI report for 2016-17 lists the drills that have taken place. Based upon this list, SCC
did not comply with either directive. Only one drill was conducted on the 7 a.m. to 3 p.m. shift,
and only one mass casualty drill was completed rather than one on each shift. Also, the
description of the mass casualty drill conducted on the night shift 8/23/2017 only involved one
injured person, so does not meet the definition of a mass casualty drill. The written critiques of
these drills are very brief.
We reviewed the medical record of eight patients sent to the emergency department (ED) in
2017 and found that ED visits were often preventable, information and recommendations from
the ED were not obtained, or if it was, not incorporated into the patient’s subsequent
treatment plan. These findings are detailed in the following paragraphs.
•

The first patient has a history of uncontrolled hypertension and end stage renal
disease. 62 Documentation of the reason for sending the patient to the hospital
emergently on 7/8/17 is very brief - shortness of breath and fluid overload. He was
discharged three days later. There is no note summarizing the findings or treatment
recommendations from the hospital. No records from the treating hospital were
obtained. He was not seen in chronic care clinic following the hospitalization until
November. This hospitalization was likely preventable if his chronic disease had been
monitored and managed more often than every three to four months. There was no
effort to review records from the hospitalization and incorporate this information into
the treatment plan.

•

The next patient was sent to the ED on 9/18/17 for severe facial swelling and confusion
resulting from an assault.63 His problem list includes quadruple coronary bypass,
hypertension, and prostatic hypertrophy. The initial response to the facial injury was
timely and appropriate. The ED took x-rays and diagnosed a zygomatic fracture and

P112 Emergency Services, June 2017, p. 20.
04.03.108 K3 Response to Medical Emergencies May 1, 2016.
62 Urgent/Emergent Patient #1.
63 Urgent/Emergent Patient #2.
60
61

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recommended tramadol for three days, twice a day for pain, and referral to an eye
specialist. Upon return to SCC the provider made the referral to an eye specialist, but
did not order the pain medication or document a rationale for deviating from the
recommendation.
•

The next patient was hospitalized emergently on 4/4/17 for abdominal pain, blood in
stool and weight loss.64 He is a 66-year-old and has diagnoses of hypertension, chronic
obstructive pulmonary disease, GERD, and prostatic hypertrophy. He complained of
black stool on 4/2/2017 and a sample was positive for blood. On 4/3/17, he was seen by
a provider for skin breakdown on his right hip. The provider did not address the problem
of blood in his stool. The provider noted that he should be scheduled for a follow-up
appointment in one week for results of biopsies from a GI consult at UIC. No follow up
appointment was scheduled. His care before the hospitalization and afterwards is
episodic. The outbound note from SCC refers to the patient having had a previous stroke
and yet this is not on his problem list. Treatment recommendations from the hospital
were not followed and there is no documentation of a rationale for an alternative
treatment plan.

•

The next patient was sent to the ED on 2/9/2017 for severe anemia with shortness of
breath and dizziness.65 He had been seen at nursing sick call five days earlier for
dizziness. He had a history of a gastrointestinal bleed and hypertension. The nurse
referred him to a provider urgently on 2/4/2017 because of a rapid pulse (124) and
elevated blood pressure (150/72). The provider ordered labs and an EKG. The EKG was
not done because it was “broken,” and labs were not resulted until 2/8/17. The
provider’s review of these results prompted the referral to the ED. Upon return from
the ED the patient was not seen by a provider in follow up until 2/17/17.
Recommendations from the ED were not acknowledged by the provider and there was
no documented rationale for deviating from the recommended plan of care. This ED
visit would likely have been avoided if the diagnostic labs had been accomplished more
quickly and treatment initiated earlier.

•

The next patient was sent to the ED on 9/30/17 for intractable low blood pressure. 66
There are no problems listed on the problem list and it has not been updated since
5/17. However, this patient was being seen by the Medical Director for chronic pain. The
Medical Director referred the patient to the UIC chronic pain clinic on 8/9/17. The
patient was taking clonazepam and lorazepam and reported these as being ineffective in
relieving his back pain. The Medical Director documented that the patient was
exhibiting drug seeking behavior. The patient asked for renewal of his medications on
8/30/17 and was scheduled to be seen on 9/5/17. He was not seen that day and made
another request to have his medications renewed before they expired on 9/16/17. He

Urgent/Emergent Patient #3.
Urgent/Emergent Patient #5.
66 Urgent/Emergent Patient #6.
64
65

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was seen the day before his medications expired and they were renewed. He was seen
again on 9/25/17 for back pain and x-rays were ordered. A Toradol injection was
ordered on 9/28/17 and he was admitted to the infirmary when his blood pressure
dropped from 137/85 at 6:00 p.m. to 114/71 four hours later. He continued to receive
Toradol injections on 9/29/17 and 9/30/17. The patient continued to report significant
pain and his blood pressure remained low, so the Medical Director sent him to the ED
on 9/30/17. The patient returned from the ED with recommendations for Norco. The
nurses contacted the Medical Director, who instructed them not to give the patient
Norco and ordered clonazepam and lorazepam instead. The patient did not see a
provider in follow up until three days after the ED visit on 9/30/17. This patient was not
seen by the UIC pain clinic until 1/24/18. Diagnostic imaging of the lumbar and thoracic
spine was recommended as well as trigger point injections for radicular and myofascial
pain. Chronic pain or the underlying cause of the chronic pain is still not listed on the
problem list. Had this patient’s chronic pain been managed the ED visit would have been
avoided. The referral to UIC took too long to effectuate.

67
68

•

The next patient was sent to the ED on 8/22/17 for chest pain. 67 He is 66 years old and
his problem list includes Crohn’s disease, heart disease, and depression. However, he is
not followed in the chronic disease clinic. He was seen for Crohn’s disease on 7/25/17,
and his blood pressure at that visit is recorded as 91/72. The provider did not remark on
this low blood pressure and no additional follow up was ordered. On 8/22/17, he
complained of chest pain, and after two hours of monitoring and treatment at SCC he
was sent to the ED. At the ED he was diagnosed with esophagitis and GERD. Follow up
with cardiology was recommended by the ED. He was not seen following the ED visit
until 20 days later. No cardiology referral was made. He was scheduled for an
enteroscopy in October 2017 and a follow up appointment for GERD in November 2017.
This patient should be followed in a general medicine chronic disease clinic and
abnormal vital signs should have been addressed by the provider who saw him in July
2017. In addition, he was not seen timely after returning from the ED and a cardiology
referral should have been made.

•

The final patient was sent to the ED on 5/4/17 for an acute infection on his right foot.68
He was diagnosed with insulin dependent diabetes and hepatitis C. He was seen in both
the diabetic and hepatitis C chronic disease clinics. He was seen in chronic clinic for
diabetes on 12/1/16 and his HbA1C was noted to be 8.2 (poor control). He was seen
again on 4/3/17 and his HbA1C was 8.7 (poor control). In February 2017 he was seen for
swelling in his legs and a diuretic (Lasix) was ordered. His legs were documented as still
swollen when he was seen by providers in March and April. Reduced sensitivity in his
feet due to diabetes is documented by the provider who saw him 4/26/17. No changes
were made in his treatment, and the frequency of chronic care appointments to manage
his diabetes was not increased. This patient with poorly controlled diabetes and

Urgent/Emergent Patient #7.
Urgent/Emergent Patient #8.

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neuropathy in his feet stubbed his toe on 5/3/17 sufficient to cause loss of a toenail and
severe bruising of the foot. He requested health care attention the next day, was
admitted to the infirmary and started on IV antibiotics, but later that day was sent to
the ED for treatment. Upon his return to SCC, the recommendations from the hospital
are noted and implemented. This ED visit was likely preventable if his diabetes had been
more closely monitored and his condition treated more rigorously.
We also reviewed six medical records of patients who were hospitalized to assess their care
before and after hospitalization. We found that, as with the persons going to the ED, patients
returning from in-patient hospitalization do not consistently have a hospital discharge
summary. We noted clinical management problems in all six records reviewed, including
significant preventable or possibly preventable harm and risk of harm to patients who had
delayed hospitalization, delayed specialty care, or lack of primary care of their underlying
medical conditions. The lack of appropriate treatment of their underlying medical conditions
resulted in deterioration and harm (myocardial infarction, stroke, and colon cancer) that was
preventable if their conditions were treated appropriately. There appears to be a significant
knowledge and practice deficit with respect to managing primary care problems, which we
attribute to the use of a surgeon instead of a doctor trained in primary care. This is a
credentialing and privileging problem. We also note that in two cases there appeared to be a
lack of documentation of episodes of care immediately preceding hospitalization. All clinical
episodes of care need to be documented in the medical record. We give summaries of these
cases below.
•

The first patient had listed problems including hypertension, asthma, type 2 diabetes,
and GERD. 69 The patient had three major risk factors for coronary heart disease
(hypertension, diabetes, and high blood lipids), but his high blood lipids were not
recognized as a problem by facility physicians. Because this condition was unrecognized,
he was not treated with anti-lipid medication, which is a standard of care. Providers saw
the patient on 24 occasions, with elevated blood pressure dating from May of 2016 until
January of 2017, but the blood pressure medications were only minimally adjusted on
only two of the 24 episodes of care. The patient’s blood pressure remained uncontrolled
over the course of an entire year. Once when seen in hypertension chronic clinic and
twice in diabetes clinic, the blood pressure was elevated but the only treatment was to
add a diuretic (at only the hypertension clinic visit). Hypertension is a risk factor for
stroke and coronary artery disease, and not treating blood pressure to an appropriate
goal places the patient at increased risk for coronary events. The diabetes was also not
well controlled.
On two occasions the patient had chest pain with elevated blood pressure. On one
occasion the patient had exertional chest pain with blood pressure of 199/128 which
constitutes hypertensive urgency. Exertional chest pain suggests acute coronary
syndrome which requires an immediate EKG and evaluation. The nurse called a doctor,

69

Hospitalization Patient #2.

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but an EKG was not done, and the patient did not receive an evaluation for acute
coronary syndrome. The doctor failed to follow generally accepted guidelines or usual
standard of care, which should have included evaluation for acute coronary syndrome.
On another occasion, a nurse called a doctor because the patient had chest pain with
blood pressure of 188/102. The doctor ordered Ativan, nitroglycerin, and a single dose
of clonidine, but did not order an EKG or send the patient to an ER. This also failed to
follow generally accepted guidelines or usual standard of care to evaluate for acute
coronary syndrome. Over the next hour, after this episode of chest pain, an LPN saw the
patient four times. During one of those episodes, the patient described chest pain like
“someone elbowing me in the chest.” Shortly after that, the LPN documented a blood
pressure of 204/93, an extremely high blood pressure that in combination with chest
pain was a red flag sign. An LPN should not have been making these repeated
evaluations, as they are not trained in assessments. As well, the patient did not have
timely transfer to a higher level of care.
There were no further notes, but the patient was admitted to a hospital at some time
unknown and diagnosed with a heart attack. All care needs to be documented in the
medical record, but the episode of care resulting in the transfer was not documented in
the medical record. The patient had a stent placed and returned from the hospital on a
statin drug. Care for this patient demonstrated a lack of knowledge of primary
prevention of heart disease and on treating angina, a common primary care problem. It
was similar to care we noted in mortality reviews at a different institution which
resulted in death. This heart attack was likely preventable if the blood pressure was
treated and if he was placed on a statin drug. Failure of the on-call doctor to admit a
patient with typical chest pain and elevated blood pressure placed the patient at
significant risk of harm and was grossly and flagrantly unacceptable.
•

70

Another patient with a history of smoking had elevated lipids with cholesterol 232, HDL
54, and LDL cholesterol 153. 70 The standard of care for these laboratory test results is
treatment with a statin drug, which was not done. On 12/8/14, the patient had an
elevated HbA1C of 6.6, which is diagnostic of diabetes. The standard of care for his
diabetes would have been to treat the condition with an oral agent and to attempt
weight loss. Diabetes with high lipids raised the risk for stroke and coronary heart
disease, and treatment with a lipid drug was indicated. The patient had approximately a
20% 10-year risk for heart disease or stroke, yet remained untreated for high blood
lipids or diabetes for years. Dating from 4/12/16, the patient had elevated blood
pressure which was also not treated. Elevated blood pressure is also a risk factor for
stroke. Thus, the patient had three major treatable risk factors for stroke for which he
was not treated, which was significantly below standard of care. On 7/10/17, the patient
developed a stroke. The patient was not treated for his elevated blood lipids or diabetes
until after return from the hospital. The patient now has right sided weakness and
aphasia (difficulty speaking). Care of this patient was grossly and flagrantly

Hospitalization Patient #3.

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unacceptable. This stroke was preventable if the patient was appropriately treated for
his cardiovascular risk factors.
•

Another patient had apparent COPD/asthma and obstructive sleep apnea. 71 Tests for
these conditions were not evident in the medical record. The patient had no monitoring
of his sleep apnea for a year. Also, on review of the current volume of medical records,
there was no evidence that the patient had ever had a pulmonary function test, which is
recommended as a cornerstone of diagnosis for both COPD and asthma. So, it was not
clear that the patient had an accurate diagnosis of his medical condition. For a year, the
patient had eight exacerbations of presumed asthma or COPD requiring use of tapering
oral steroids. The patient had oxygen saturation at 88% or lower on 10 different
occasions despite being on what appeared to be maximal medical therapy (Advair
diskus, albuterol nebulization, Singulair, and Xopenex). 72 The standard of care with this
level of oxygen saturation in persons with COPD is to obtain an arterial blood gas and
assess whether the patient needs continuous oxygen therapy. Despite indications for
oxygen therapy, the patient never received an arterial blood gas or evaluation for the
need of oxygen therapy and did not receive continuous oxygen therapy. As well, on six
occasions the patient had red flag abnormal vital signs signifying possible need for a
higher level of care, but was not referred to a hospital or higher level of care, which
placed the patient at significant risk of death. These episodes included:









On 5/15/17, the patient had productive cough, labored breathing, wheezing, and
oxygen saturation of 82%. A doctor admitted the patient to the infirmary but did not
obtain a chest x-ray or laboratory tests. An arterial blood gas should have been
performed immediately. The patient should have been sent to a hospital because of
the significant oxygen desaturation.
On 4/18/17, a nurse found an oxygen saturation of 80% with diffuse wheezing. Even
though the oxygen saturation improved to 88% after treatment, a provider did not
see the patient. This was a critically low oxygen saturation which should have been
resulted in immediate hospitalization for further prompt evaluation.
A nurse evaluation for oxygen saturation of 86% and hypotension (blood pressure
81/49). The nurse took no action. 73
A nurse evaluation for oxygen saturation of 84% with hypotension (blood pressure
88/41). The nurse took no action.
A nurse evaluation for oxygen saturation of 84% and hypotension (blood pressure
85/43). The nurse took no action.
A nurse evaluation for oxygen saturation of 86% with hypotension (blood pressure
95/43). The nurse took no action.

Hospitalization Patient #4.
An oxygen saturation of 88% is used by Medicare as the threshold for use of continuous oxygen therapy.
73 Low blood pressure suggests but is not diagnostic of shock. Combined with severely abnormal oxygen saturation, this patient
should have been sent immediately to a hospital for diagnosis and evaluation, yet the nurse took no action and did not even
consult a physician. The nurse evaluating the patient was an LPN but did not document consulting with a supervising RN, which
is required by Illinois nursing regulations when LPNs are involved in assessments.
71
72

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This patient was eventually admitted to a hospital, but the hospital report was not in the
medical record and the prison providers did not document knowledge of what occurred
at the hospital or note any hospital recommendations. Providers did not appear to have
an accurate diagnosis. If the patient had asthma, he should have been admitted to a
hospital on multiple occasions for oxygen desaturation, but was not. If the patient had
COPD or overlap syndrome, he should have had an arterial blood gas and considered for
continuous oxygen therapy. If the patient had either asthma or COPD, the patient
should have had pulmonary function tests. Care for this patient was grossly and
flagrantly unacceptable. Providers did not appear to know how to care for this patient’s
disease and the patient should have been referred to a pulmonologist for better
diagnosis and management. The failure to know how to manage this patient placed the
patient at risk of harm.
•

Another patient was 56 years old and was incarcerated at Graham on 9/15/15 before
being transferred to SCC. 74 His initial weight was 213 pounds. Despite being over 50,
there was no documented evidence of preventive screening for colorectal cancer, which
is a standard of care. Colorectal cancer screening is recommended for all persons over
50 years of age but does not appear to routinely occur in the IDOC. On 11/8/16, a doctor
saw the patient for complaint of blood in his stool. The doctor did a digital rectal
examination and felt what he thought was a hemorrhoid. The stool was guaiac positive,
which indicates blood. The doctor ordered hemorrhoid cream and a three-month follow
up. The standard of care for a guaiac positive stool in a 56-year-old man is colonoscopy
to rule out colon cancer or another source of the bleeding. On 11/29/16, a doctor
ordered fecal occult blood tests and on 12/1/16, the tests were positive. On 1/4/17, a
doctor ordered a GI consultation; the weight was 186 pounds, which was a 27-pound
weight loss since incarceration. The doctor failed to document recognition of the weight
loss and took no history about weight loss. The standard of care is to obtain timely
colonoscopy because weight loss and blood per rectum in a 56-year-old requires
exclusion of cancer. Instead, the doctor failed to take sufficient history and ordered a
routine work up, which was significantly delayed. There is a known delay in getting GI
consultation scheduled at UIC. Instead of obtaining this test at another center, the
patient was allowed to wait with a condition that should have been evaluated much
sooner.
Four months later, on 4/10/17, an annual history and physical examination of this 56year-old did not include colorectal cancer screening. The GI consultation ordered on
1/4/17 was approved on 1/11/17 but did not occur until 7/7/17, about six months later.
The GI consultant recommended colonoscopy and EGD, but this did not occur until
11/27/17, at which time the patient had locally invasive metastatic rectal cancer. The
patient was admitted directly to the hospital from colonoscopy and when he returned
to the prison with cancer pain, the pain was not addressed. This patient with need of
colorectal screening failed to have it offered. The patient had documented weight loss

74

Hospitalization Patient #6.

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that was unrecognized for well over a year. When he showed signs of weight loss and
bloody stools, it took over a year to obtain a work up for colon cancer. These delays in
obtaining specialty care most likely resulted in dissemination and advancement of his
colon cancer, which caused harm.
In addition to this event, the patient, who was on psychotropic medication for a mental
health condition, developed a hand tremor on only one hand. A doctor diagnosed
Parkinsonism without performance of a history or physical examination and started
Cogentin, which has no indication for Parkinsonism. This is below standard of care with
respect to diagnosis of Parkinsonism. Two weeks later the same doctor, without
performing a history or physical examination, ordered Sinemet, a drug used for
Parkinsonism. The doctor made the diagnosis without a history or physical examination
supporting that diagnosis. Six months later, the patient was referred to a neurologist.
The neurology consultation occurred nine months after the referral. When the
neurologist saw the patient, he found no evidence of Parkinsonism and recommended
tapering the patient off Sinemet. The doctors at SCC did not stop the Sinemet. The
doctors at SCC failed to document sufficient history or physical examination to support
their diagnosis and failed to follow a neurology recommendation to taper the patient off
a possibly unnecessary drug. These two episodes of care for this patient were grossly
and flagrantly unacceptable.
•

75

Another patient had a history of gout. 75 He developed swollen joints and had multiple
provider encounters for his complaints but did not have thorough history or physical
examinations. Providers were treating the patient with bursts of steroids without having
established a firm diagnosis of gouty arthritis and without addressing treatment of his
uric acid, which is standard of care in treatment of gout. During two episodes of swollen
joints, providers aspirated the joint for a joint culture and treated the patient for gout
without obtaining an analysis of the joint fluid for crystals, which is the standard of care
for diagnosing gout. After initially treating the patient for gout, another provider started
treating the patient as if the patient had rheumatoid arthritis without definitively
establishing the diagnosis. It appeared that the providers did not understand how to
diagnose either gout or rheumatoid arthritis, and the patient should have been referred
to a rheumatologist for consultation. The patient developed redness on the front of the
thigh encircling to the back of the thigh; the area was swollen. Despite an extensive area
of possible infection, the nurse did not consult a physician, but referred the patient for a
three-day follow up. Two days later, the patient developed fever to 103.6°F and a doctor
started intravenous antibiotics. The following day the patient was sent to a hospital,
where extensive debridement was necessary for an abscess. The referral by the nurse to
a provider was not timely and most likely resulted in extension of the infection. The
management of this patient’s swollen joints failed to follow generally accepted
guidelines.

Hospitalization Patient #1.

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•

Another patient had a problem list at IDOC including diabetes, hypertension, and HIV
infection.76 Consultant notes indicated that the patient had hypertension, diabetes,
dyslipidemia, HIV infection with AIDS, Bell’s palsy, lower extremity neuropathy, and
chronic thrombocytopenia. The patient was not being followed at IDOC for all of his
medical conditions. The patient also had hypertension. The blood pressure goal for
persons with diabetes is optimal when below 130/80. This patient had elevated blood
pressure (>130/80) on five occasions when seeing a provider between January and May
of 2017. On none of these occasions did the provider adjust the blood pressure
medication. In May of 2017, the patient developed chest pain and was admitted to the
hospital. There was no hospital discharge report in the record, so it was unclear whether
the patient sustained a heart attack, but an IDOC doctor mentioned that the patient had
coronary artery bypass surgery.
When the patient returned to prison he was admitted to the infirmary. The patient had
exertional chest pain and shortness of breath on two occasions on the infirmary which
did not result in nurses calling a doctor. The patient told a nurse that he felt “jittery and
my breathing is funny,” yet a doctor discharged the patient from the infirmary to
general population without evaluating the chest pain and shortness of breath. This is
below standard of care, particularly in someone with a recent coronary event. A couple
days after discharge from the infirmary a nurse charged the patient $5.00 to evaluate an
episode for chest pain. The nurse cynically wrote that “I/M arrived in HCU for a CMT
chest pain call and was more concerned with asking for a new wheelchair.” The nurse
did not consult a physician for a complaint of chest pain in a patient with recent
coronary artery bypass surgery. On 6/8/17, the patient developed a temperature of
100.2°F with a pulse of 128. Documentation was poor, but it appeared that the patient
was eventually sent to a hospital, where pulmonary embolism was diagnosed. The
hospital record was not in the medical record. The evaluations by nurses on the
infirmary and in general population were significantly deficient, as the patient had
critical complaints, yet the patient was not referred to a provider and the nurse did not
consult a provider. All episodes of care need to be documented in the medical record.
The failure of the provider to evaluate the patient on discharge from the infirmary when
the patient had complaints of difficulty breathing was below standard of care. The
patient may have had pulmonary embolus when discharged from the infirmary which
was unrecognized. This placed the patient at risk of harm.

In summary, we concur with the First Court Appointed Expert’s findings that ED and hospital
reports were often absent in the medical records reviewed and the care of patients was
problematic before the ED and hospital visit and after the patient’s return to SCC. We also
found that SCC is not following its own written directives regarding the emergency response,
first aid equipment and supplies, and the frequency and content of drills.

76

Hospitalization Patient #5.

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We agree with the First Court Appointed Expert’s recommendation that the QI program
monitor and report results on the timeliness, appropriateness, and continuity of care of
patients sent to the ED and hospital. The lack of appropriate medical care before and after
hospitalization supports our opinion about the lack of appropriately trained physicians in the
IDOC. We make additional recommendations found at the end of this report.

Specialty Consultations
Methodology: We interviewed scheduling personnel, reviewed tracking logs, and reviewed
medical records of patients who received specialty care. We reviewed care related to
consultation requests.
First Court Expert Findings
The First Court Expert found anecdotal evidence that it takes as long as a month before UIC
receives information regarding an approval for a specialty consultation. Nine records were
reviewed of patients scheduled for consultations or a procedure. Six of the nine records
reviewed demonstrated problems. Problems included no reports and failing to follow
recommendations of the consultant.
The First Court Expert recommended that the timeliness of access to specialty services needs to
improve and that there needed to be a reliable method of communication between the
scheduler and clinician to ensure timeliness of appointments based on urgency of need.
Current Findings
We found no improvement in specialty services since the First Court Expert’s report and noted
significant problems in specialty care that caused harm to patients.
The procedure for specialty care is the same at SCC as at NRC. A provider is to write a referral
on the date the referral is requested. Within five working days, a collegial review is to occur
followed by approval and then a scheduled appointment. Of 11 consultations we reviewed with
respect to this procedure, all 11 had a collegial review documented in the medical record, but
only five of the 11 had this collegial review timely. The contract and administrative directive on
specialty care calls for a collegial review in five days. We reviewed 35 consultations to assess
whether a consultation report was present. Formal reports were present in the medical record
in only 19 times (54%). This is similar to the First Court Expert’s finding.
For every consultation, a provider is to see the patient to review the consultation results with
the patient within five days. In 10 consultations we reviewed for this purpose, a provider saw
the patient after all 10 consultations. The patient was evaluated timely in eight of 10 postconsultation visits. However, the quality of the evaluation was very poor. The provider
documentation in the medical record did not give the status of the patient. In none was there a
history updating the patient’s condition with respect to the consultant’s findings. In five of the
10 post-consultation provider visits, the doctor documented that he was seeing the patient for
a post-consultation visit but failed to document what occurred at the consultation. On two
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post-consultation visits the doctor failed to identify that a biopsy had been done, and these
biopsy results were never noted in the IDOC medical record. In two post consultation visits, the
consultant’s recommendations were not addressed. 77
The First Court Expert found that there was poor communication between the scheduler and
the clinician with respect to scheduling. We agree.
Collegial reviews are not consistently timely. We inspected the tracking log for consultations
completed from 1/1/17 to 3/31/17. There were 321 completed consultations during this time
period. For 35 (11%) consultations, the collegial review was documented as occurring more
than two weeks after the date of referral. We also note that referrals are not placed in the
record until the consultation is completed, so doctors will not know from the record whether a
referral was requested until after it is completed. Since the referral is a medical record
document equivalent to a physician order, it is our opinion that these should be placed in the
medical record at the time they are ordered to ensure that all referrals are visible to all
providers.
The First Court Expert recommended the need to track specialty care steps to ensure timeliness
of scheduled offsite consultations. The logs being used for this purpose do not reliably or
accurately track this information. We found the tracking log to be unreliable with respect to
ability to track the steps of a specialty consult, including the date of referral, the collegial
review, the approval, the scheduled appointment date, and the completed appointment date.
For the three-month period of study cited above, 22 (7%) of 321 collegial reviews were
documented as occurring before the date of referral. This is not possible and suggests that the
documented date of referral is not accurately provided or that some entries are post-dated. We
reviewed the electronic tracking log for the month of January of 2017. There were 86
completed consultations in this log. Of these, 60 (70%) consultations were documented as
being completed before the consultation was documented as having been referred. Since we
received this document late we were not able to discuss this finding with the scheduling clerk.
The IDOC has an arrangement with UIC in which the IDOC is allowed 216 admissions to the UIC
hospital and 2160 consultation visits annually free of charge. The incentive to obtain free care
appears to result in some patients not receiving timely care, which causes harm. This is
especially true for gastroenterology. For the 55 gastroenterology consults completed in 2016
and 2017, the average time from referral to completion of the consult was approximately six
months. We note that since the referral dates are not accurately stated, these delays may be
even longer. Some of these delays were for diagnostic studies which would result in harm if not
timely accomplished.
There did not appear to be any effort to reschedule important consults to other centers so that
timely care could be obtained. We were told that past due appointments are managed by
Wexford and discussed at collegial reviews. We did not see evidence of this. We noted in the
77

These consultations were from Specialty Care Patient #3 and included consultations from 3/23/16 through 9/8/17 inclusive.

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hospital section of this report a case in which a patient with weight loss and bleeding from his
rectum was not evaluated in gastroenterology clinic for over six months and did not receive a
necessary colonoscopy for an additional four months, at which time an advanced cancer was
noted. When any consultation is delayed beyond what is reasonable standard of care for a
condition, the consultation should be scheduled with a different consultant. If Wexford is
managing these cases, there needs to be evidence in the medical record of how they are doing
this. The doctors in the case of this patient with rectal cancer did not appear aware of the delay
in care and its urgency, and did not refer to a provider so timelier care could be obtained. There
was no evidence in the medical record that Wexford corporate utilization management was
following this delay or considering its effect on the patient. There was no evidence that this
sentinel event was reviewed by the CQI committee except to list it as a delayed diagnosis.
The offsite scheduling log does not document in all cases whether a referral is to UIC or to a
local provider. However, we were told that most referrals for off-site consultation are to UIC.
The use of UIC in preference to local providers even when UIC appointments cannot be
scheduled timely creates the appearance of saving money instead of protecting the interest of
the patient. The offsite consultation process as it currently exists is a patient safety issue. Until
it can be corrected, it should be abandoned, and doctors should be allowed to refer directly to
consultants until Wexford can ensure patient safety.
Patients with need of specialty care referral were not always referred for care. We noted in the
hospital reviews above a patient who should have received pulmonary consultations and
pulmonary function tests who did not receive that care. One patient should have been referred
to a rheumatologist to evaluate for his arthritis. This underutilization is not monitored by
Wexford or IDOC but is a significant problem. We believe that this is another manifestation of
the lack of proper credentialing and privileging of physicians.

Infirmary Care
Methodology: The clinic space and equipment in the infirmary were inspected, nursing staff
were questioned, clinical charts audited, porters questioned, and patient-inmates interviewed.
There was only limited contact with the infirmary physician.
Fist Court Expert Findings
The First Court Expert recommended that infirmary patients should be seen timely according to
policy requirements, and if clinicians choose not to treat patients according to currently
accepted recommendations and guidelines, the rationale for these decisions should be
articulated in the health record. The expert noted concerns about the frequency, quality, and
completeness of documentation.
Current Findings
We agree with the findings of the First Court Expert concerning timely admission and progress
notes, the lack of documented rationale for treatment decisions, and the quality and

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completeness of the provider documentation in the infirmary. We identified additional findings
and confirmed some of the First Court Expert’s findings as follows:
• Admission RN and provider notes were generally written in accord with the established
timelines.
• Provider progress notes are consistently written on a weekly basis for chronic infirmary
patients. Nurse notes are written daily and commonly provide more useful information
on the clinical status of a patient than did provider notes.
• Problem lists were found to be incomplete and even inaccurate.
• Provider notes were consistently illegible, often lacked the rationale for modifications in
treatment, failed to list reasonable differential diagnoses, failed to develop clear
treatment plans, and rarely documented the status of patients’ chronic illnesses.
• The care in the infirmary is episodic and primarily focuses only on acute problems.
• There was little if any documentation that pertinent physical examinations were being
performed by the providers.
• The quality of care provided by the providers assigned to the infirmary is inconsistent
and often inadequate.
• For records we reviewed, throughout 2017 we found no comprehensive provider notes
that updated the status and plan of treatment for all of a patient’s problems. Only with
the assignment of a new provider in 2018 were some comprehensive provider notes
written that provided reasonable, readable, understandable documentation of both the
current acute and chronic illnesses of patients.
• The care provided to patients on chronic anticoagulation is poor. The use of warfarin
and the subsequent need for frequent INR testing creates logistical barriers that may
not be adequately addressed in this correctional setting. The use of newer
anticoagulation medications that do not require frequent ongoing measurement of the
level of anticoagulation should be strongly considered by the IDOC.
• The condition of the patient beds (non-adjustable heads, inability to raise or lower the
height of the beds, non-functional railings) interfered with the ability of the nursing and
medical staff to provide proper examinations and perform needed treatments. The
physical safety of the nurses who are involved with transferring patients from beds to
wheelchairs is also put at risk by not having beds that can be raised or lowered. SCC
needs to replace all of the current beds with hospital beds. At least one electrical bed is
needed in the infirmary.
The infirmary has two wings; one wing has 11 two-bed rooms and the other, 11 single-bed
rooms. The two wings are served by an enclosed central nursing station that has doors that
open directly into each adjoining wing. It was reported that the infirmary has 24/7 nurse
staffing, with at least one RN on each shift. Correctional officers were noted on both wings
during the site visit. Patients are examined in their rooms; there is no examination room on the
infirmary. There is no dayroom on the infirmary and TVs are not allowed on the unit. Inmates
rarely leave their rooms except for testing/offsite consultations, but those whose physical
condition allows have access via a ramp to a recreation yard. There are two negative pressure
respiratory isolation rooms; neither of the patients in these rooms were in need of respiratory

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isolation. Neither of the negative pressure units were fully functional on the first day of the site
visit. A new physician, recently assigned to the infirmary within the last one to two months,
makes rounds almost daily.
The infirmary has a capacity of 32 patients. During the site visit, 24 beds were occupied. The
majority of patients on the unit had chronic conditions and have had or will have lengthy stays
in the infirmary. A large number of the patients are disabled and need assistance with activities
of daily living. The infirmary has the appearance of a long-term nursing home. There were
functional nurse call devices in all of the 2-bed rooms, but some of the patient-inmates lacked
the mental capacity or physical ability to use these devices. The nursing station had no
capability of direct visual or audio monitoring of any of the patient rooms. Most of the railings
on the beds are not operational. The combination of poor audiovisual monitoring capability, an
at-risk-for-fall patient population, and non-functional railings creates a potentially unsafe
environment for many men in the infirmary. We noted on a death review that a patient with
dementia had 13 falls over a year and a half. 78 Because there were no physical examinations by
a physician it wasn’t clear if the patient was physically injured. Risk of injury is clearly present
on this unit. Only one patient (in restraints) had a correctional officer stationed outside his
room for one-on-one observation. A number of the patient-inmates require one-on-one
observation due to risk of falls.
IDOC Administrative Directive 04.03.120 Offender Infirmary Services has several requirements,
including that nurses must complete admission notes with vital signs on admission and
providers must write an admission note within 48 hours of admission. Acute level infirmary
patients are to have at least three provider notes per week; chronic patients require only
weekly notes. Four infirmary charts of chronic patients were audited (two were long-term
patients and their charts had been pared down); the other two had nurse admission notes on
the day of admission and provider notes on the next working day. All four of the infirmary
charts reviewed had at least weekly provider progress notes and all had daily nursing notes and
vital signs measured.
A number of concerns and deficiencies in the care provided to infirmary patients were noted.
Two patients had diabetes listed on their problem list, but they were not on diabetic meds and
their blood sugars were normal. Neither had HbA1C testing performed to confirm the diagnosis
(and control if they indeed had diabetes). None of the provider progress notes ever commented
on diabetes for these two individuals. One patient had a single note stating that Wexford
replaced his CPAP machine, but sleep apnea was not on his problem list and his medical record
and his infirmary chart did not have any provider notes from 2016-2018 addressing sleep apnea
or CPAP use. This same patient had a history of significant deep vein thromboses with occlusion
of three veins in his abdomen and left leg, yet he was not on blood thinners nor was there a
provider comment providing the rationale for not using blood thinners. A patient blacked out
on two occasions (blood pressure dropped to 90/60 on second occasion) within a three-week
period and was seen three times by a physician without documented neurological or cardiac
78

Mortality Review Patient #9.

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exams. He was not assessed or tested for orthostatic hypotension, cardiac arrhythmias, or an
atypical seizure. The provider notes contained no clinical information or possible cause for
these episodes. The patient was eventually referred to UIC Neurology without a reason for
referral; this referral could have been a routine follow-up for patient’s seizure disorder. The
care of patients on chronic oral anticoagulation therapy (warfarin) is inconsistent. One patient
with recurrent DVTs on chronic anticoagulation was well controlled for many months, then the
warfarin was discontinued without a justification recorded in the progress note. Another
patient on warfarin was not adequately anticoagulated after nine weeks of treatment. INRs, all
sub-therapeutic, were measured weekly and the warfarin dose was increased three times;
however, the frequency of INR testing and pace of dosage augmentation should have expedited
as per standard of care. One infirmary patient with hypertension had elevated blood pressure
readings for 11 months but his medications were not increased to achieve control. The provider
wrote regular very brief notes with little clinical information that were difficult to read and did
not comment on why antihypertensive meds were not increased. It was only after a new
provider was assigned to the infirmary that blood pressure meds were increased, and
hypertension control achieved.
The provider notes on the audited charts were extremely brief, commonly illegible, and
contained little clinical information. The lack of comprehensive provider notes made it difficult
to understand the patients’ current conditions and progress or deterioration. This created
barriers to the delivery of adequate care for the nursing staff and providers who cover the unit
when the infirmary provider is off duty. The quality and continuity of care provided in the
infirmary did not meet the community standard of care. 79
The following summaries of infirmary patients’ records highlight the findings and concerns
noted above.
•

This patient is a 53-year-old whose problem list includes DM, recurrent DVT, on chronic
anticoagulation, left ankle wound/ulcer, and chronic abdominal wound post-aorto-iliac
bypass. 80 Blood sugars were normal and the patient was not on diabetic medication.
HbA1C was never performed to confirm the diagnosis. On 1/30/18, the MD wrote that
the patient denied a history of diabetes. It is likely that this patient does not have
diabetes and this diagnosis should be removed from the problem list. Weekly INRs were
performed to measure adequacy of anticoagulation, and warfarin dose was increased
four times over nine weeks; all of the INR’s were sub-therapeutic (1.1-1.4). Standard of
care is to increase the warfarin dose quickly until a therapeutic level is achieved (2.03.0) and then decrease the frequency of testing. This patient is still at risk for a recurrent
DVT after nine weeks of treatment. UIC specialists ordered warfarin be stopped and the

79

We refer also to Mortality Review Patient #9 for another example of this. Over six months on the infirmary, a doctor wrote
notes 19 times that stated, “No specific complaint, no change, dementia, continue same care” despite the patient having
multiple falls and being hospitalized for heart failure. Then over a nine-month period, the same doctor wrote 30 notes stating,
“No specific complaint. No change. Dementia, post colectomy for metastatic ca [cancer]. Continue same care.” This was grossly
and flagrantly unacceptable evaluation for a person with significant illness.
80 Infirmary Patient #1.

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anticoagulation switched to injectable low molecular weight heparin before the patient
was transferred to UIC for surgical repair of a large post-op abdominal wound. The
infirmary provider discontinued the oral warfarin but failed to order the injectable
anticoagulation; this put the patient at risk for a clot.

81
82

•

This patient is a 58-year-old with coronary artery disease post-percutaneous
transluminal coronary angioplasty (PTCA), peripheral arterial disease s/p right Iliac
artery stent, DVT, diabetes, seizure disorder, neurogenic bladder, and L-S disc disease.81
He has regular provider notes and daily nursing notes with vital signs. He had a CPAP
machine, but sleep apnea was not on the problem list nor was it ever addressed in any
provider progress notes. The patient was on seizure medications, which were increased
after he reported to UIC Neurology specialists that he had a seizure a few months prior
to his visit. The provider notes never commented, even once, during his seven months in
the infirmary, about the status or control of his seizure disorder. Even though the
patient had a history of massive deep vein thromboses, the infirmary progress notes did
not once comment on why this patient was not prescribed anticoagulation medications.
There may be a valid reason for not ordering anticoagulants, but the progress notes
failed to address this important, even life threatening, issue. The patient was noted to
have blacked out on 12/10/17 and again on 12/31/17 (blood pressure dropped to
90/56); MD notes on 12/11/17 only noted that the patient had no complaints and
continued present management, and on 12/19/17 stated no change. The patient was
not assessed or tested for orthostatic hypotension, cardiac arrhythmias, or an atypical
seizure. The provider notes contained no clinical information or possible cause for these
episodes and the patient was eventually referred to UIC Neurology without a reason for
referral; this referral could have been a routine follow-up for patient’s seizure disorder.
The patient had another episode on 1/13/18 in which he reported to the RN he might
pass out. His blood pressure was again low (90/50). A new provider wrote a
comprehensive note on 1/15/18 and referred the patient to Cardiology and Vascular
Surgery at UIC. Again, the patient’s blood pressure was low, 91/45, and no intervention
was ordered by the provider. None of the five provider notes since the second blackout
episode in which low blood pressure was recorded documented any consideration that
the patient’s current treatment included four to five meds that can lower blood
pressure and should be pared down.

•

This patient has a history of DVT on chronic anticoagulation, s/p total right replacement
with joint infection, hypertension, and hyperlipidemia. 82 There was no problem list in
the infirmary chart. The INRs were consistently therapeutic in 2017; warfarin was
discontinued in August 2017. There was no provider note on the rationale for stopping
anticoagulation. During the last third of 2017, swelling of his right knee was noted and
antibiotics started with orthopedic consultation. The patient underwent surgical
removal of the infected prosthesis and right knee fusion. On hospital return, the patient

Infirmary Patient #2.
Infirmary Patient #3.

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was readmitted to the infirmary with an RN admission note on 1/26/18, and a physician
admission on 1/29/18 (the next working day). The 11 provider notes between 9/18/17
and 1/15/18 contained so little clinical information that it was very difficult to
understand the patient’s diagnoses and previous surgeries, the reason for the knee joint
infection, and the treatment plan. A number of the notes were illegible or so brief as to
be uninformative. Unclear progress notes and plans interfere with the provision of
quality care and put the health of the patient at risk.
•

This 70-year-old patient was admitted to the infirmary on 1/24/17; RN and physician
admission notes were on the day of admission. 83 The patient’s diagnoses included
atherosclerotic heart disease (ASHD), congestive heart failure, hypertension, stroke in
2005 with weakness and inability to walk, and benign prostatic hypertrophy (BPH).
Nursing notes were written daily and vital signs taken daily. Provider notes were
documented weekly, but they contained little clinical information. Some of the provider
notes were totally illegible. The patient’s blood pressure readings were repeatedly
elevated except for the two times the patient attended the hypertension chronic care
clinic, which did not comment on the elevated blood pressures taken in the infirmary
and did not increase the hypertension medication. A new infirmary provider assumed
care of this patient in January 2018 and noted on 1/1/18 that the blood pressure was
not controlled; the hypertension medication dose was increased, and at a follow-up visit
on 1/10/18, it was noted that there had been a good response to the increased dose
and the blood pressure was controlled. On 2/16/18, the patient voiced a concern about
increased urinary frequency, urgency, and hesitancy. The provider ordered a urinalysis
(normal) and oxybutynin to treat this problem. It is disturbing that the previous
infirmary provider failed to address the elevated blood pressure readings during 2017.
The practice of SCC providers not addressing uncontrolled chronic conditions and
shifting this responsibility to the single illness chronic care clinics resulted in an
unjustifiable delay in treatment for this hypertensive patient who had already suffered a
stroke. Elevated blood pressure is a risk factor for stroke. Until January 2018, the
provider notes were illegible and created a risk to the health of this infirmary patient.

In summary, the lack of quality, legible, comprehensive provider notes that address both the
ongoing acute and chronic needs and illnesses of each infirmary patient puts the health and
safety of all infirmary patients at risk. We agree with the recommendations of the First Court
Expert and have additional recommendations that are found at the end of this report.

Pharmacy and Medication Administration
Methodology: We reviewed medication services by meeting with the DON. We also toured the
medication room and observed nurses as they prepared, administered, and documented
medication administered. We reviewed medication administration records, medication room

83

Infirmary Patient #4.

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inspection reports, pharmacy reports delivered at the monthly CQI meetings, the Wexford–
IDOC contract, Administrative Directives, and SCC operational policies and procedures.
First Court Expert Findings
The First Court Appointed Expert made no recommendations in the area of
pharmacy/medication administration. The system used, policies, and practices described in that
report are unchanged today.
Current Findings
The current system to provide patient medication is unsafe and does not assure the five
“Rights:” the right patient, the right medication, the right dose, the right route at the right time.
The following practices need to be stopped and safer practices and procedures adopted:
• Handwritten orders and transcription of orders to the MAR
• Pre-pouring medication
• Not using the MAR to document administration of medication at the time it is given.
Chronic disease patients are not monitored to ensure continuity in treatment nor is their
compliance with prescribed treatment assessed. Prescription end dates do not coincide with
chronic clinic appointments and require patients to request renewals via sick call.
In addition, we found that medication errors are documented and reported, but not analyzed
to determine root causes or trended to identify problems and improve patient safety.
Persistent problems with medication practices are not subject to corrective action or systematic
CQI.
Orders and Delivery of Medication
Medications are obtained from BosWell Pharmacy Services, via subcontract with Wexford.
Prescriptions are faxed to BosWell and filled in 30-day “blister packs,” and then transported to
SCC. A pharmacy technician at SCC receives and inventories the medications and then puts
them into stock supply or onto the medication cart. Staff reported that when prescriptions are
faxed to BosWell before 2:30 p.m. each day, medications are received within 24 hours via
United Postal Services (UPS). Prescriptions faxed after 2:30 p.m. are received in two days. If
medications are urgently needed, staff uses a local pharmacy, Jewel-Osco Pharmacy in Joliet,
Illinois.
We toured the medication room in the clinic and the room behind, where the pharmacy
technician works, and where medication is stored until it is needed for administration. These
two rooms were clean, uncluttered, well lighted, and kept secure. There is a refrigerator with a
thermometer and temperature log that was up to date. We conducted a random count of
controlled substances and found it to be accurate. Our observation is that the amount of
controlled substances was larger than may be necessary, making accountability time consuming
and increasing the chance of error and potential for diversion. We recommend that the
responsible pharmacist review and perhaps adjust PAR stock levels for controlled substances.

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After the provider writes the medication order, a nurse reviews it and if it is a nurse
administered medication, transcribes it onto the patient’s medication administration record
(MAR). When the medication arrives from BosWell, a pharmacy technician checks off that it
was received. The pharmacy technician separates Keep on Person (KOP) medications from
Nurse Administered (NA) medications and determines the patient housing locations. Nurse
administered medications are transported by the pharmacy technician to the medication room
for storage in medication carts and subsequent administration to patients. Pharmacy
technicians and/or medical technicians distribute KOP medications directly to inmates in the
housing units. They also transcribe the KOP order onto the patient’s KOP MAR. This was
observed being done using the blister pack, not the original provider order. This practice is not
sufficient to identify dispensing errors made by the pharmacy. We recommend that the original
order be used when transcribing to the KOP MAR.
Transcription errors are by far the most common type of medication error reported to the SCC
CQI committee. 84 These include not transcribing the order onto the MAR, transcribing orders
incorrectly, not discontinuing medications on the MAR when ordered, not transcribing orders
from one month to the next, or transcribing these incorrectly. While these errors have been
reported, there is no documented evidence that this has been identified as a systems problem
to be studied and examined for possible improvement.
We also reviewed monthly medication inspection reports completed by a BosWell pharmacist
from March 2017 through February 2018. These inspections include verifying MAR
documentation using a sample of 20 patients. We found medications not transcribed onto the
MAR, medications that have an order to discontinue still being administered, and the
medication being administered differing from that transcribed onto the MAR, as examples of
problems in the care of individual patients that are documented each month. There is no
documentation or other report that medication errors are trended or analyzed to identify
systemic sources of error, nor has it been identified as a problem to be addressed by CQI.
The Contract Monitoring Reports provided note continuing violation of the AD concerning
control of medications, but no penalty or corrective action is documented. When asked, the
HCUA stated that the problem is that nurses do not accurately and completely sign out
controlled medications and attributed this to distractions when busy with patient care. The
October 2017 Contract Monitoring Report lists this as a violation of ADs and notes the vendor,
Wexford, was notified of the problem on 12-14-16. Accountability for controlled substances is a
high safety priority and systematic efforts to identify and limit risk of error as well as potential
diversion should be in evidence. At SCC there is no documentation of attempts to investigate
and revise systems, equipment, or processes to minimize or eliminate this as a source of error.
Medication errors have long been recognized as a substantial area of focus in improving the
safety of patient care. 85 Handwritten orders and transcription have been eliminated in many
84
85

SCC Annual CQI 2016-17, Pharmacy Services.
Institute of Medicine (2000), To Err is Human: Building a Safer Health System. Washington DC: The Academies Press.

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correctional health care programs because of error and inefficiency. An obvious solution is to
install computerized provider order entry (CPOE) and eliminate transcription by hand using
labels generated from the computerized order after it has been reviewed by a pharmacist.86
Automated dispensing cabinets are being used more often now to record the withdrawal of
controlled substances and eliminate handwritten controlled substances logs, such as that which
is in use at SCC. Upgrading pharmacy services in this way requires capital expenditure and
would only likely happen as a statewide decision made by IDOC. But if these pervasive
problems are not identified, discussed, studied, or reported at the facility level, IDOC is without
notice that there is a systemic issue that must be addressed statewide.
Medication Administration
Nurses administer medications to inmates in their cell. Medication administration is scheduled
to begin at 7:30 a.m. and 7:30 p.m. and is completed within two hours. We observed nurses
preparing medications for administration. Nurses compared MARs against medication blister
packs to ensure the accuracy of the order and then popped medication out of the blister pack
and put it into small while envelopes. Written on the envelopes is the name of the patient, ID,
housing location, and names of the medications. The envelopes do not contain order start and
stop dates. 87 Nurses then place medication envelopes into a clear plastic bag to take to the
housing units. Nurses do not transport MARs to the housing unit along with the medications.
We accompanied a nurse escorted by a correctional officer to R unit. Each cell had one or two
inmates. For each patient receiving medication, the nurse called out the inmate’s name and
informed him she had medication and asked to see his identification card, which includes a
recent photo. The nurse then gave the medication envelope to the patient through the cell
bars. The patient took the envelope, poured medication into his hand, and passed the envelope
back to the nurse. If a patient did not want to take a particular medication he put it back in the
envelope before returning it to the nurse. Sometimes the nurse performed an oral cavity check.
She indicated that she did this for patients taking mental health medications and any others she
had a concern about. We observed an inmate ask if he could take his medication later in the
morning because he had an appointment to have lab drawn at the clinic. The nurse indicated
that she would return later with his medication. The interaction between the nurses
administering medication and inmates in the cells was outstanding in professionalism and
respect.
The nurse did not document administration of the medication onto the MAR at the time the
medication was given. After the nurse finished administering medications she returned to the
clinic and documented on the MAR which medications had been administered using the white
envelopes. Medication not taken by inmates was discarded.
Problems with medication administration at SCC include:
86Patient Safety Network. (2017) Medication Errors, Agency for Healthcare Research and Quality available at
https://psnet.ahrq.gov/primers/primer/23/medication-errors.
87 The SCC Operations Policies and Procedure, p. 128 states that “Medication envelopes will be utilized that will comply with
state and federal requirements,” but does not specify what those requirements are.

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•
•
•
•

Repeated use of the same envelopes is a source of transmission for infectious disease
because they are handled by the patient and returned to the nurse.
Nurses do not have a way to verify medication that is not taken. Visual identification is
not sufficient.
The MAR is not available to the nurse at the time medication is administered and
therefore is not used as a reference when there is a concern or question at the point of
patient care.
Medication is not documented at the time it is given and contributes to errors and
omissions in documentation of patient care.

Renewal of Chronic Disease Medications
Chronic disease medications are provided to patients monthly either as “Keep on Person” (KOP)
or each dose is administered by a nurse. The scheduled appointments for chronic disease clinic
do not coincide with the end date on medications ordered for chronic disease. Patients are
expected to sign up for sick call to request medication renewal before the order expires and is
subject to co-pay. 88 Diabetics taking insulin are expected to draw up and administer their own
dose. Diabetic inmates complained that those who are newly diagnosed receive no education
about their condition or how to administer insulin. 89
There is no provision or written directive to regularly monitor continuity of medications or
compliance with ordered medications as part of the chronic care program. We interviewed one
inmate whose chronic disease medication was not provided for a month. It was only reinitiated
when he sought care and finally saw a provider.90 Chronic disease patients are not monitored
to ensure continuity in treatment nor is their compliance with prescribed treatment assessed.

Infection Control
Methodology: We interviewed health care leadership and nursing staff assigned to infection
control duties, reviewed the Infection Control Manual, CQI Minutes, and other documents
related to communicable diseases and infection control.
First Court Expert Findings
The First Court Expert Report noted that a specific nurse had responsibility for compliance with
IDOC policy concerning communicable diseases, blood borne pathogens, and compliance with
Illinois Department of Public Health reporting requirements as well as the HIV and HCV clinics.
Inspection of the health care areas and inquiry about infection control practices resulted in no
concerns or recommendations from the First Court Appointed Expert.
Current Findings

Institutional Directive #04.03.103K3.
Medication Administration Patients #1-2.
90 Medication Administration Patients #6.
88
89

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Responsibility for infection control is dispersed amongst several staff nurses, the DON, and
HCUA. The HCUA facilitates and monitors sanitation inspections and is diligent in following up
on identified concerns until correction has been achieved. He also submits information required
for reportable communicable diseases. One staff nurse is assigned responsibility for managing
the HCV clinic and another nurse manages the HIV clinic. The DON has oversight responsibility
for compliance with infection control procedures and works closely with the HCUA in this
regard.
CQI Minutes and the 2016 Annual Report show that communicable disease data is collected
and reported monthly. There is minimal to no discussion of the meaningfulness of the data
reported. There has been no assessment of TB conversion at SCC to evaluate the risk for
transmission of tuberculosis while in the prison. The Centers for Disease Control (CDC)
recommends that such a study be conducted periodically to determine risk of transmission,
which then guides prevention and surveillance activities specific to the level of risk. 91 CQI
minutes also report statistics regarding skin infections due to methicillin-resistant
staphylococcus aureus (MRSA). Data does not include tracking of skin infections due to other
pathogens. Equipment and instructions for prevention, response, and reporting of occupational
exposures were readily available at the facility. Inmates working in the health care area have
received training in personal protective equipment and exposure control; they are also
vaccinated for hepatitis A and B.
The IDOC Infection Control Manual was reviewed. It was last updated in 2012. While the
material in the manual is thoughtful and many resources are provided, some of them are out of
date. The manual should be updated at least every two years. An up-to-date and accurate
infection control manual is critically important in guiding the work of staff assigned these duties
in the absence of dedicated positions for trained infection control staff, as is the case at SCC.
The IDOC Nursing Treatment Protocols, revised March 2017, were reviewed and provide
guidance to nurses in the care of common infectious diseases and infections such as scabies,
urinary infection, rash, pediculosis, chicken pox, and skin infections.
Many infection control challenges and hazards were observed during our site visit at the facility.
These are detailed in the section of this report on Clinic Space and Sanitation. In particular, the
Airborne Infection Isolation (AII) rooms were not functional, the equipment to manage airflow
had not been serviced for years, and these are not inspected as part of the sanitation rounds.
Also, the practices of the hemodialysis program do not comply with CDC recommendations to
prevent infections, particularly hepatitis B, among chronic hemodialysis patients. 92 Finally, a
lack of barrier protection on reusable surfaces was observed throughout the health care areas.
Fabric covered chairs and tables were torn and sometimes repaired with duct tape, paper
MMWR (2006) Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC.
(RR09). Centers for Disease Control available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5509a1.htm.
92 MMWR (2001) Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients. Vol.
50/No. 99-5, Centers for Disease Control. See also Update to the 2001 Hemodialysis Recommendations available at
https://www.cdc.gov/dialysis/guidelines/index.html.
91
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covers were not available in one of the provider exam rooms, and patient care equipment was
rusted and could not be cleaned. Environmental controls to prevent transmission of infection
are inadequate and risk harm to patients cared for at SCC.
Tuberculosis screening is completed annually. Inmates who were previously positive for latent
tuberculosis infection are screened using a questionnaire for symptoms of tuberculosis disease
and are referred to a provider if symptomatic. All other inmates are screened using a Mantoux
skin test. Symptom screening is not completed. We observed nurses reading skin tests while
also administering medication at the cell front. The nurse did palpate the inmate’s forearm for
induration and documented the results contemporaneously on the skin of her hand to be
transcribed to the chart after medication rounds were completed. Reading of the TB skin test
should be done in a clinical setting with good lighting and a tool to measure induration, such as
the nurse sick call rooms in the housing area. Nurses should not read TB skin tests cell side.
Inmates may request HIV testing at any time and it is also offered to inmates just before release
from incarceration. Inmates who are infected with HIV are managed as part of the chronic clinic
program with oversight from UIC. Currently 11 inmates are being followed at six-month
intervals. Inmates may choose to have their medication given to them to keep and take or they
may have the nurse administer it to them dose by dose. This later method is offered for those
inmates who are concerned about maintaining the privacy of their medical information.
Medications are written to coincide with their next scheduled HIV clinic appointment. The
nurse managing the clinic draws the patient’s blood before the appointment so that the results
are available to the provider at the time of the follow-up appointment. Peer educators provide
regular sessions on Thursdays for newly diagnosed inmates. They also provide pre-release
education.
The inmate porters working in the infirmary had documentation that they had received training
on blood borne pathogens in prison, including hepatitis B and HIV, restroom sanitation, and on
their job description. The records of two infirmary porters were verified that both had been
vaccinated or had immunity to hepatitis A and B.
Hepatitis C (HCV) disease is also managed via the chronic care clinic. IDOC physicians with some
assistance from a Wexford infectious disease doctor manage the care of patients with hepatitis
C. When an IDOC physician determines that the patient needs treatment of the hepatitis C, the
patient is referred to a Wexford infectious disease doctor. When the Wexford infectious
disease doctor determines that treatment is indicated the patient is referred via telemedicine
for treatment with the UIC hepatitis team. All other hepatitis C care needs (cirrhosis
management and screening for hepatocellular carcinoma) are managed by Wexford facility
physicians. Forty-nine HCV patients are being followed currently; six have been treated and
two have been referred for treatment. According to staff interview, the biggest challenge for
HIV and HCV clinics is coordinating scheduling and access to the telemedicine equipment that is
shared with the mental health program.

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Dental Program
Dental: Staffing and Credentialing

Methodology: Reviewed staffing documents, interviewed dental staff, reviewed the Dental Sick
Call Log and other documents.
First Court Expert Findings
• SCC has a dental staff of one full-time dentist, one 20-hour part-time dentist, two fulltime assistants, and a full-time hygienist.
• Dr. Mitchell is employed by the IDOC and the rest of the staff are employed by Wexford.
• CPR training is current on all staff, all necessary licensing is on file, and DEA numbers are
on file for the dentists.
• The number of dentists and hygienists is adequate to meet the needs of this institution.
• The lone assistant is overworked in a clinic with this number of dentists.
• Overall, this is a strong team that works well together to create a very busy and smoothrunning clinic.
Current Findings
We agree with the First Court Expert with respect to clinic operations; however, as we noted in
our NRC report, it is difficult to assess the adequacy of either NRC’s or SCC’s dental staffing
independently, since personnel move between facilities.
SCC has one full-time dentist (Dr. Orenstein) who serves as Dental Director, two full-time dental
assistants, and a full-time dental hygienist 93, who are all Wexford employees. In addition, there
are two part-time dentists who are IDOC employees. 94 Dr. Orenstein and the dental hygienist
routinely assist NRC with intake dental exams.

Dental: Facility and Equipment

Methodology: Toured dental clinic, radiology area, and dental intake area to assess cleanliness,
infection control procedures, and equipment functionality. Reviewed the quality of x-rays and
compliance with radiologic health regulations.
First Court Expert Findings
• The clinic consists of four chairs and units in a spacious single room area. One unit is
dedicated to hygiene care. The dental units were rather new and in good condition. Free
movement around each unit was acceptable. Providers and assistants had adequate
room to work, and none of the chairs interfered with each other.

The Dental Department 2017 Annual Summary reported that, the “dental hygienist from Stateville comes here to assist with
intake on Tuesday, Thursday, and Friday.” NRC CQI Annual Report, 2016-2017, p. 23. Consequently, the dental hygienist does
not contribute a full FTE to SCC.
94 Each provides care 53 days/year per Don Mills, Health Care Unit Manager.
93

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•
•

•
•

The chairs were over 20 years old but were not torn or overly worn and functioned well.
Cabinetry was very old and worn. Countertops were broken, corroded, and badly water
damaged in one of the corners.
There was extreme water damage in the cabinet under the sink. Work surfaces were
badly pitted and catered from use. Plexiglas was placed over these surfaces to provide a
smooth work surface capable of disinfection. The x-ray unit is in good repair and works
well. The autoclave is rather new and functions well. The compressor is in good repair.
The instrumentation is adequate in quantity and quality. The handpieces are old but
well maintained and repaired when necessary.
The ultrasonic unit was not working. I was told that a request for repair had been
submitted.
There was a separate, large sterilization and laboratory area of adequate size. It had a
large work surface and a large sink to accommodate proper infection control and
sterilization. Laboratory equipment was in a separate area of this space and did not
interfere with sterilization. The staff had a separate small room for office space.

Current Findings
Facilities and equipment are unchanged from the First Court Expert’s Report and remain
adequate. We concur and note that the previously inoperative ultrasonic unit had been
repaired. Moreover, we identified current and additional findings as follows.
The clinic is clean, and the chairs are spaced adequately. All equipment is operational. The
countertop in the infection control area is cracked and cannot be disinfected properly. The
cabinet under the sink shows signs of water damage. Another cracked countertop was covered
with plexiglass; however, liquids seep under the plexiglass, creating an environment conducive
to bacterial growth. Storage areas are clean and orderly. Antibiotics and analgesics are labeled
and accounted for in a log.
There is a laboratory area; however, there is no lathe for model trimming. The dentist said that
they send untrimmed casts to the dental laboratory. The infection control area has enough
space; however, the sink is in the middle of the area, preventing optimal instrument flow.
Despite this, instruments can be disinfected adequately.

Dental: Sanitation, Safety, and Sterilization

Methodology: Reviewed Administrative Directive 04.03.102. Toured dental clinic. Observed
dental treatment room disinfection. Interviewed dental staff. Observed screening examinations
and patient treatment.
First Court Expert Findings
• Surface disinfection was performed between each patient and was thorough and
adequate. Proper disinfectants were used. Protective covers were utilized on some
surfaces. Unit recycling was thorough and adequate. The clinic was neat, clean, and
orderly.

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•
•

•
•

All instruments were properly bagged, sterilized, and stored. No instruments were
maintained in bulk. All handpieces were sterilized and in bags.
The sterilization procedures were adequate and proper. Flow from dirty to clean to
sterilized was improper, as bagging of instruments was done in front of the ultra-sonic
unit. Cleaned instruments were passed back over the dirty area. The ultrasonic was not
functioning. There was not a biohazard label posted in the sterilization area.
Safety glasses were not always worn by patients. Eye protection is always necessary.
There was no warning sign posted where x-rays were taken to warn pregnant women of
possible radiation hazards.

Current Findings
Sanitation, safety, and sterilization have not changed materially since the First Court Expert’s
Report. We concur with the First Court Expert; however, we identified current and additional
findings as follows.
Surface disinfection between patients was adequate although difficult due to cracked counter
surfaces. Instrument sterilization procedures were adequate and proper. Flow from dirty to
clean to sterilized was improper, as bagging of instruments was done in front of the ultrasonic
unit. Cleaned instruments were passed back over the dirty area. There was not a biohazard
label posted in the sterilization area. 95
Safety glasses were not worn routinely but are worn only when large fillings were being
removed. Eye protection is always necessary. 96, 97 There was no warning sign posted where xrays were taken to warn pregnant women of possible radiation hazards, nor was a lead apron
with a thyroid collar used consistently.98,99 There is documentation that “those aspects of your
CFR 1901.145(e)(4). “The biological hazard warning shall be used to signify the actual or potential presence of a biohazard
and to identify equipment, containers, rooms, materials, experimental animals, or combinations thereof, which contain, or are
contaminated with, viable hazardous agents.”)
96 “We use personal protective equipment […] as well as provide eye protection to patients for all dental procedures.” We
Take Infection Control Seriously. UIC College of Dentistry. Viewed at https://dentistry.uic.edu/patients/dental-infection-control,
February 2, 2018. Emphasis added.
97 Guidelines for Infection Control in Dental Health-Care Settings ---2003. MMWR, December 19, 2003/ 52(RR17):1:16; pp. 1718. (“PPE [personal protective equipment] is designed to protect the skin and the mucous membranes of the eyes, nose, and
mouth of DHCP [dental health care provider] from exposure to blood or OPIM [other potentially infectious materials]. Use of
rotary dental and surgical instruments (e.g., handpieces or ultrasonic scalers) and air-water syringes creates a visible spray that
contains primarily large-particle droplets of water, saliva, blood, microorganisms, and other debris. This spatter travels only a
short distance and settles out quickly, landing on the floor, nearby operatory surfaces, DHCP, or the patient. The spray also
might contain certain aerosols (i.e., particles of respirable size, <10 µm). Aerosols can remain airborne for extended periods and
can be inhaled” and “Primary PPE used in oral health-care settings includes gloves, surgical masks, protective eyewear, face
shields, and protective clothing (e.g., gowns and jackets). All PPE should be removed before DHCP leave patient-care areas (13).
Reusable PPE (e.g., clinician or patient protective eyewear and face shields) […]”). Emphasis added. Moreover, protective
eyewear protects against objects or liquids accidentally dropped by the provider.
98 Each radiation area shall be conspicuously posted with a sign or signs bearing the radiation caution symbol and the words,
“CAUTION RADIATION AREA”. Occupational Safety and Health Standards – Toxic and Hazardous substances. 29 CFR
1910.1096(e)(3)(i). Emphasis in original.
99
While radiation exposure from dental radiographs is low, it is the dentist’s responsibility to follow the ALARA Principle (As
Low as Reasonably Achievable) to minimize the patient’s exposure. Dentists should follow good radiologic practice and (inter
alia), use protective aprons and thyroid collars. Dental Radiographic Examinations: Recommendations for Patient Selection and
Limiting Radiation Exposure. American Dental Association and Food and Drug Administration (2012), 14.
95

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radiation producing equipment and operating procedures reviewed by the inspector were
found to follow applicable Illinois radiation protection regulations;” however, neither the
equipment’s model and serial number(s) nor the operating procedures reviewed were
specified. 100

Dental: Review Autoclave Log

Methodology: Review last two years of entries in autoclave log, interview dental staff, tour
sterilization area.
First Court Expert Findings
• A review of spore testing logs revealed that a “Maxi-test” in office biological indicator
system was in use. The incubator was maintained in the sterilization area. The results
were logged weekly.
• There was a gap in logged results from the last week of January to the first week in April
with no explanation provided. I was assured that the testing was done during this
period. It is essential that these logs be accurately maintained over a long period of
time.
Current Findings
Autoclave log maintenance has improved since the First Court Expert’s Report and is adequate.
Spore testing was performed weekly and documented. No negative results were recorded.
Unlike the finding of the First Court Expert, there were no gaps in the sterilization record.

Dental: Comprehensive Care

Comprehensive or routine care 101 is non-urgent treatment that should be based on a health
history, a thorough intraoral and extraoral examination, a periodontal examination, and a visual
and radiographic examination.102 A sequenced plan (treatment plan) should be generated that
maps out the patient’s treatment.
Methodology: Interviewed dental staff, reviewed one dental chart of inmates who received
non-urgent care, observed dental treatment, and reviewed Daily Dental Reports.
First Court Expert Findings
• One of the most basic and essential standards of care in dentistry is that all routine care
proceeds from a thorough, well-documented intra and extra-oral examination and a
well-developed treatment plan, to include all necessary diagnostic x-rays. A review of 10
records revealed no comprehensive examination was performed in three of the records
and very minimal examinations were performed in three others.
Letter from Illinois Emergency Management Agency to Walter Nicholson, Assistant Warden, Statesville Correctional Center
dated July 21, 2017. CQI 2-16-2017_4. Pdf, p. 7.
101 Category III as defined in Administrative Directive 04.03.102.
102 Stefanac SJ. Information Gathering and Diagnosis Development. In Treatment Planning in Dentistry [electronic resource].
Stefanac SJ and Nesbit SP, eds. Edinburgh; Elsevier Mosby, 2nd Ed. 2007, pp. 11-15, passim.
100

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•

•
•
•

We reviewed 10 dental records of inmates in inactive treatment classified as Category 3
patients. In only four records did a meaningful comprehensive examination precede
routine care. No examination of soft tissues or periodontal assessment was part of the
treatment process.
Hygiene care and prophylaxis were inconsistent, provided in six of the 10 patient
records. A further review showed that bitewing radiographs were part of the treatment
process in eight of the 10 records.
Oral hygiene instructions (OHI) were not always documented in the dental record as
part of the treatment process.
Restorations were, in two of the 10 patients, provided from the information from the
Panorex radiograph. This radiograph is not diagnostic for caries. A periodontal
assessment was not done in any of the records.

Current Findings
Comprehensive care has not improved materially since the First Court Expert’s Report. We
concur with the First Court Expert; however, we identified current and additional findings as
follows.
Administrative Directive 04.03.102 specifies that “within 10 working days after admission to a
reception and classification center […] each offender shall receive a complete dental
examination by a dentist” (¶IIF2, emphasis added). However, the NRC does not perform a
complete (or comprehensive) examination.
When the inmates arrive at SCC, a comprehensive (routine) examination is not performed and a
treatment plan is not produced unless a routine exam is requested by the inmate or the inmate
is due for a biennial exam. Consequently, many inmates will not have a comprehensive exam
and treatment plan for two years, if at all. 103
This was not the practice reported by the NCCHC based on a site visit May 16-19, 2016.
The dentist also completes a full dental examination on every newly arrived
inmate within one week and provides some oral instruction and written
materials on proper oral hygiene and preventive oral education. […]. 104
Since the intake examination performed at NRC is so cursory and does not include bitewing x-rays or a periodontal probing,
inmates may be unaware of existing dental disease, so they would not request a routine examination at SCC. Dentate or
partially dentate adults who are new patients should receive an “[i]ndividualized radiographic exam consisting of posterior
bitewings with panoramic exam or posterior bitewings and selected periapical images.” Furthermore, recall patients should
receive posterior bitewing x-rays every 12 to 36 months based on individualized risk for dental caries. With respect to
periodontal disease, “[i]maging may consist of, but is not limited to, selected bitewing and/or periapical images of areas where
periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically.” Dental Radiographic Examinations:
Recommendations for Patient Selection and Limiting Radiation Exposure. American Dental Association and U.S. Food and Drug
Administration, 2012. Table 1, pp. 5-6.
104 NCCHC Technical Assistance Report, p. 61. This practice was neither described by the First Court Expert nor found by our
team. Furthermore, it is not set forth in Administrative Directive 04.03.102. It is, however, consistent with NCCHC Oral Care
Standard P-E-06, which, in addition to requiring a screening within seven days of admission, requires that an oral examination
be performed by a dentist within 30 days of admission. National Commission on Correctional Health Care, Standards for Health
103

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Of 10 records of inmates who received routine care, all had recent bitewing or periapical x-rays,
and none documented a soft tissue exam or periodontal assessment. 105 Four were without a
treatment plan.106 Treatment plans were scanty and not in a prioritized list format. In three
records, treatment was not sequential. 107 Oral hygiene instruction was not documented in two
records. 108 We found no evidence of extended wait times or backlog of services.

Dental: Intake (Initial) Examination 109

Methodology: Reviewed 10 dental records of inmates that have received intake (initial)
examinations recently. Reviewed Administrative Directive 04.03.102. Reviewed SCC CQI
Reports.
First Court Expert Findings
• Reviewed 10 inmate dental records that were received from the reception centers
within the past 60 days to determine if: 1) screening was performed at the reception
center and 2) a panoramic x-ray was taken, to insure the reception and classification
policies as stated in Administrative Directive 04.03.102, section F. 2, are being met for
the IDOC.
Current Findings
The dental intake exam has not changed materially since the First Court Expert’s Report and
remains inadequate. While the First Court Expert reported aspects of the intake examination
process, we focused on a clinical measure – the quality of the panoramic radiograph and the
adequacy of the charting and treatment plan. This explains our divergent findings. In addition,
we identified current and additional findings as follows.
While the First Court Expert reported that “policies as stated in Administrative Directive
04.03.102, section F. 2, are being met for the IDOC”, that finding overlooked the most
important issue – the inadequacy of the intake examination.

Services in Prisons, 2014, p. 81. Emphasis added. See also National Commission on Correctional Health Care, Standards for
Health Services in Prisons, 2018, p. 96, ¶6.
105 Stefanac SJ. (A panoramic radiograph has insufficient resolution for diagnosing caries and periodontal disease. Intraoral
radiographs (e.g., bitewings) and periodontal probing are necessary), p. 17. Also, (Periodontal Screening and Recording (PSR),
an early detection system for periodontal disease, advocated by the ADA and the American Academy of Periodontology since
1992, is an accepted professional standard.), pp. 12-14. See American Dental Hygiene Association. Standards for Clinical Dental
Hygiene Practice Revised 2016, pp. 6-9. (Periodontal probing is also a standard of practice for dental hygiene).
106 That is, starting with an oral prophylaxis (cleaning) and proceeding with extractions, periodontal treatment, fillings, and
prosthetics. Note that question #6 on the Wexford Peer Review Form for Dentists – PR-001C (“Is a plan for care documented?”)
addresses a treatment plan.
107 Comprehensive Care Patients #3, 5, 7 and 10.
108 Comprehensive Care Patients #8 and 9.
109 The First Court Expert Report describes the examination performed at intake as a “Screening Examination;” however,
Administrative Directive 04.03.102 describes it as a “complete dental examination.” We use the terminology of the
Administrative Directive and refer to the intake or Initial Dental Examination as a complete dental examination.

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Of 10 records of inmates who received intake exams at the NRC, one had no dental
information 110 and all but two of the remaining records (78%) had a clinically inadequate
panoramic x-ray111 that Dr. Orenstein attributed to the age of the x-ray and film processing
units.
“Oral hygiene instructions” was stamped in all the charts. The SCC dental hygienist said that she
does not provide OHI at the examinations. Furthermore, the exams occur so quickly, adequate
OHI simply cannot be provided by the dentist.
Of the 10 records, only one documented that an initial examination and treatment plan was
done.112 Medical histories were filled out in all the records; however, Intake (Initial)
Examination Patient #2 had hypertension noted in the problem list in the medical chart but not
in the health history in the dental chart. One patient was noted as Classification IIa; 113 however,
a recommended disposition 114 was not indicated. The inadequacies of the NRC intake dental
exam were identified in a Quality Improvement Study report that is discussed the Dental
Quality Improvement Committee section of our NRC report.

Dental: Extractions

Methodology: Reviewed records of randomly selected inmates that have had extractions
selected from Daily Dental Reports October 2017 through January 2018. Interviewed the
dentist.
First Court Expert Findings
• Reviewed 10 dental records of dental surgical inmates to determine: 1) if recent preoperative radiographs reflecting the current condition of tooth extracted (that is,
showing apices of teeth); 2) the reason for extraction is documented; and 3) there is a
signed consent form.
• In four of the 10 records reviewed, the reason for the extraction was not documented.
• In two of the records, a proper diagnostic x-ray was not present. This is a serious
omission.
• Record entries are often very difficult to follow. Treatment at times seemed disjointed
and lacking in continuity. The time between appointments can be long due to
rescheduling associated with failed appointments.

Intake (Initial) Examination Patient #6.
The principal problem was inadequate contrast, especially in the middle portion of the face. In addition, several films had
the number that links the film to an inmate chart superimposed over tooth roots.
112 Dental: Intake (Initial) Examination Patient #2. The record noted that it had been reviewed 2/6/18; however, there was no
clinical entry.
113 “An oral condition, if left untreated, that would cause bleeding or pain in the immediate future.” Administrative Directive,
Attachment A.
114 There are three choices: 1) schedule immediately at R&C, 2) schedule routine exam at receiving institution, and 3) schedule
immediately at receiving institution. Since Classification II is urgent care, the problem should have been dealt with at the NRC or
immediately upon arrival at SCC.
110
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•

Also, antibiotics were often given after extractions without a documented reason. They
seemed to be provided prophylactically. This is not a standard of care. They should be
prescribed only when indicated by a well-established diagnosis.

Current Findings
Extraction care has improved since the First Court Expert’s Report but remains inadequate. We
concur with the most of findings in the First Court Expert’s report, but note that we found that
(of nine charts reviewed) all charts had clinically adequate preoperative x-rays. However, we
identified current and additional findings as follows.
We agree with most of the First Court Expert’s findings although we found all charts had a
signed consent form that identified the tooth number; however, five did not state the
diagnosis, that is the reason the tooth was to be extracted. 115 Documentation was poor, 116 with
a diagnosis not being reported for three patients. 117 There was no documentation that the
health history was updated in four charts.118 Post-extraction antibiotics were prescribed
without documented evidence of infection. 119

Dental: Removable Prosthetics

Methodology: Reviewed Daily Dental Reports from October 2017 through January 18, 2018.
Interviewed dental staff.
First Court Expert Findings
• We reviewed dental records of five patients who received completed partial dentures to
determine if restorative procedures were completed prior to fabrication of partial
dentures. Removable partial denture prosthetics should proceed only after all other
treatment recorded on the treatment plan is completed. Continuity of care is important
and the periodontal, operative, and oral surgery needs all should be addressed first.
• In only one of five records reviewed on patients receiving removable partial dentures
were oral hygiene instructions provided.
• Periodontal assessment was not provided in any of the records, and in only one of five
records was a prophylaxis and/or a scaling debridement provided. Because a
comprehensive examination was part of only two records and treatment plans were
very incomplete, it is almost impossible to ascertain if all necessary care, including
operative and/or oral surgery treatment, is completed prior to fabrication of removable
partial dentures.

Extraction Patients #2, 3, 4, 6, and 7.
For Extractions Patient #1 (Ext #24 7/14/17), chart entries for 9/15/17, 10/4/17, 10/20/17, 11/1/17, 11/15/17, 12/22/17,
12/28/17, and 2/26/18, were illegible. Similarly, the chart of Extraction Patient #5 had several illegible entries.
117 Extraction Patients #1, 2 (illegible), and 4 (illegible).
118 Extractions Patients #1, 3, 6, and 7.
119 Comprehensive Care Patient #1 had teeth extracted 5/4/17 and 5/18/17, and Amoxicillin was prescribed without a
documented infection. Similarly, Extraction Patients #3, 5, 7, 8, and 9 had post-extraction Amoxicillin prescribed without a
diagnosed infection. Extractions Patient #5’s chart contained many illegible entries. The patient returned from having tooth #1
extracted by Joliet Oral Surgeons 9/1/17 and was prescribed Amoxicillin without a diagnosis of infection.
115
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Current Findings
Removable prosthetics care is unchanged from the First Court Expert’s Report and remains
inadequate. We concur with the First Court Expert; however, we identified current and
additional findings as follows.
Of six records selected from a list of completed partial dentures, none of the removable partial
dentures were fabricated based on a formal treatment plan. None of the charts documented a
PSR; however, one chart 120 mentioned periodontal status. Two charts121 did not document that
an oral prophylaxis (cleaning) was performed and one patient 122 had a partial denture
impression taken before restorative treatment was complete.

Dental: Sick Call/Treatment Provision

Methodology: Interviewed dental staff. Reviewed Dental Sick Call Log from 10/3/17 through
1/22/18.123 Reviewed Daily Dental Reports from 10/3/17 through 1/17/18. Reviewed records of
seven inmates who were seen on sick call. Reviewed recent intake examination records.
First Court Expert Findings
• Inmates access sick call through an inmate request form or via a direct call from a staff
member if it is perceived as an emergency, in addition to a “Request Log” that logs
inmate request forms.
• An Emergency Log tracks patients seen as “emergency.” These inmates are seen the
same day as the request. For 2014, thus far, 12 inmates were seen as an emergency. All
were toothaches, abscesses, or trauma.
• There is no real triage system in place to evaluate urgent care needs (toothaches, pain,
swelling) from the request forms. Of the inmates placed in the Request Log, the average
wait for an appointment was about 12 days. This is for all request forms. Of the requests
logged in as toothaches, pain, or swelling, the average wait was approximately six to
seven days. These inmates should be seen within 24-48 hours.
• In none of the dental records reviewed was the SOAP form used. As a result, treatment
was usually provided with little information or detail preceding it. Sick call record entries
often did not include clinical observations or diagnosis to justify provided treatment.
Little continuity was established.
• In all records, the immediate complaint was addressed. Only emergency care was
provided.
Current Findings
While some aspects of urgent care have improved since the First Expert’s Report, it remains
inadequate, and we concur with the First Court Expert’s findings. However, we identified
current and additional findings as follows.
Prosthetics Patient #1. In addition, #1 and #2 were extracted (10/6/16) based on an inadequate and three-year-old
panoramic x-ray. There was no consent form and Amoxicillin was prescribed without a documented infection.
121 Prosthetics Patients #4 and 5.
122 Prosthetics Patient #6.
123 Dental Bates 40-46.
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Inmates are informed that they can access health care (including dental care) as part of the SCC
intake process. 124 In the alternative, they can submit a specific request for dental care on a
form that is collected periodically and delivered to the dental clinic.
Dr. Orenstein’s clinical progress notes are extremely difficult to read at best, and indecipherable
at worst. A particularly egregious example of this is in the dental chart of Medically
Compromised Patient 1, where the entire page comprising entries from 5/3/17 to 8/14/17 is
located. There are many similar entries in this chart (as well as other charts).
Of 10 inmates who sought a dental appointment for painful conditions, one did not have a
diagnosis documented, 125 one had the health history updated, 126 and five did not use the SOAP
format. 127 Three patients received prescriptions for antibiotics although no infection was
documented. 128
Inmates can enter their names in a Sick Call Request Log. The January 2018 RN Sick Call Log
contained 11 entries related to dental care, of which seven charts were available for review. All
the inmates were seen by nursing and referred to dental; however, two encounters129 did not
have nursing notes. While most requests were for routine care, three 130 were for painful
conditions.131 Some nursing progress notes mention pain; however, the nursing protocol for
toothache/dental pain was not used and analgesics were not dispensed. Patients #1, 5, and 6
were seen by a dentist in five, 15, and six days, respectively.

Dental: Orientation Handbook

Method: Reviewed the Orientation Handbook and related documents.
First Court Expert Findings
A review of the “Offender Orientation Manual” for SCC and the NRC revealed that dental care
was well represented and the instructions as it relates to access to care is adequate.
Current Findings
Inmate orientation to dental care has not changed substantially since the First Court Expert’s
Report and we agree with the First Court Expert that it remains adequate. Inmates are
informed that they can access health care (including dental care) as part of the SCC intake

SCC Access to Care document.
Dental Sick Call Patient #1. This patient also had #16 extracted 12/4/17, but a consent form is not present.
126 Dental Sick Call Patient #5.
127 Dental Sick Call Patients #1, 2, 4, 8, and 10. Note question #5 on the Wexford Peer Review Form for Dentists – PR-001C (“Is
the provider documenting in the SOAP format?”).
128 Dental Sick Call Patients #5 (Amoxicillin 12/12/17), #6 (Amoxicillin 12/22/17), and #7 (Clindamycin 12/19/17).
129 Dental RN Sick Call Patients #2 and 3.
130 Dental RN Sick Call Patient #1.
131 Dental RN Sick Call Patients #1, 5, and 6.
124
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process. In the alternative, they can submit a specific request for dental care on a form that is
collected periodically and delivered to the dental clinic. 132

Dental: Policies and Procedures

Methodology: Reviewed Administrative Directives that deal with the dental program.
Interviewed dental staff. Reviewed dental charts. Toured dental clinical areas. Reviewed SCC
organizational chart.
First Court Expert Findings
• A well-developed policy and procedures manual insures a dental program that is well
understood and run with continuity. It addresses all aspects of the dental program to
provide consistency of care and management.
• The policy and protocol manual for the dental program at SCC addresses only dental
personnel and their duties and responsibilities. It only states that the dental program is
responsible to provide dental care to the offender population. No specifics were
provided on access to care, provision of care, clinic management, dental services
provided, infection control, etc.
• The dental director said that this was developed by administration who thought it was
sufficient.
Current Findings
Dental policies and procedures have not changed materially since the First Expert’s Report and
we agree that they are inadequate and should be expanded.

Dental: Failed Appointments

Methodology: Reviewed Dental Sick Call log. Interviewed dental staff. Reviewed Daily Dental
Reports.
First Court Expert Findings
A review of monthly reports and daily work sheets revealed a failed appointment rate that
averaged 40%. This is a very high percentage and reflects a serious problem in getting inmates
to the clinic for their appointments. I was told that they shared my concern and were frustrated
at the lack of success in addressing this problem. I was told that the reasons for failed
appointments included the following: 1) inmates do not get their passes; 2) inmates go to other
programs or appointments; 3) inmates go to recreation; 4) inmates go to commissary; and 5)
inmates are in lockdown. The percentage does reflect lockdown days, which average about two
a month. The problem is compensated for by overscheduling every day. As such, many inmates
are seen every day, and a large number also fail to show.
The administrative staff, including the Warden, shared the concern and frustration of the dental
staff and want to help them address the problem of failed appointments.

132

Access to Care Document.

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Current Findings
We concur with the First Court Expert that failed appointments have not improved materially
since then and remain inadequate. Moreover, we identified current and additional findings as
follows.
The failed appointment rate does not appear to be deemed an important measure by SCC
leadership. For example, it did not appear on the six-page October, November, or December
Dental Reports133 as a key metric. Failed appointment rates are not reported by the dental
department.

Dental: Medically Compromised Patients

Methodology: Reviewed health history form and records from recent intake exams. Compared
the health history in the dental chart to the medical problem list.
First Court Expert Findings
A review of six dental records of inmates who were on anticoagulant therapy revealed that
three of the records had no health history documentation as part of the dental record. In the
other three records, it was documented and red flagged. In all cases of provided dental care to
these patients, medical staff was consulted, and anticoagulant therapy precautions were
addressed and followed. When asked, the dental providers indicated that they do not routinely
take blood pressures on patients with a history of hypertension.
Current Findings
Documenting the health history of medically compromised patients has deteriorated since the
First Court Expert’s Report. We concur with the First Court Expert that documentation of the
health history of medically compromised patients was inadequate. Moreover, we identified
current and additional findings as follows.
Several patients had chronic conditions important to dental treatment that were on the
medical problem list and on the health history in the dental chart. 134 Other patients had
problems noted on the medical problem list but not on the health history in the dental chart.135
There was no documented periodontal assessment nor follow-up for the diabetics, which is
particularly problematic given the relationship between periodontal disease and diabetes. 136
CQI Monthly Oct 2017_1.pdf, p. 7; CQI Monthly Nov_2.pdf, pp. 13-18; and CQI Monthly Dec 2017_2, pp. 13-18, respectively.
Medically Compromised Patient #1 (Coumadin). The record reports that Coumadin therapy was (appropriately) stopped for
two days before a planned extraction. Patient #10 (Coumadin). Patient #6, 8, and 9 (diabetes).
135 Medically Compromised Patients #4 and 5 (diabetes); Patients #3 and 7 (Coumadin). Patient #7 received an intake screening
12/15/15 but did not receive a complete examination until his 1/11/18 biennial examination. Patient #3 was taking Warfarin
11/23/16 – 2/20/17 and Coumadin from 2/19/17 – 5/18/17 and 3/22/17 – 6/22/17; yet the health history was not updated,
and anticoagulant use was not noted.
136 See, for example, Herring ME and Shah SK. Periodontal Disease and Control of Diabetes Mellitus. J Am Osteopath Assoc.
2006; 106:416–421; Patel MH, Kumar JV, Moss ME. Diabetes and Tooth Loss. JADA 2013;144(5);478-485 (adults with diabetes
are at higher risk of experiencing tooth loss and edentulism than are adults without diabetes); And Teeuw WJ, Gerdes VE, and
Loos BG. Effect of Periodontal Treatment on Glycemic Control of Diabetic Patients. Diabetes Care 3 3:421-427, 2010
(periodontal treatment leads to an improvement of glycemic control in type 2 diabetic patients).
133
134

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Dental: Specialists

Methodology: Interviewed dental staff, reviewed CQI documents, and reviewed dental charts
of inmates who were seen by an oral surgeon.
First Court Expert Findings
Dr. Frederick Craig, an oral surgeon, is available on an as-needed basis, usually once a month,
sometimes twice. Dr. Craig is also used by several other IDOC institutions. The dental program
also utilizes Joliet Oral Surgeons, a local oral surgery group, for more difficult cases and for
general anesthesia. Pathology services are the same as for medical pathology. They give the
specimen to the appropriate medical person for processing. All radiographs were current, and
all record entries were adequate. The NRC utilizes these services through SCC.
Current Findings
Oral surgery consultation has changed substantially since the First Court Expert’s Report and is
adequate. We concur with the First Court Expert’s findings. Questions have been raised about
the performance of the onsite oral surgeon and are addressed in the CQI section (infra). Dr.
Craig has not provided onsite oral surgery services in the past year. SCC has recently located
another oral surgeon willing to provide onsite services.

Dental: CQI

Methodology: Reviewed CQI minutes and reports. Interviewed dental staff.
First Court Expert Findings
The dental program contribution to monthly CQI includes a thorough documentation of dental
statistics and productivity numbers. There is an ongoing CQI report for the dental program that
seeks to improve the ability of segregation inmates to get to the dental clinic for their
appointments. It is a study that looks at the reasons why they are not getting to the clinic.
These findings must be used to develop procedures to improve this problem. Consideration
should be given to conduct ongoing studies with the NRC.
Current Findings
The dental CQI program has improved since the First Court Expert’s Report. We agree with the
First Court Expert that the dental CQI program should not be limited to reporting data and that
studies must be used to drive changes in policy, procedures, and practices. Moreover, we
identified current and additional findings as follows.
The SCC Annual CQI Report 2016-2017 mentioned two dental issues. The first was a discussion
of the Oral Surgery Study which addressed problems associated with Dr. Craig, an oral surgeon
who treats inmates onsite at several IDOC prisons. 137

Stateville Annual CQI 2016-17_1.pdf, p.15. pdf p. 15. Dr. Craig is no longer being referred patients from SCC (although he was
still seeing patients at other IDOC prisons) due to “performing the wrong procedure and talked patients out of procedures”
(id.).

137

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A clinical outcome review of 56 inmates referred to Dr. Craig for onsite oral surgery found that
he performed the wrong procedure on one patient; 17 patients were sent offsite for their
procedure; several patients were sent to an offsite oral surgeon for the procedure or a
complication of the onsite procedure; 10 patients refused when informed of potential
complications; and 13 were evaluations, follow-ups, or reschedules. 138 The committee
recommended that the issue should continue to be monitored (id.). A follow-up study was
reported 9/29/17, and another follow-up was planned in six months. 139 Dr. Meeks
recommended a Root Cause Analysis be performed on Dr. Craig. NRC AWP Konopka asked if a
Peer Review was performed. Dr. Meeks also suggests that Dr. Funk and Mr. Mote monitor Dr.
Craig's progress at other institutions. Dr. Funk commented that Dr. Craig is still employed at
Pontiac C.C. and a few other facilities. Dr. Craig is performing minimal surgery procedures,
keeping patients onsite per Dr. Funk. Doug Mote will investigate further and report findings to
Dr. Meek and Dr. Funk (id., p. 15). 140
The other study focused on compliance with aspects of the Dental Administrative Directive
based on dentists’ review of dental charts, primarily from NRC. 141 Among the findings from the
NRC charts were that 62% had no charting of pathology, with the remainder having only a
partial charting. 142 Furthermore, “in all the patients reviewed, visible heavy tartar [calculus] was
never charted or indicated. The periodontal needs were never indicated” and “the dental
radiographs from NRC varied in diagnostic quality.” 143 (Id.)

Internal Monitoring and Quality Improvement
Methodology: Interview facility health care leadership and staff involved in CQI activities.
Review the internal monitoring and CQI meeting minutes for the past 12 months.
First Court Expert Findings
The First Court Expert found that there were no CQI meetings since October 2013 (the visit was
in February 2014) and no minutes since July of 2013. The minutes contained no narrative, no
analysis of the data presented, and no studies. This program was described as “nonfunctioning.” The grievance process was stated to be “non-functioning” because there was no
interview of the grievant.

Stateville Annual CQI 2016-17_2.pdf, p. 34.
CQI Monthly Oct 2017_3.pdf, pp. 15-20.
140 We requested of IDOC and Wexford 1) the root cause analysis that Dr. Meeks recommended; 2) any focused peer review
that may have been performed on Dr. Craig; 3) any documentation related to Dr. Funk or Mr. Mote's monitoring of Dr. Craig;
and 4) any actions taken re Dr. Craig at the other IDOC prisons where he sees patients (e-mail from Dr. Puisis to Nicolas Staley
dated 3/9/18). They have yet to be provided.
141 Specifically, 1) whether a complete dental exam with charting of the oral condition was performed within 10 days of arrival
at Reception and Classification Center; 2) whether a diagnostic panoramic radiograph was taken on each inmate; and 3)
whether inmates’ treatment needs were classified appropriately. Quality Improvement Study. Of 24 charts, 21 were from NRC.
142 “The missed pathology included abscessed teeth, teeth that needed extraction, [and] periodontal disease, (+3) mobility in
teeth, grossly decayed teeth, impacted wisdom teeth, wisdom teeth in the maxillary sinus, and numerous visible dental caries”
(id.).
143 Seven of the Panorex x-rays were of poor quality and unable to obtain any diagnostic information, or 33%” (id.).
138
139

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The First Court Expert recommended reinvigoration of the CQI program. He recommended
professional performance reviews with feedback to the clinician and nurses with respect to the
sick call process. He recommended that leadership of the CQI program must be retrained
regarding CQI philosophy and methodology along with design and data collection, and that the
training include how to study outliers in order to develop targeted improvement strategies.
Current Findings
The First Court Expert found that the CQI program was non-functioning. We found that the CQI
program was functioning but functioning so poorly that it was effectively non-functioning. We
did not evaluate the grievance process because we did not receive the CQI minutes until the
Wednesday evening during our tour, too late to evaluate the grievances presented in that
report.
The CQI program at SCC was ineffective for the following reasons:
• The Annual CQI Plan has no goals or objectives related to problems areas at the facility.
• The Annual CQI Plan is a generic plan which is a word-for-word duplicate of the plan
used at NRC, even though NRC and SCC are different facilities with different missions.
The Annual CQI Plan failed to identify the upcoming year’s agenda of CQI work.
• Credential and privilege reviews of physicians are performed by nurses who do not have
the capacity to review physician privileges.
• Review of credentials fails to include one-time primary source verification. The CQI
coordinator and HCUA did not understand what primary source verification meant even
though it is an administrative directive requirement.
• The Governing Body of the CQI committee consists of the Warden, an ex-warden, and
the Agency Medical Director. Health trained staff are underrepresented on the CQI
Governing Body.
• The CQI studies do not investigate quality of care or appropriateness of care even when
this is required by administrative directives, for example with respect to offsite services.
• The leadership does not appear to understand the difference between outcome and
process studies. Outcome studies were not based on a clinical outcome and most
outcome studies appeared to be performance measures instead of outcome studies.
• Mortality review is not performed. Instead, a death summary is done by a physician
involved in provision of care. This summary fails to include a critical review of the death
and does not identify problems in order to prevent further mortality. Though we have
found preventable deaths in our death reviews, there is no evidence that the system is
attempting to identify problems so that these deaths can be prevented.
• Infection control data appears inaccurate.
• The Medical Director summary in the annual CQI report from NRC is an identical wordfor-word duplicate of the Medical Director summary from SCC with the exception of a
single sentence about NCCHC accreditation, which NRC is not engaged in. These are
different facilities with different missions and should have a different summary by the
Medical Director.

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•

While the concept of internal audits is sound and potentially useful, five of six audits did
not include the reported findings. Also, these audits only focus on process issues and
should also include quality of care.

The purpose of SCC CQI was not to identify and solve problems in order to improve care. This
appears to be a result of lack of leadership. The Director of Medical Records is the CQI
Coordinator. She has no training in CQI. She is well trained for her work as a Director of Medical
Records but poorly trained for her assignment to be CQI Coordinator. Her knowledge of CQI is
to “follow the ADs.” She stated that her role as Coordinator is to set the calendar of studies
required by the IDOC, to remind staff to complete their studies, and to manage the paper flow.
For this purpose, she spends about four hours a month. She is not involved in developing a CQI
plan and stated that the Governing Body (the Warden, an ex-warden, and the Agency Medical
Director) develops the plan with the IDOC Regional Coordinator. She believes that all studies
required by the AD on CQI are completed. She failed to understand the meaning of some of the
required studies. There is no method by which SCC identifies problems. None of the other
leaders of the medical program have had any training in CQI.
SCC does not maintain a manual of CQI as required by the AD. The Annual CQI Plan is a generic
plan that contains no identified problems and has no specific plans for the upcoming year’s CQI
projects. This is inconsistent with the requirements of the AD. 144 The plans from NRC and SCC
were identical even though the institutions have different missions and different sets of
problems. The plans do not include an agenda for the past or upcoming year with respect to
CQI projects that have been identified from problem prone areas. The summary of the annual
CQI meeting failed to discuss the prior year’s plan, major findings, or accomplishments based
on identification of problems and corrective actions undertaken.
The HCUA and vendor Director of Nursing (both nurses) are responsible for reviewing all
professional credentials and privilege sheets, but as nurses they are not capable, in our opinion,
of reviewing credentials or privileging of the physicians. The CQI AD states that one-time
primary source verification is to be done. 145 The CQI AD states that the vendor is to do this.
Neither the CQI Coordinator nor the HCUA could tell us what primary source verification meant.
There was no evidence that this was done. The CQI plan states that the program reviewed
100% of credentials. Yet for physicians, verification consisted only in verifying that they had a
license.
Medical program staff are underrepresented on the Governing Body. The Governing Body of
the CQI committee is the Warden, the vendor Regional Manager and the Agency Medical
Director. The vendor Regional Manager is an ex-warden with no prior formal training in health
care management or in a health care discipline. This means that the controlling votes of the
AD 04.03.125 Quality Improvement Program, item II.F.b. states, “Annually develop or update a Quality Improvement Plan
based on a program that identifies problems and opens channels of communication for appropriate resolution of identified
concerns.” [our emphasis]
145 AD 04.03.125 Quality Improvement Program item II.I.h. states, “A one-time primary source verification shall be conducted
by the comprehensive health care vendor for all licensed contractual staff.”
144

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Governing Body is a current Warden and an ex-warden who works for the vendor. This is
unlikely to result in effective direction for the CQI program and also means that two individuals
with criminal justice training control the medical CQI program.
An AD requirement to monitor the quality and appropriateness of offsite care is not being
done.146 The annual report merely lists the number of offsite visits, without any evaluation of
appropriateness or quality. We discussed a case of delayed diagnosis of colon cancer in the
hospital section of this report. This same patient is mentioned in the December 2017 CQI report
as a delayed diagnosis. Yet there was no discussion as to why the diagnosis was delayed and no
attempt to remedy the root cause problem to prevent these types of delays in order to prevent
morbidity and mortality. The AD requires that all UM denials are monitored to ensure that
necessary and appropriate care is provided.147 This task is assigned to the HCUA, who is a nurse.
It is our opinion that a nurse is incapable of determining if physician or other provider referrals
for offsite care are necessary or appropriate. This should be done by a physician. We noted that
aside from providing the numbers of individuals who obtained offsite services, there was no
evidence of any monitoring or evaluation for quality of care or appropriateness. To merely list
these visits is not evidence of quality of care or appropriateness.
We asked for but did not timely receive the list of denials of offsite care for SCC and were not
able to review these before we ended the tour. However, it is not clear from the CQI data
presented that the denials were appropriate. These data merely list the number of events that
occurred without any evidence that the quality or appropriateness was evaluated or was
adequate.
The section of the annual CQI report on offsite services states that over 95% of individuals are
evaluated within five days of their offsite appointment without any evidence that the quality of
these evaluations is adequate. As we discuss in the specialty care section, post offsite physician
evaluations are not of adequate quality. At some of these visits, doctors did not have the
consultant report and in others, the doctor did not document what had occurred at the
consultation or during hospitalization. Some recommendations of consultants were not
addressed. It is insufficient to merely state that a doctor saw the patient.
The CQI studies included two process studies and four outcome studies. Clinical outcomes are
end point measures of health status such as mortality, hospitalization, an HbA1C level of 7 or
less, or normal blood pressure. An outcome study measures the effectiveness of interventions
based on the ultimate outcome measure. An example would be to study the effect of colorectal
cancer screening on colon cancer mortality or the effect of increasing the interval of chronic
AD 04.03.125 II.I.2.b Off-Site Offender Care Services item II.I,2. j. states, “A monthly review of the quality and
appropriateness of care of 100% of the following cases not to exceed a total of 50 cases in each area shall be conducted by
health care staff. A standard comparison and analysis of the current month to the previous month and the current month to the
same month one year earlier shall be provided.”
147 AD 04.03.125 Quality Improvement Program item II.I.2.j. Utilization Review states, “A weekly review of 100% of all
Utilization Review denials shall be conducted by the Health Care Administrator to ensure offenders are receiving necessary and
appropriate care.”
146

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clinic visits on obtaining a normal blood pressure. The studies performed at NRC were not
based on a clinical outcome, with one exception. SCC studied whether one inmate treated with
Harvoni had a sustained virologic response. While this is an outcome, it is not a good study, for
two reasons. First, there was only one patient. Secondly, studies have already been done with
Harvoni showing its effectiveness with respect to sustained response. This study adds no value
to patient care. None of the remaining studies included a clinical outcome. These studies
included:
• Whether the pharmacy changed the duration of a non-formulary medication without
notice.
• Whether UIC laboratory results were received within 48-72 hours.
• Whether an injury report was signed by a provider.
These are all performance measures and not outcome studies.
None of the individual CQI studies in the annual report evaluated for quality of care. The RN sick
call study found that 74% of a sample of nurse sick call appointments was referred timely to a
physician. This study did not consider whether the nurse evaluation or physician evaluation was
of adequate quality. Also, although the study identifies a problem, it does not investigate
causes as to why 26% of patients were not seen timely and did not propose a solution. Half of
the patients not seen did not even have a note in the medical record. There was no comment
on identification of possible causes for these poor results and no solution except to monitor the
providers. A month later this study was repeated, and only 76% of patients referred by a nurse
to a provider were seen within 72 hours. The question why this occurred was not answered
even though the result was nearly identical to the prior month. The proposed solution was to
repeat the study. The study was repeated in March, two months later and 91% of inmates were
timely referred. Three months later the study was repeated and only 72% of patient referred by
a nurse to a physician were seen within the specified 72 hours. Again, there was no analysis of
why this occurred and there was no proposed solution to improvement. This study did not
consider the quality of the nurse or physician evaluations. This study was repeated numerous
times showing similar poor results without any effort to identify the root cause of the problem
or any attempt to seek resolution of the problem.
The laboratory section of the annual CQI report lists the number of phlebotomies done per
month. The only important quality metric in this data is the number of re-draws. However,
month to month this process seems to be in control. While it is useful to monitor to ensure
maintaining control, efforts should be redirected to problem prone areas. We noted that
abnormal laboratory tests were often not followed up, patients with abnormal laboratory tests
requiring treatment were not followed up, and patients were not always treated. This led to
preventable morbidity in two cases (myocardial infarction and stroke). This type of problem
should be investigated.
Mortality review is not done. The Medical Director, who may have been responsible for care of
patients who die, provides a summary of the death which gives no indication as to whether any
problems were identified. This is not a mortality review. It draws no conclusions as to the
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quality of care and gives no information as to whether problems exist or improvements are
needed. We note that at this facility the physician performing the mortality reviews is a surgeon
and does not have the training to adequately perform analysis to determine if care for the
primary care problems was adequate.
The data for MRSA do not seem credible. For 2016-2017, only seven persons were treated for
MRSA infection at SCC. This does not seem credible, as MRSA is an extremely common
infection. In a subsequent email exchange with the HCUA we were told that there was only one
positive MRSA culture in 2017, with nine suspected cases. This seems extraordinarily low and
may reflect lack of cultures of patients being treated. It would be appropriate for an infection
control study to investigate how many patients are currently being treated for this infection at
this facility and to investigate whether there is underreporting of this infection.
There were six internal audits done at SCC presented in the annual CQI report. Three of these
audits were done on the same day. These audits included:
• Chronic illness clinic is completed in the appropriate month.
• A progress note is completed for all individuals engaging in a hunger strike.
• All inmates have a physical examination as per administrative directive requirements
and problem lists are updated.
• A staff signature is present on all admissions to the infirmary. Nurses will complete a
nursing admission note and vital signs will be recorded as required.
• The Medical Director reviews the treatment protocols.
• Only a physician discharges a patient from the infirmary.
None of the internal audits reviewed the quality of care. These audits reviewed process items
related to administrative directives. These audits are useful to ensure that processes of care are
carried out in accordance with requirements. However, they do not assess whether the care
provided was of adequate quality. Only one of the six audits included the data and it is
therefore unclear whether these audits were actually done. The audit of Offender Infirmary
Services noted that in two of 10 files reviewed, a physician, psychiatrist, or dentist did not
discharge the patient from the infirmary as required. The remainder of the internal audits did
not include any data to verify that the audit had actually been done.
Clinical performance enhancement is a method of periodic evaluation of the clinical
performance of individual practitioners. For this purpose, Wexford, as required by their
contract with IDOC, performs peer review of its physicians. We were told that Medical Directors
perform these reviews for all staff physicians and mid-level providers at their facility and that
Medical Directors from another facility perform the review for the Medical Director.
There are four standardized formatted questionnaires used for peer review, which are found in
Appendix B. These questionnaires include infirmary, chronic care, sick call, and laboratory/x-ray
utilization. There are several questions related to quality of care, particularly related to the plan
of care being adequate, but most questions are process related. A single episode of care is used

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for each patient and the questionnaire is repeated multiple times for each area of service in
which the provider engages. 148
For the physician assistant at SCC there were two reviews, which consisted of reviews of 15
episodes of care for provider sick call and 10 episodes of care for laboratory/x-ray utilization. In
total, 328 questions were asked. 327 (99.69%) were found adequate. One question (0.30%) was
inadequate. No problems were identified.
For the staff physician, 341 questions were asked and 338 (99.1%) were adequate. The
remaining three questions were not applicable. No problems were identified.
The recent Medical Director had two peer reviews by different physicians. In total, 465
questions were asked. 361 (77.6%) were adequate, 55 (11.8%) were not applicable, and 49
(10.5%) were inadequate. The inadequacies consisted of:
• Failing to write notes
• Failing to document clinical correlation to the complaint
• Failing to document clinically significant findings
• Failing to ensure timely follow up
• Failing to document a targeted physical examination
• Failing to have an appropriate plan of care
• Failing to document patient education.
The clinical performance of the Medical Director, a surgeon, was worse than the physician
assistant. In our own record reviews, we found many more inadequacies than were found in
these reviews. The Medical Director rarely took an adequate history, rarely performed an
adequate physical examination, and seldom included an adequate assessment or plan of care.
We identified morbidity and mortality as a result of poor care. Yet the peer reviews purport to
demonstrate nearly 100% adequate care. We find these peer reviews less than adequate in
describing the extent of problems with quality of care. There are no peer reviews of sentinel
events, including death.149 This fails to protect patients from risk of ongoing harm. We noted in
the hospital section of this report multiple instances of harm (myocardial infarction, stroke,
delayed diagnosis of colon cancer) that resulted from inadequate care and find that the lack of
sentinel event reviews results in increasing the risk of harm to patients. The review of clinical
care needs to include sentinel events, including appropriately performed mortality review.

An episode of care is a single unique provider-patient visit.
The Joint Commission defines a sentinel event as unanticipated events in a healthcare setting resulting in death or serious
physical injury or risk of injury to the patient not related to the natural course of the patient’s illness. These events call for
immediate investigation and response.
As found at https://www.jointcommission.org/assets/1/6/CAMH_2012_Update2_24_SE.pdf.
148
149

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Recommendations
Leadership, Staffing, and Custody Functions
First Court Expert Recommendations
1. Stateville requires its own Health Care Unit Administrator position. We agree with the
First Court Expert’s recommendation that SCC have its own HCUA. This has been
accomplished.
2. Stateville requires its own staffing allocation specifically to meet the Stateville service
demands. We agree with the First Court Expert’s recommendation. We add that in order
to ensure the staffing allocation is adequate, a staffing analysis be performed as listed in
recommendation 5 below.
3. Only trained primary care clinicians (Internal Medicine and Family Practice) should be
providing primary care to this population. Physicians should be board certified in a
primary care field. We partly agree with the First Court Expert’s recommendation. We
would find board eligible physicians acceptable at facilities with a low percentage of high
acuity patients. 150 Facilities housing complex patients should have a board certified
primary care physician.
4. All health care providers should have access to electronic medical references. We agree
with the First Court Expert’s recommendation. We suggest universal access to
UpToDate®. 151
Additional Recommendations
5. A staffing plan should be developed that includes appropriate relief factors and that
evaluates for expected service requirements.
6. Health care leadership staff need to receive an orientation to their positions that
reasonably informs them of the expected assignments.
7. The use of “traveling medical directors” should not be permitted to contractually
substitute as filling a Medical Director position. Failure to have a permanent Medical
Director should incur contractual penalties. Coverage physicians should be used as
necessary, but coverage physicians should not constitute a filled Medical Director
position.
8. An additional IDOC Regional Coordinator should be added to reduce the span of control
for this individual.
9. Review of physician credentials and privileges needs to be performed by a physician.
10. Privileging of physicians must include verification of residency training for the services
expected to be provided. Physicians should not be allowed to be privileged to perform
services for which they have no formal training.
Board eligible is a physician who has completed training in a residency but has not yet received certification. In this case,
board eligible would mean that a physician has successfully completed residency training in internal medicine, family practice
or emergency medicine.
151
UpToDate® is a clinical decision support resource that can be accessed over the Internet or from a dedicated server. It has
pharmacy information and clinical decision support for general medical practice.
150

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11. Contract monitoring should include evaluation of quality of care as provided by the
vendor.

Clinic Space, Sanitation, Laboratory, and Support Services
First Court Expert Recommendations
1. Designated exam rooms should be made available with appropriate equipment in cell
houses B, E, and F to allow sick call to occur with reduced movement demands. We
agree with this recommendation.
Additional Recommendations
2. The first aid kits in the correctional officer rooms on the housing units should be
regularly inspected and re-supplied after each use.
3. The infirmary beds need to be properly repaired or replaced with hospital beds so that
the height of the bed can be modified, the head adjusted, and the railings are
operational.
4. A quantity of electrical beds that meet the needs of the infirmary patient population
should be purchased.
5. Continue to conduct monthly documented safety, sanitation, and infection control
inspections/environmental rounds, focusing at a minimum on all health care areas, the
infirmary patient rooms including the negative pressure rooms, the hemodialysis unit,
and the dietary department, with monthly reporting to the CQI Committee.
6. Pest control must continue to be addressed in the infirmary.
7. The safety and sanitation defects in the infirmary tub room floor must be corrected.
8. The birds in the inmate dining and food serving areas must be removed and the area
properly sanitized.
9. A sanitarian should be hired to review sanitation issues including the washing of cooking
and eating instruments, the maintenance of required temperatures in the meat freezer,
vermin, pests, and other potential environmental sanitation hazards.
10. Develop and implement a plan to daily monitor and document negative air pressure
readings when the room(s) is occupied for respiratory isolation, and weekly when not
occupied.
11. All medical equipment must have no less than annual documented inspections and
calibrations by a bioengineering team. Each individual piece of medical equipment must
have a current date of inspection label.

Medical Records
The First Court Expert had no recommendations.
Current Recommendations
1. Install an electronic medical record. Include at the point of care access to UpToDate® for
all staff.

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2. If an electronic medical record is not used, modify or improve the paper record files so
that they do not come apart during routine use.
3. Negotiate with local consultants and hospitals to timely obtain consultation and hospital
reports, as this is a major patient safety and liability issue.
4. When records from consultants are unavailable, the providers need to communicate
with consultants to timely obtain necessary information about the consultation to
protect patient safety.
5. Create a unified record that includes nephrology consultations and necessary
information about dialysis, including laboratory testing if done.

Intrasystem Transfer
First Court Expert Recommendations
1. The intrasystem transfer process needs to be appropriately addressed to effectively
ensure continuity of care for patients who enter with prior diagnosed problems. This
should be monitored by the QI program. We agree with this recommendation.
Additional Recommendations
2. Health care leadership develop and implement a tracking log that documents
completion of all intrasystem transfer activities and identifies instances of incomplete
transfer information.
3. Written directives of IDOC and Wexford be revised to add responsibility for the sending
IDOC facility to accurately complete the Health Status Summary in advance of inmate
transfer. 152

Nursing Sick Call
First Court Expert Recommendations
1. Custody issues should not interfere with the provision of timely health care. We agree
with the First Court Appointed Expert’s recommendation that custody issues should not
interfere with timely provision of health care, especially as it pertains to patient privacy
in segregation.
2. There should be no such thing as a “no show” in a prison. Patients may refuse care but
should be required to report to the health services area when scheduled. This
recommendation has been implemented and all inmates who have signed up for sick call
are seen by nursing staff and may refuse the encounter at that time.
Additional Recommendations

Documents to be revised include the IDOC-Wexford contract, Wexford Policy and Procedure, p. 118 Transfer Screening, and
SCC Operations Policies and Procedure, p. 118 Transfer Screening.
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2. IDOC Institutional Directive 04.03.103K Offender Health Care Services be revised to
incorporate the procedure and practices for sick call as reflected in the SCC Operations
Policy and Procedure P103 Non-Emergency Health Care Requests and Services.
3. Sufficient numbers of RNs need to be employed so that LPNs are not assigned to
conduct sick call.
4. RNs should perform and document an assessment of each patient in accordance with
treatment protocol forms and/or sound nursing judgement.
5. RNs should refer patients to providers in accordance with the treatment protocol and in
accordance with sound nursing judgment. The urgency of the referral should be
documented and used to schedule provider appointments.
6. The sick call documentation forms should be revised to indicate if the referral is
emergent, urgent, or routine.
7. The adequacy of nursing assessments and the plan of care should be monitored by
nursing service as part of the peer review or CQI.
8. Custody staff should stand at a distance from the sick call room in segregation so that
they can provide visual security but not hear the substance of the interaction.
9. Custody staff should remove restraints without delay when requested by the nurse to
complete the evaluation of a health complaint.
10. Providers should see patients timely according to the urgency of the referral. 153
11. Health care leadership should develop and monitor quality indicators associated with
each step of the sick call process. There should be evidence of steps taken to address
areas of improvement needed for performance that does not meet the quality
indicators.

Chronic Care
First Court Expert Recommendations
1. Patients should be scheduled in accordance with their degree of disease control, with
more frequent visits when disease control is poor and less frequent visits for those
under good control. This is a statewide policy issue which needs to be corrected.
2. For diabetes clinic:
a. Meals should be served on a predictable schedule to facilitate the coordination of
insulin administration with food consumption.
b. Type 1 diabetics should have access to physiological insulin replacement with three
to four injections per day.
3. For HIV clinic:
a. Patients with HIV infection should be formally enrolled in the chronic care program
just as patients with other diseases are.
b. Facility clinicians should be providing primary care to this population. This would
include actively monitoring this high-risk population for medication compliance, side

153 Emergent referrals should be seen immediately, urgent referrals should be seen the same day and routine referrals seen
within 72 hours.

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effects, and the primary care complications related to the disease and its treatment,
such as hyperlipidemia, diabetes, and cardiovascular disease.
c. The chronic care nurse should be doing medication compliance checks with HIV
patients at least monthly.
d. Problem lists in the medical record must be incomplete and accurate.
We agree with these recommendations.
Additional Recommendations
4. Chronic care provider progress notes must be legible, communicate the rationale for
modifications in treatment, list reasonable differential diagnoses, document pertinent
physical findings and symptoms, and record clear treatment plans.
5. The Office of Health Services should use national standards of care for their chronic
illness guidelines. A Chronic Care procedure should specify timelines for clinic intervals
and laboratory testing.
6. Age and gender based routine health maintenance, including cancer screening and
immunizations for patients with and without medical conditions, must be provided in
accord the United States Preventive Services Task Force (USPSTF) guidelines and other
national standards of care. A and B rated guidelines of the USPSTF should be used for
the annual health examination.
7. Disease specific chronic care clinic visits should end. Chronic care visits must address all
medical conditions of the patient. Strictly focusing on a single specific disease and not
addressing other associated clinical problems is not in the best interest of the patient
and delays needed interventions.
8. The chronic care providers must regularly document the review of the MAR, the CBG
tests, the nursing and provider sick call notes, and blood pressure readings when they
see patients in the disease-specific chronic care clinics.
9. Nursing or CQI staff should do monthly medication compliance audits on all patients
with HIV, diabetes, chronic anticoagulation, seizure disorders, and other chronic
illnesses as needed. The results should be communicated to the providers and to the
CQI Committee.
10. The IDOC should develop a plan to shift anticoagulation treatments from Vitamin K
antagonists (warfarin) to newer types of anticoagulants that do not require frequent
ongoing lab testing to determine the adequacy of anticoagulation. The frequent lab
testing and medication adjustments are logistically complicated and put patient-inmates
at risk for poor outcomes. Utilizing newer anticoagulation medications that do not
require frequent ongoing measurement of the level of anticoagulation should be
strongly considered by the IDOC.
11. Patients with selected chronic illnesses including diabetes, hypertension, and
hyperlipidemia should have the 10-year cardiovascular risk calculated to determine if
they require a HMG CoA-reductase inhibitor (statin drug) and the proper dosage to
minimize the risk of myocardial infarction, stroke, and other cardiovascular diseases.

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Urgent/Emergent Care
First Court Expert Recommendations
1. The urgent/emergent program requires review and feedback both with regard to
timeliness, appropriateness, and continuity of care. This should be done by clinical
leadership and the QI program. We agree with this recommendation.
Additional Recommendations
2. Establish a list of supplies and equipment to be included in each of the first response
bags and the disaster bags, and to identify where each is located in the bag. This list
should be used to resupply any bag after use and to conduct a monthly inventory.
3. Each of the openings in the bag should be sealed with a numbered plastic tag. The
integrity of the seal should be checked and documented on the emergency equipment
log at the beginning of each shift.
4. Healthcare leadership should review actual practices against the SCC ID # 04.03.108 K3
and the Healthcare Operations Policy and Procedure P112 and identify deviations.
Revisions to the written directive should be considered and/or a corrective action plan
implemented to bring actual performance into compliance with written directives. 154
5. Because clinical leadership does not appear to understand when a clinical situation is a
problem, the IDOC should engage outside medical consultants to examine the quality of
care for sentinel events to give feedback and assist in monitoring the clinical care.
6. When the provider at the facility fails to know what diagnosis the patient is or how to
manage the patient’s problem, that patient needs to be referred to another provider,
possibly a consultant, who does know how to manage the patient’s clinical problem.
This is a particular problem in the IDOC because of the large number of physicians
without primary care training.

Specialty Consultations
First Court Expert Recommendations
1. Scheduled offsite services need to be improved with regard to timeliness of access to
these services as well as follow up after the service is provided.
2. There should be a reliable method of communication between the scheduler and the
clinicians to ensure that patients who require specialty consultation are scheduled
commensurate with the urgency of their need.
We agree with these recommendations.
Additional Recommendations
3. If the current process of utilization of offsite care is to be used, the IDOC, not the vendor,
should develop a standardized offsite tracking log on an Excel spreadsheet that should be
used at all sites. This tracking log should be used to report timeliness of collegial reviews,
approvals, and appointments to the QI committee.
154

For example, the number of drills required at SCC exceeds that required by NCCHC.

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4. Referrals for offsite care should be first documented as a physician order in the medical
record. The original referral form should be filed in the medical record on the date it was
initiated by the provider. Copies of this form can be used by the scheduler to manage
scheduling.
5. Medical providers should be permitted to send patients to offsite consultants without
going through the collegial review process on the basis of patient safety.
6. When UIC specialty care is significantly delayed, e.g., gastroenterology, an alternate local
consultant should be used to obtain care.
7. Any denial of care needs to be documented in the medical record using documentation of
the person who denied care.
8. At follow up provider visits after consultations, the provider should be required to
document the results of the consultation, update the status of the patient, and update the
treatment plan based on the consultation. If consultant reports are unavailable, the
provider should use other communication efforts to determine what occurred at the
consultation.

Infirmary Care
First Court Expert Recommendations
1. Patients should be seen timely according to policy requirements while in the infirmary.
2. If clinicians choose not to treat patients according to currently accepted
recommendations and guidelines, the rationale for these decisions should be articulated
in the health record.
We agree with these recommendations.
Additional Recommendations:
3. Problem lists in the infirmary charts must be complete and accurate.
4. Provider notes must be legible, communicate the rationale for modifications in
treatment, list reasonable differential diagnoses, document pertinent physical findings
and symptoms, record clear treatment plans, and write regular comprehensive progress
notes that update the status of each and every acute and chronic illness.
5. As noted in the Clinic Space section, the infirmary beds need to be properly repaired or
replaced with hospital beds so that the height of the bed can be modified, the head
adjusted, and the railings are operational. A number of electrical beds should be
purchased for the infirmary. The condition of the infirmary beds puts at risk the safety
of patient-inmates and staff.

Pharmacy and Medication Administration
The First Court Appointed Expert made no recommendations concerning pharmacy and
medication administration.
Current Recommendations
1. Consider reducing the volume of controlled medications in stock.
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2. The original order should be used when transcribing the order onto the MAR; the blister
card should not be used.
3. Medication should be administered in patient specific, unit dose packaging. The practice
of pre-pouring should be eliminated.
4. The MAR should be used by the nurse to verify the medication, dose, and route of
administration is correct immediately before giving the medication to the patient. The
nurse should consult the MAR before answering any questions or concerns the patient
has about the medication.
5. Medication should be documented at the time it is administered.
6. Printers should be provided so MARs can be printed at the facility at the end of the
month and when a new order is written.
7. A system for timely renewal of chronic disease and other essential medications should
be developed.
8. Nurses should refer any patient who does not receive three consecutive doses of nurse
administered medication prescribed for a chronic disease to the treating provider. The
treating provider should meet with the patient and determine if treatment should be
modified to improve adherence.
9. Patient adherence with KOP medications prescribed to treat chronic disease should be
monitored at regular intervals (monthly by nursing and by the provider at each chronic
disease visit).
10. Revise the policy and procedure for medication administration to provide sufficient
operational guidance to administer medications in accordance with accepted standards
of nursing practice.
11. The CQI program should develop, implement, and monitor quality indicators related to
pharmacy services and medication administration.
12. Root cause analysis and corrective action plans should be used to target the causes of
performance that is below expectations. Corrective action should consider software and
mechanical means to improve patient safety, such as computerized provider order
entry, use of bar coding, patient specific unit dose packaging, etc.

Infection Control
First Court Expert Recommendations
1. The First Court Expert had no specific recommendations for infection control for SCC.
However, The First Court Expert recommended that each facility have a specific nurse
assigned responsibility for infection control, and because SCC did have such a
designated nurse at that time, no recommendations regarding infection control were
made. SCC no longer has a single designated nurse assigned to infection control. There
were important infection control issues identified during our site visit but no one at SCC
had identified that these were issues that needed attention. We concur with the First
Court Expert’s recommendation that each facility, now including SCC, have a designated
infection control nurse responsible for compliance with IDOC policy concerning
communicable diseases, blood borne pathogens, and compliance with Illinois
Department of Public Health reporting requirements as well as the HIV and HCV clinics.
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Additional Recommendations
2. SCC should have a designated infection control nurse responsible for compliance with
IDOC policy concerning communicable diseases, blood borne pathogens, and
compliance with Illinois Department of Public Health reporting requirements as well as
the HIV and HCV clinics. This infection control nurse should also be responsible for
monitoring and prevention of communicable disease outbreaks.
3. Infections and communicable disease data should be analyzed and discussed as part of
the monthly and the annual CQI meetings. This should include discussion of trends,
updates from the CDC and review of practices. The risk for transmission of TB infection
is one example of a periodic review and analysis that should be done by the infection
control program at SCC.
4. Track and report skin infections due to all pathogens, not just MRSA, including
infestations with scabies or body lice.
5. Update the IDOC Infection Control Manual now and at least every two years.
6. Airborne Infection Isolation (AII) rooms need to be regularly serviced, inspected by
knowledgeable individuals, and monitored regularly. The maintenance of adequate air
changes and pressure should be documented on a log specifically as part of the infection
control program.
7. Also, the practices of the hemodialysis program need to be brought into compliance
immediately with CDC recommendations to prevent infections, particularly hepatitis B,
among chronic hemodialysis patients.155

Dental Program
Dental: Staffing and Credentialing

First Court Expert Recommendations
1. Serious consideration should be given to hiring a second dental assistant. The lone
assistant has too many duties to perform and the dentists are often left working without
an assistant. This recommendation is moot since a second dental assistant has been
hired.
2. All surgeries should be performed with an assistant. We agree with this
recommendation.
We agree with these recommendations.
Additional Recommendations
3. NRC and SCC dental staffing should be realigned to reflect the mission of each
institution.

MMWR (2001) Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients. Vol.
50/No. 99-5, Centers for Disease Control. See also Update to the 2001 Hemodialysis Recommendations available at
https://www.cdc.gov/dialysis/guidelines/index.html.
155

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4. Staffing should be increased to accommodate performing comprehensive dental exams
on all prisoners either at intake or within 30 days of arrival from a reception and
classification center.

Dental: Facility and Equipment

First Court Expert Recommendations
1. Replace the cabinetry and countertops, as they are very old, worn and irreversibly
damaged. Proper infection control is almost impossible on these surfaces. We agree.
The countertops should be replaced.
We agree with this recommendation.
Additional Recommendations
2. Patients wear lead aprons with thyroid collars when dental radiographs are taken.156
3. There should be an equipment replacement plan to inform budget preparation.
4. The clinic equipment should include a sphygmomanometer and stethoscope.

Dental: Sanitation, Safety, and Sterilization
First Court Expert Recommendations: None
Additional Recommendations: None

Dental: Review Autoclave Log

First Court Expert Recommendations
1. That the sterilization spore testing log be accurately maintained and kept on record
indefinitely.
2. That safety glasses be provided to patients while they are treated.
3. That a biohazard warning sign be posted in the sterilization area.
4. A warning sign be posted in the x-ray area to warn of radiation hazards, especially
pregnant women.
We agree with these recommendations.
Additional Recommendations: None

Dental: Comprehensive Care

First Court Expert Recommendations
1. Comprehensive “routine” care should be provided only from a well-developed and
documented treatment plan based on a thorough, well-documented intra and extra-oral
examination, to include a periodontal assessment and detailed examination of all soft
tissues.
While radiation exposure from dental radiographs is low, it is the dentist’s responsibility to follow the ALARA Principle (As
Low as Reasonably Achievable) to minimize the patient’s exposure. Dentists should follow good radiologic practice and (inter
alia), use protective aprons and thyroid collars. Dental Radiographic Examinations: Recommendations for Patient Selection and
Limiting Radiation Exposure. American Dental Association and Food and Drug Administration (2012), 14.
156

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2. In all cases, appropriate bitewing or periapical x-rays be taken to diagnose caries.
3. Hygiene care be provided as part of the treatment process.
4. Care be provided sequentially, beginning with hygiene services and dental prophylaxis.
5. That oral hygiene instructions be provided and documented.
We agree with these recommendations.
Additional Recommendations
6. An examination and sequenced treatment plan should be offered to all inmates within
30 days of transfer from a reception and classification center.
7. IDOC should develop protocols for periodontal diagnosis that include the use of
Periodontal Screening and Recording and appropriate radiographs.
8. All routine dental examinations should include a sequenced treatment plan.

Dental: Intake (Initial) Examination

First Court Expert Recommendations: None.
While the First Court Expert found the records in compliance with their evaluation criteria, 157
they did not address the more critical issues relating to the quality of the screening that are
addressed below.
Current Recommendations
1. The reason(s) for the inadequate quality of the panoramic x-rays should be investigated
immediately and the equipment replaced if necessary.
2. Since there is insufficient time at the screening to provide proper oral hygiene
instruction, it should not be stamped in the dental chart.

Dental: Extractions

First Court Expert Recommendations
1. A diagnosis or a reason for the extraction be included as part of the record entry. This is
best accomplished through the use of the SOAP note format, especially for sick call
entries. We note that this is a peer review evaluation criterion. 158
2. Proper diagnostic x-rays be available for every surgical procedure.
3. Prescribe antibiotics only as necessary. Prescribing routinely after extractions is not a
standard of care. We agree with this recommendation. Antibiotics should be prescribed
after an extraction only when justified clinically and the reason for the prescription
documented in the record.
We agree with these recommendations.
Additional Recommendations
4. Consent forms should state the reason for the extraction.

Dental: Removable Prosthetics
157
158

Whether screening was performed at the reception center and a panoramic x-ray was taken.
Wexford Peer Review Form for dentists – PR-001C.

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First Court Expert Recommendations
1. A comprehensive examination and well-developed and documented treatment plan,
including bitewing and/or periapical radiographs and periodontal assessment, proceed
all comprehensive dental care, including removable prosthodontics.
2. That periodontal assessment and treatment be part of the treatment process and that
the periodontium be stable before proceeding with impressions.
3. All operative dentistry and oral surgery as documented in the treatment plan be
completed before proceeding with impressions.
We agree with these recommendations.
Additional Recommendations: None

Dental: Sick Call/Treatment Provision

First Court Expert Recommendations
1. Use the SOAP format for sick call entries. It will assure that the inmate’s chief complaint
is recorded and addressed, and a thorough focused examination and diagnosis precedes
all treatment.
2. Develop a triage system that insures that inmates with urgent care complaints are seen
in a timelier manner, 24 to 48 hours.
We agree with these recommendations.
Additional Recommendations
3. When the dental clinic is closed, or the dentist will not be available for 24 hours, a midlevel provider should perform a face-to-face examination for all inmates submitting a
request that states or implies the existence of dental pain.
4. All face-to-face assessments should be documented in nursing progress notes.
5. The nursing protocol for Toothache/Dental Pain should be used where clinically
appropriate.
6. All requests for dental care should be time stamped and logged and a record of when
the inmate was seen by a provider and the disposition should be maintained.
7. The quality and legibility of dentists’ progress notes should be addressed in peer
reviews.

Dental: Orientation Handbook

First Court Expert Recommendations: None.
Additional Recommendations: Pending - To date we have not received the handbook.

Dental: Policies and Procedures

First Court Expert Recommendations
1. Develop a thorough and detailed Policy and Procedures manual that describes and
guides all aspects of the dental program. We agree with this recommendation.

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Additional Recommendations: None.

Dental: Failed Appointments

First Court Expert Recommendations
1. Work with the institution administration to develop and implement strategies to
address this problem.
2. Utilize a vigorous CQI process to address this problem. Use these findings to implement
procedures to continually improve this high rate of failed appointments.
We agree with these recommendations.
Additional Recommendations
3. Require the failed dental appointment rate to be reported to the CQI Committee
monthly.

Dental: Medically Compromised Patients

First Court Expert Recommendations
1. The medical history section of the dental record be kept up to date and that medical
conditions that require special precautions be red-flagged to catch the immediate
attention of the provider.
2. That blood pressure readings be routinely taken on patients with a history of
hypertension, especially prior to any surgical procedure.
We agree with these recommendations.
Additional Recommendations: None.

Dental: Specialists

First Court Expert Recommendations: None.
Additional Recommendations: None.

Dental: CQI

First Court Expert Recommendations
1. Because of the number of deficiencies noted in the dental program, a more vigorous CQI
program should be implemented to address these deficiencies. From the CQI process,
policies and procedures should be established that will continually correct these
deficiencies to develop a stronger program. We agree with this recommendation.
2. Include the NRC in this invigorated CQI process. Many areas need to be addressed for
improvement at that institution. This recommendation is moot since the NRC has a
separate CQI Committee.
Additional Recommendations

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3. The dental CQI program (as well as all other components of the dental program) lacks
guidance from a dentist with experience in corrections. This expertise should reside
centrally at IDOC and not from a Wexford employee or contractor. 159

Internal Monitoring and Quality Improvement
First Court Expert Recommendations
1. The CQI program, which should have identified many of these programmatic
deficiencies, must be reinvigorated with leadership that has had appropriate training
with regard to CQI philosophy and methodology.
2. There should be professional performance reviews with feedback, both for the
advanced level clinicians and nurses, with regard to the sick call process.
3. The leadership of the CQI program must be retrained regarding CQI philosophy and
methodology, along with study design and data collection.
4. This training should include how to study outliers in order to develop targeted
improvement strategies.
We agree with these recommendations.
Additional Recommendations
5. The CQI program needs to develop methods of identification of problems with respect
to both process and clinical quality of care.
6. The CQI program at SCC must be separate from the CQI program at NRC. Annual reports
must be uniquely developed. Reports used for NRC should not be used for SCC.
7. Primary source verification should be verified by the IDOC in conjunction with their AD
on quality improvement. Whenever a new doctor is utilized at the facility for coverage
or permanent placement, the primary source verification for that provider should be
reviewed by the Agency Medical Director and local leadership to ensure that the
candidate has primary care credentials.
8. The Governing Body of the facility with respect to the medical program should have
majority representation of persons trained in a medical discipline.
9. Quality of care and appropriateness of care need to be incorporated into the CQI
program.
10. Mortality review and sentinel event reviews need to be included in the CQI program.
11. Internal audits should be performed by medical personnel and need to include the data
used to draw their conclusions. These should include a quality of care component.
12. Provider peer reviews should increase emphasis on quality of care.

Dr. Meeks does not have a dentist on his staff and relies on Dr. Sandhu (a Wexford consultant) for dental advice. He would
like a dental director on his staff, since relying on a vendor’s employee is problematic. See also Dr. Meeks’s 1/19/18 interview
by Dr. Michael Puisis (“[Question] Is he [Dr. Meeks] responsible for the dental program? Response: He said yes, he is
responsible. But he said this with an expression of frustration. [Question] How does he provide that oversight? Response:
Basically, he relies on the Wexford Dental Director for this oversight. He acknowledged that this was not a good arrangement
and prefers that he have a Chief of Dentistry who is a state employee and part of his regional team.” (id. questions #35, 36).
159

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13. External reviewers not associated with the vendor should be used for all mortality

reviews, all sentinel event reviews, and peer reviews of all non-primary care trained
physicians.

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Appendix A
SCC Positions
Position Title

Budgeted Vacant
positions Positions

Leave of Effective Employer
Absence Vacancies

Health Care Unit
Administrator
Medical Director
Physician
Physician
Assistant
Medical Record
Director
Director of
Nursing
Supervisory
Nurse
Registered
Nurses
Licensed Practical
Nurses
CMT*
Certified Nurse
Assistant
Health
Information
Associate
Office Associate
Staff Associate
Medical Supply
Supervisor
Pharmacy
Technician
Med Room
Assistant
Assistant Site
Manager
Dental Director
Dentist

1

0

0

0

IDOC

1
1
1

1
0
0

0
0
0

0
0
0

Wexford
Wexford
Wexford

1

0

0

0

Wexford

1

0

0

0

Wexford

2

1

1

2

Wexford

28

11

1

12

Wexford

12

2

0

2

Wexford

17
6

5
1

6
1

11
2

IDOC
Wexford

2

1

0

1

IDOC

3
3
1

1
0
0

0
0
0

1
0
0

IDOC
Wexford
IDOC

1

0

0

0

IDOC

1

0

0

0

Wexford

1

0

0

0

Wexford

1
1

1
0

0
0

1
0

IDOC
Wexford

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Dentist**
1
0
0
0
IDOC
Dental Assistant
1
0
0
0
Wexford
Dental Assistant
1
0
0
0
IDOC
Dental Hygienist
1
0
0
0
Wexford
Dialysis
6
0
0
0
Naphcare
Registered Nurse
Dialysis
3
0
0
0
Naphcare
Technician
Totals
98
24
9
33
*CMTs are either medical technicians or licensed practical nurses (LPN). All newly hired CMT staff are LPNs.
** IDOC hired dentists work half time and are counted and paid as a full-time position.

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Appendix B
Provider Peer Review Questions
The sick call questions were:
1. Was the patient seen within 72 hours?
2. Does the encounter reflect the reason why the referral was made?
3. Is the recorded history comprehensive and relevant for the patient’s Chief Complaint?
4. Is a targeted physical exam with pertinent findings documented?
5. Was appropriate and comprehensive testing done?
6. Were laboratory and diagnostic tests documented and addressed?
7. Is the plan of care appropriate and documented?
8. Is pertinent patient education documented?
Laboratory/X-ray Utilization questions were:
1. Was the lab test/x-ray appropriate for diagnosis or clinic?
2. Was the lab test result received within 24 hours and x-ray result received within 72
hours?
3. Was the lab test/x-ray result initialed and dated by a physician within 72 hours of
receipt?
4. Were clinically significant findings documented in the progress notes?
5. Was plan, as indicated, carried out?
6. When follow-up care was requested, was this carried out in a timely manner?
Chronic Disease questions include:
1. Is the subjective portion comprehensive for clinic (including interval activity for seizure
and asthma clinic)?
2. Does the clinic include pertinent vital signs?
3. Is a targeted physical exam with pertinent findings documented, including OHS chronic
clinic requirements?
4. Were relevant laboratory parameters documented and acted upon when indicated?
5. Was treatment appropriate for this visit (including additional referrals, additional
testing, medication adjustment, ACE inhibitor use, etc.).
6. Was appropriate education for this encounter documented?
7. Was the level of disease delineated?
Infirmary admissions questions:
1. Is an infirmary admission note completed with diagnosis?
2. Does the admission history and physical as documented adequately described this
patient’s condition?
3. Is indication for admission and type of admission (chronic vs. acute) clearly specified?
4. Are three weekly visits for acute admissions and weekly visits by an MD documented?

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5. Is the plan of care appropriate for admission diagnosis?
6. Is MD response to significant nursing entries evident?
7. Is a discharge note with follow-up care evident?

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Mortality Reviews
2nd Court Appointed Expert Report
Lippert v. Godinez

August 2018

Prepared by Michael Puisis DO

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Introduction
We reviewed 33 medical records of patients who died. For each death we assigned a
designation of preventable, possibly preventable, or not preventable. Parts of five records were
missing and we therefore could not determine whether the death was preventable or not. Of
the 33 records, 12 were preventable, seven were possibly preventable, nine were not
preventable, and five had missing record documents making determination of preventability
not possible.
Definitions we use for these designations are as follows:
Not preventable death – A death that could not have been prevented or significantly
delayed despite identified opportunities for improvement in the medical care.
Possibly preventable death – A death wherein opportunities for clinical intervention or
errors related to care delivery were identified that MIGHT have prevented or significantly
delayed the patient’s death.
Preventable death – A death wherein opportunities for clinical intervention or errors
related to care delivery were identified that WOULD have prevented or significantly delayed
the patient’s death.

Lippert v. Godinez

IDOC Death Summaries

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IDOC Mortality Reviews 2018
Patient List

Patient #1 Danville; Possibly Preventable...................................................................................... 3
Patient #2 Sheridan; Preventable .................................................................................................. 4
Patient #3 East Moline; Not Preventable ...................................................................................... 6
Patient 4 East Moline; Not Preventable ........................................................................................ 7
Patient 5 East Moline; Not Preventable ........................................................................................ 7
Patient 6 Decatur; Possibly Preventable........................................................................................ 8
Patient 7 Dixon; Preventable ......................................................................................................... 9
Patient #8 Dixon; Possibly Preventable ....................................................................................... 10
Patient #9 Stateville; Not Preventable......................................................................................... 12
Patient #10 Stateville; Preventable.............................................................................................. 15
Patient #11 Stateville; Insufficient Chart Information to Determine Preventability ................... 17
Patient #12 Stateville; Insufficient Chart Information to Determine Preventability ................... 18
Patient #13 Stateville; Preventable.............................................................................................. 20
Patient #14 Stateville; Not Preventable....................................................................................... 23
Patient #15 Dixon; Preventable ................................................................................................... 23
Patient #16 Stateville; Insufficient Chart Information to Determine Preventability ................... 26
Patient #17 Dixon; Preventable ................................................................................................... 27
Patient #18 Dixon; Possibly Preventable ..................................................................................... 30
Patient #19 Dixon; Preventable ................................................................................................... 32
Patient #20 Logan; Not Preventable ............................................................................................ 34
Patient #21 Menard; Possibly Preventable.................................................................................. 36
Patient #22 Menard; Preventable................................................................................................ 37
Patient #23 Menard; Possibly Preventable ................................................................................. 40
Patient #24 Menard; Not Preventable......................................................................................... 42
Patient #25 Menard; Preventable................................................................................................ 43
Patient #26 Menard; Not Preventable......................................................................................... 45
Patient #27 Menard; Preventable................................................................................................ 46
Patient #28 Western; Not Preventable........................................................................................ 49
Patient #29 Taylorville; Possibly Preventable .............................................................................. 52
Patient #30 Hill; Preventable ....................................................................................................... 54
Patient #31 Illinois River; Insufficient Chart Information to Determine Preventability .............. 57
Patient #32 Pinckneyville; Insufficient Chart Information to Determine Preventability............. 58
Patient #33 Robinson; Preventable .............................................................................................. 60

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Patient #1 Danville
This patient was 56 years old. Current standards of care recommend colorectal cancer
screening beginning at age 50.1 However, at IDOC annual examinations, the providers only
provide an offer of a digital rectal examination with guaiac testing for the purpose of evaluating
the prostate and apparently for colorectal cancer screening. Even if the digital rectal
examination were done with guaiac testing, this would be inadequate, as an annual colorectal
cancer screening will miss more than 90% of colon abnormalities.2 The patient was offered a
digital rectal exam on 1/5/15 but not during 2016.
The patient began losing weight, first documented on 9/30/15 (six pounds based on a 3/9/15
visit compared to the 9/20/15 visit). The patient transferred from WICC to IRCC on 1/16/17 and
the weight was 152 pounds, which was an 18-pound weight loss since 3/9/15. The weight loss
was unrecognized until 4/21/17, when a doctor documented a 19-pound weight loss. The
patient apparently had been losing weight for about a year and a half, but it had been
unrecognized.
An abnormal albumin level was present since at least 2/11/16. The alkaline phosphatase was
elevated and total protein low on 4/20/17, yet these abnormal labs were never evaluated. On
4/20/17, the patient also had a hemoglobin of 6, which is extremely low. The patient was sent
to an ER, where EGD was done 4/22/17 showing gastritis. Colonoscopy was recommended but
not done until 6/15/17. In the interim, on 5/17/17 the patient developed unilateral leg swelling
but was not evaluated for this. Generally accepted guidelines for unilateral leg swelling include
exclusion of leg thrombosis. This was not done and as a result placed the patient at significant
risk of harm.
Advanced colon cancer was identified on 6/15/17. Colorectal surgery follow up was
recommended in two weeks, but did not occur for a month. In the meantime, the patient was
again evaluated for unilateral leg swelling. The doctor presumably thought that the patient
might have a deep vein thrombosis, because he ordered a D-dimer test, a test to evaluate for
thrombosis. This condition is life threatening, yet the patient was not admitted to a hospital
and the D-dimer test was not done. Instead, the doctor only gave diuretics. This was grossly and
flagrantly unacceptable.
The patient was admitted to the infirmary for severe edema on 8/3/17. Aside from prescribing
a diuretic, there was no attempt to evaluate why the patient had edema. Two days later the
patient was admitted to a hospital, where advanced metastatic colon cancer with ascites and
anasarca due to the cancer was noted. The patient had malnutrition (consistent with the low
albumin), severe ascites, and non-curable colon cancer. The patient was too high a risk to
U.S. Preventive Services Task Force colorectal cancer screening as found at https://www.cancer.org/cancer/colon-rectalcancer/detection-diagnosis-staging/acs-recommendations.
2
American Cancer Society Recommendations for Colorectal Cancer Early Detection as found at
https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/colorectal-cancerscreening2#tab.
1

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perform surgery. The patient expired 8/16/17, nine days after admission to the hospital. We
identified 49 errors of care from 1/5/15 until his death on 8/17/17. There were 13 episodes
when nurses should have referred to a provider but did not. Key deficiencies were lack of
colorectal cancer screening; failure to recognize weight loss; failure to timely refer for
evaluation of weight loss, anemia, fever, and abdominal pain; and failure to timely refer to
exclude deep vein thrombosis in a person with unilateral leg swelling.
The patient was not offered colorectal cancer screening consistent with contemporary
standards. This death was therefore possibly preventable. The current standard is to perform
colorectal cancer screening for early diagnosis and prevention of colon cancer and cancer
death. Failure to perform this service results in preventable death. The colonoscopy was not
timely.

Patient #2 Sheridan
This patient was 30 years old. He had repair of a Tetralogy of Fallot3 as a child. He had a late
complication of that pediatric surgery (pulmonic valve regurgitation) and was in the process of
medical evaluations for replacement of his pulmonic valve prior to his incarceration. Pulmonic
regurgitation gives rise to atrial and ventricular heart arrhythmias with risk of morbidity and
mortality. In May of 2015, the patient apparently experienced blood clots resulting in a stroke
and was taking anticoagulation for that purpose. The patient became incarcerated in the midst
of a work up regarding his valve replacement. While at the Stephenson County Jail in Freeport,
Illinois, the patient’s cardiologist communicated with the jail on 8/26/15, telling them what
work up was remaining prior to valve replacement. The jail continued the work up. An MRI
angiography, the final diagnostic study prior to surgery, was scheduled for 12/3/15, but the
patient was transferred to the IDOC on 11/5/15.
An NRC physician assistant did an intake physical examination on 11/5/15, but failed to take an
adequate history and did not attempt to contact the patient’s cardiologist or to obtain old
records. Despite the Stephenson County Jail having knowledge of the patient’s condition, the
IDOC apparently did not know the patient’s condition, and other than referring to UIC
cardiology, made no attempt to find out the patient’s diagnosis. The patient’s civilian
cardiologist’s letter to the Stephenson County Jail was in the patient’s IDOC medical record but
it is not clear when it arrived in the record or whether it was reviewed. The physician assistant
at NRC reception made the wrong diagnosis of aortic stenosis, without supporting evidence.
The physician assistant took no history and only relied on the nursing history. The physician
assistant examination documented a systolic murmur, when pulmonic regurgitation is a
diastolic murmur. Although the physician assistant’s note documented that an urgent follow up

3 Tetralogy of Fallot is one of the most common congenital heart conditions. The surgery to repair this anomaly can result, later
in life, in abnormalities of the pulmonic valve resulting in incompetence of the pulmonic valve. This can result in dyspnea and
other symptoms. Cardiac arrhythmias are common when this occurs. When pulmonic regurgitation occurs as a complication,
replacement of the valve may be indicated, as it was in this individual.

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with a physician was requested, this did not occur. If the diagnosis was unclear, a prompt
echocardiogram should have been done.
The patient transferred to Sheridan on 11/18/15, but the transfer form failed to indicate that
the patient had pending surgery. A doctor did not evaluate the patient until 12/10/15, a month
later. The doctor documented that the patient was to have balloon valvuloplasty surgery prior
to incarceration, but made no attempt to contact the patient’s cardiologist. Balloon
valvuloplasty is a procedure performed on a stenotic heart valve like aortic stenosis but is not
used for pulmonic incompetency. The patient was not scheduled for balloon valvuloplasty. The
doctor made no attempt to discover what valve was affected. Without documenting the
current status of the patient or the urgency of surgery, the doctor referred the patient to UIC
cardiology as a routine visit for evaluation of symptomatic aortic stenosis, not pulmonic
regurgitation. The valve involved could have been identified by performing echocardiogram at a
local hospital which should have been done.
As a civilian, the patient was being managed by a pediatric cardiologist due to the nature of his
condition, but the doctor sent the patient to a regular cardiologist. The doctor also did a
physical examination documenting an irregular heart rhythm with a murmur, and wrote a
differential diagnosis of atrial fibrillation with aortic stenosis. The doctor ordered an EKG. There
were two EKGs in the chart, both undated and both with sinus rhythm. The patient did not have
atrial fibrillation. The doctor ordered metoprolol without giving a reason. Presumably, it was for
aortic stenosis with atrial fibrillation, but the patient did not have either of these conditions.
This was a potential problem, because metoprolol can cause atrial conduction abnormalities
causing arrhythmias, which this patient was at risk for because of his pulmonic regurgitation.
The patient’s blood pressure was normal, the patient was not in heart failure, and the patient’s
pulse was 92. Thus, there was no indication for this medication, but it had potential for
significant adverse effects. The doctor did not make an appropriate diagnosis and did not base
the diagnosis on sufficient diagnostic information. The Wexford physicians did not contact the
patient’s civilian cardiologist or read his letter, which was in the medical record. Metoprolol
carries a warning for its potential to cause heart block, and increases the potential for
conduction disturbances. This patient’s pulmonic regurgitation already placed the patient at
risk for cardiac arrhythmias, and prescribing metoprolol could make this worse and may have
been the cause of his death, which was cardiac arrhythmia.
The patient saw a UIC cardiologist on 1/13/16. The cardiologist at UIC was unable to identify a
more specific history than the patient was supposed to have repeat surgery on one of his heart
valves. The UIC consultation was by a cardiology fellow, who recommended that the facility
obtain records from the treating cardiologist, get an echocardiogram to evaluate which valve
was involved, and to schedule a follow up. An echocardiogram was done on 2/9/16 and showed
severe pulmonic regurgitation but no aortic stenosis. The echocardiograph cardiologist
recommended a stress EKG test, and if poor, referral to cardiovascular surgery for pulmonic
valve replacement. Doctors did not order the stress test until 4/25/16, almost three months

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later; it was approved on 4/27/16. The Sheridan doctor did not call the UIC cardiologist or the
echocardiologist to identify urgency.
On 3/24/16, a doctor saw the patient and noted that the patient had his echocardiogram, but
the report was unavailable almost two months after the procedure, so the doctor did not know
the results of the echocardiogram. There had also been no attempt to call the patient’s civilian
cardiologist. The blood pressure was low, at 98/62. Despite the low blood pressure, and the
patient complaint of having “near falls,” and lack of indication, the doctor continued the
metoprolol. The patient’s symptoms may also have been due to his pulmonic regurgitation, but
the IDOC doctors failed to identify his diagnosis despite the recent evidence on
echocardiogram. This was the last in-person evaluation of the patient before he died and there
are no further in-person evaluation notes.
There is an autopsy indicating that the patient died on 4/28/16, but there are no antecedent
notes for the time period immediately before death, so it is unclear where the patient died or
what the circumstances of the death were. The coroner listed the cause of death as cardiac
arrhythmia. In our opinion, this was likely due mostly to his pulmonic regurgitation, but also
possibly due to use of metoprolol.
This death was preventable. A proper history and communication with the patient’s civilian
cardiologist should have resulted in earlier intervention and valve replacement, which is
typically very successful in this condition, particularly in a 30 year old otherwise healthy man.
Remarkably, the true diagnosis of the patient was unknown to IDOC medical staff for the entire
IDOC incarceration of almost six months, even though the patient’s treating cardiologist was
collaborative with jail staff at the Stephenson County Jail and even though his letter explaining
the treatment plan was in the IDOC file. Also, an echocardiogram identified a critical valve
problem but for several months the echocardiogram was not reviewed. As well, the use of
metoprolol without clear indication placed the patient at risk of cardiac conduction
abnormalities that already affected the patient due to his pulmonic valve disorder. This may
have contributed to the patient’s arrhythmias, which the coroner said caused his death. The
quality of care of physicians was below standard of care with respect to obtaining an accurate
history and communicating with a treating physician and with respect to use of metoprolol
without a diagnosis or indication. Also, the absence of medical records around the time of
death reflects poor medical record keeping or documentation. Over the approximate six
months of incarceration in the IDOC, there were 10 errors we identified, principally not
following up after consultation, not developing an appropriate treatment plan, and not
obtaining an adequate history.

Patient #3 East Moline
This was a 47-year-old man admitted to IDOC with a history of hypertension. The patient
transferred to East Moline on 2/8/17. This patient had significant problems identified over the
course of several months, including: anemia (hemoglobin as low as 8.9), persistent cough with

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decreased peak expiratory flow rates, increased heart size with possible pericardial effusion,
elevated sedimentation rate (69 and 98), elevated C-reactive protein of 43.8 (nl <8), and weight
loss. While it is our opinion that hospital referral should have been offered as soon as 10/13/17
(for difficulty breathing, 30 pound weight loss, anemia, elevated sedimentation rate, and
globular heart on x-ray suggestive of pericardial effusion), a doctor ultimately offered transfer
to the hospital on 10/23/17. The patient refused hospital admission. The patient declined and
died at EMCC on 11/3/17. An autopsy was not done.
This death was not preventable largely because the patient refused referral to a hospital.
However, the there was a significant delay in offering to send the patient to a hospital, and the
patient was kept at the facility with evidence of a life-threatening condition on 10/13/17.

Patient #4 East Moline
This was a 43-year-old with no history of medical problems who had a sudden collapse and died
of a pulmonary embolism. This death was not preventable.

Patient #5 East Moline
This was a 75-year-old man who had his reception screening at NRC on 8/8/17. The patient had
history of diabetes, hypertension, coronary artery disease, glaucoma, asthma/COPD, sleep
apnea, and umbilical hernia. The NRC history was very poor, and though documenting prior
cardiac surgery and stent placement, the details were not specified. The patient was on two
medications (Brilinta and oxybutynin) for which no indication was given. Although the Brilinta
may have been used for the stent, it was not clear, and the date of the stent was beyond the
time for which this type of anticoagulant is used.
The patient transferred to East Moline Correctional Center on 8/22/17, and was confused when
he arrived. For that reason, he was housed in the health care unit. This apparently was new
onset of confusion, as the patient had not been confused at NRC. Despite confusion, the doctor
did not order tests to evaluate for this for several days. The patient never had a CT scan, which
is often performed for persons with new onset of confusion. On 8/28/17, the patient
apparently bit his tongue sufficient to create a large laceration of the tongue, which bled
profusely. The patient was on a powerful anticoagulant, which may have contributed to the
bleeding. The patient’s tongue and lips were swollen, and the patient could not swallow.
The patient was timely sent to a hospital, where the patient died not long after arrival. Doctors
judged that the patient had angioedema from being on Lisinopril. The patient should have had
an autopsy but did not. It is not clear if the recent confusion was at all related to the cause of
death and whether the death may have been due to bleeding rather than angioedema. While
the hospital diagnosis was likely, an autopsy should have been performed. This death was not
preventable.

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Patient #6 Decatur
This patient had known cirrhosis, type 2 diabetes being treated with insulin, hypertension, and
a long-standing skin disorder. The skin disorder was such that it caused itching and scratching,
and became infected. Doctor-directed treatment of the skin rash failed to resolve the problem
over a period of at least eight months. Doctors did not make a definitive diagnosis and did not
appear to know what the rash was, yet did not refer the patient to a dermatologist for a
definitive diagnosis. At autopsy, the pathologist documented that the patient had diffuse
psoriatic-like skin lesions.
The patient also had cirrhosis due to hepatitis C. Though the patient had a high level of fibrosis
and appeared to pass from compensated to decompensated liver disease under care of the
IDOC, the patient was not documented as having been offered treatment for hepatitis C.
Though physicians knew that the patient had cirrhosis, they also did not offer generally
accepted care for cirrhosis, such as endoscopy screening for esophageal varices, beta-blocker
medication to reduce complications of varices, or screening for hepatocellular carcinoma,
which is recommended to be done by ultrasound examination every six months. It is not clear
why this patient was not sent to the UIC hepatitis C consultants. Doctors also failed to recognize
decreasing HbA1C levels, with episodes of hypoglycemia that was likely due to the patient being
on insulin and having advanced liver disease. This placed the patient at risk of significant
hypoglycemia.
The patient developed fever, abdominal pain, and hypotension consistent with septic shock,
but was not sent to the hospital for evaluation for two days. The hospital record was not in the
record for this first hospitalization. The patient returned to the facility and was housed on the
infirmary. Apparently based on a second hospital admission, the patient was found to have
possible cholecystitis with stones and advanced cirrhosis, making surgery too high-risk. The
patient returned to Decatur Correctional Center.
On the day of return, the patient began vomiting blood4 repeatedly and was hypotensive,
indicating shock. Nurses called a physician several times, but the doctor did not send the
patient to a hospital until he came into the facility about five hours later. This was grossly and
flagrantly unacceptable. The doctor eventually came to the facility and sent the patient to the
hospital. Prior to sending the patient to the hospital and during the time the patient was in
shock, the doctor obtained a do-not-resuscitate/do-not-intervene status and communicated
this to hospital personnel, who then did not attempt interventions. The patient signature on
the DNR document was disorganized and unlike the patient’s typical signature. The patient died
in the hospital not having received aggressive care.
The coroner listed the cause of death as bleeding esophageal varices. The patient’s death was
possibly preventable. If the patient had generally accepted care (including treatment of the
Vomiting blood in a person with cirrhosis strongly suggests esophageal varices. When this occurs, immediate hospitalization is
indicated. If the patient had been on prophylactic beta blocker medication, this may have been avoided.

4

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hepatitis C, endoscopy surveillance with treatment of esophageal varices, and preventive beta
blocker treatment for the varices) early in the course of her disease, her death may have been
preventable or delayed. The patient should have been under care of the UIC hepatology group,
but was not. Aggressive treatment in the hospital may also have delayed death. The method of
obtaining “informed consent” during the time that a patient is in shock should call for an
internal review of the IDOC practices of obtaining informed consent.

Patient #7 Dixon
This patient was a 51-year-old man with history of obesity, hypertension, and high blood lipids.
He also was deaf and did not have medical examinations consistently with an interpreter. He
was given hearing aids, but these were malfunctioning for periods of time. The patient also had
a history of alcoholism and elevated liver function tests, but these were not followed at least
since 2014. The patient had minimal elevation of blood glucose levels. Given his significant
obesity (as high as 292 pounds), hypertension, and high blood lipids, screening for diabetes
would have been good practice. The patient did receive routine metabolic panels, but it was not
clear that the glucose tests being done were fasting. In any case, doctors appeared unaware of
the risk for diabetes.
The patient developed cough, tachycardia, and low blood pressure. The blood pressure had
recently been elevated. On 10/27/16, the blood pressure was 160/96 and was 98/62 on
11/11/16. This significant and unanticipated drop in blood pressure went unnoticed. The pulse
was 112. Despite the abnormal vitals, the nurse did not refer to a provider. Two days later, a
nurse referred the patient to a nurse practitioner for vomiting. The patient was deaf and the
nurse assisting the nurse practitioner documented that the patient did not understand the
nurse’s questions, so the nurse was unable to obtain an accurate history. The nurse practitioner
documented that the patient had several days of fever, sore throat, headache, and vomiting.
The patient had tachycardia (116). Based on these constellation of symptoms that included
fever, unrecognized weight loss, hypotension, tachycardia, and vomiting, the NP diagnosed
pharyngitis and dehydration. This was grossly and flagrantly unacceptable and made worse by
fact of not having an appropriate translator for this deaf patient. The NP took no history with
respect to the vomiting and failed to order any laboratory tests despite the patient not having
eaten in four to five days, and having vomiting and dehydration. The NP started an intravenous
antibiotic (Ancef) for pharyngitis, which is not typical standard of care. Vomiting and not eating
are not associated with pharyngitis and should have resulted in investigation of another
diagnosis. Further diagnostic work up was indicated but not done.
The patient was admitted to the infirmary on 11/13/16. A physician saw the patient on
11/14/16, but took no history of the patient’s symptoms of vomiting, not eating, or
dehydration. The doctor merely continued the same care as the NP, but ordered next day
laboratory tests to assess the dehydration. These lab tests were never done. These tests should
have been immediately done.

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The patient deteriorated. On 11/14/16, the patient became hypothermic, with temperature of
94.9°F with altered mental status. This new red-flag finding was consistent with sepsis and the
patient should have been immediately hospitalized or immediately assessed with diagnostic
studies, but the doctor failed to address these problems. Later that same day, the patient
became unresponsive. An unresponsive patient, with history of vomiting, dehydration, and
hypothermia should be immediately hospitalized. No action was taken, which was grossly and
flagrantly unacceptable.
On 11/15/16, the patient was found kneeling and lying on the floor. The nurse did not take his
vital signs and did not consult a physician. Despite the patient’s altered mental status and
weakened status, a doctor did not see the patient on the infirmary unit on 11/15/16. Ordered
labs were not done. On 11/15/16, the patient was not talking. This level of altered mental
status should have resulted in immediate hospitalization. This was grossly and flagrantly
unacceptable care.
On 11/16/16, the patient opened his eyes only to stimulus and was unable to feed himself. At
7:53 a.m. on 11/16/16 the patient was still unresponsive, and the blood pressure was 68/
palpable. The patient was in shock and the patient was transferred to a hospital. At the
hospital, diabetic ketoacidosis was diagnosed, which had been unrecognized at the prison. The
patient was severely dehydrated and had significant abnormalities of his liver function. The
patient died the day of arrival.
This death was preventable. On multiple occasions, he should have been sent to a higher level
of care for laboratory testing and better monitoring than was available at the prison. The
patient had vomiting, abnormal vital signs for three days, and altered mental status for two
days, yet was not appropriately evaluated. The patient had vomiting, hypothermia, tachycardia,
lower than normal blood pressure, dehydration, and altered mental status. The failure to admit
to a hospital earlier in the course of care was grossly and flagrantly unacceptable practice.

Patient #8 Dixon
This was a 45-year-old with a history of smoking and mental illness who brought to medical
attention a lump on the neck on 2/5/16. A nurse practitioner and then a doctor saw the patient,
but the doctor noted that the 2 by 2 centimeter mass was likely a lymph node and ordered a six
month follow up. The neck mass was described as hard. A hard 2 cm neck mass should be
considered cancer until proven otherwise. The patient was evaluated multiple times, but the
hard neck mass was not evaluated for cancer despite that this presentation must exclude
cancer. The patient began losing weight on 3/29/16, but it was unnoticed by physicians. A
doctor saw the patient again for a neck mass and swollen uvula on 4/29/16, and started
antibiotics for a presumed infection. On 5/9/16, a nurse practitioner identified increased throat
swelling and ordered a different antibiotic. The patient had lost weight, but it was unnoticed.
The patient was repeatedly evaluated by doctors and nurse practitioners and the neck mass
increased to a golf ball size, but it was diagnosed as infectious. The patient was finally sent to a

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hospital on 5/15/16, three months after initial symptoms, and a CT scan showed a neck mass,
likely a tumor. This could have been diagnosed three months earlier.
The patient continued to lose weight and the patient eventually went to UIC for evaluation, but
reports were not obtained and doctors at Dixon failed to document the status or progress of
the patient’s specialty care. Chemotherapy and radiation therapy apparently started in midSeptember 2016, about four months after the initial CT scan showing a likely cancer and seven
months after identification of the neck mass. During chemotherapy there were no reports and
doctors at Dixon failed to document the progress of the patient’s therapy.
The patient continued to lose weight, yet even when described as cachectic, the doctor did not
perform a nutritional assessment, and failed to determine whether the patient was able to eat
or what he could eat, given his cancer. When the oncologist was preparing the patient for
chemotherapy, a doctor at Dixon told the patient to “fatten up,” without any evaluation with
respect to whether the patient was able to eat, or what his nutritional status was. Except for
giving Boost, no action was taken until, when hospitalized for chemotherapy, the patient had a
gastrostomy tube inserted.
The patient developed pressure ulcers. Repeatedly, doctors failed to evaluate the ulcers. On
two occasions, the patient had an irregularly irregular heartbeat. After the first episode, an EKG
was not done but should have been done. On the second occasion, a routine EKG was noted
showing premature atrial contractions.
In early September, the patient passed out and had hypotension (60/40). This level of blood
pressure is compatible with shock. The patient also had altered mental status. Instead of
sending the patient to a hospital, the doctor placed the patient on an infirmary for 23-hour
observation. The following day, a doctor presumed the patient had a seizure without ordering
or having any diagnostic tests (CT brain, EEG, EKG, laboratory tests) to confirm his diagnosis.
Instead of ordering diagnostic testing, the doctor released the patient to general population
without any plan except to tell the patient to use a wheelchair.
The patient was hospitalized in November for chemotherapy, but after hospitalization a doctor
did not document the therapeutic plan of the patient. Three days after release from the
hospital the patient was not responding, was lethargic, and was found on the floor. Instead of
sending the patient to a hospital or obtaining an immediate EKG, the doctor ordered neuro
checks and asked to be called if the patient became unresponsive. Doctors should not wait until
someone becomes unresponsive after a potential syncopal episode; they need to send the
patient to a hospital or perform immediate tests to determine the cause of the syncope. The
following day, a nurse noted that the patient had unequal pupils. A doctor saw the patient, and
although noting that the patient experienced a fall, the doctor failed to perform a neurologic
examination and did not order an EKG. This was grossly and flagrantly unacceptable care. The
following day, the patient was unresponsive and was sent to a hospital. The patient had
experienced cardiac arrest and had atrial fibrillation, but died after arrival to the hospital.
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There were multiple missing reports from consultants. The patient had first signs of malignancy
in February of 2016, but did not have an appropriate diagnostic CT scan until May of 2016. A
biopsy was done sometime in May, but there was no report and it was not clear when this
occurred. A PET scan was not done until late June 2016. Chemotherapy and radiation therapy
did not start until sometime in mid to late September. Treatment was not started until seven
months after first symptoms. Treatment at the facility after chemotherapy and radiation
therapy were at times grossly and flagrantly unacceptable. The patient had an irregularly
irregular pulse and experienced syncope, but was not sent to a hospital. Three weeks later, a
doctor ordered a routine EKG, which appeared to show premature atrial contractions. A
radiation oncologist recommended that Dixon evaluate the patient’s premature atrial
contractions, but there was no report to identify what the concern was. The patient was found
to be unresponsive and lethargic, and was on the floor. The nurse called a doctor in the evening
and the doctor, instead of sending the patient to a hospital, ordered neuro checks and to call
him back if the patient was unresponsive. The following day the patient had unequal pupils, yet
the doctor still did not admit the patient to a hospital or evaluate the patient for his syncopal
episode. The following day, the patient was admitted to a hospital after being found
unresponsive. The patient had atrial fibrillation, developed cardiac arrest, and died. Because of
the delay in diagnosis, delay in treatment, failure to evaluate multiple potentially life
threatening events (unequal pupils, syncope, and altered mental status), this death was
possibly preventable.

Patient #9 Stateville
This 79-year-old patient had hypertension, chronic kidney disease, and dementia from an
unknown cause. The medical records lacked information to such an extent that it was not
possible, on review of the prison records, to determine the status of the patient’s conditions at
almost any point in his two year stay on the infirmary at Stateville. The only reliable source of
documentation was from offsite hospital reports, but these reports were not consistently filed
in the medical record. The only partly reliable onsite source of information was from nursing
notes.
The patient was apparently a full-time resident of the infirmary since at least 2014. Dating from
December of 2013 until June of 2014, the doctor’s progress notes, 19 in number, were identical
and stated in their entirety, “No specific complaint, no change, dementia, continue same care.”
That was the extent of the note which was repeated over and over. There was no effort to
monitor the patient for any of his medical conditions until the patient deteriorated and needed
to be hospitalized. The nurses were the only health care staff who appeared to be monitoring
the patient.
On 6/28/14, the patient was confused, with low oxygen saturation, and was sent to a hospital.
The hospital discharge summary was not in the medical record except for an echocardiogram
that showed severe left heart dysfunction, an ejection fraction of 30%, and pulmonary

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hypertension. This echocardiogram is consistent with significant cardiac and pulmonary disease.
When the patient returned from the hospital the patient was on oxygen, but the doctor did not
review what had occurred in the hospital, except to note that the patient had a stroke and had
respiratory failure. The patient’s capacity for performing routine daily activity was not discussed
in the patient’s therapeutic plan and not addressed. The status of the patient’s condition was
not described. Despite documenting that the patient had a stroke, the only neurological
examination documented was a confusing two word statement which was, “alert, confused,”
which was unintelligible. None of the findings on the echocardiogram were included in the
problem list and none of these findings were followed clinically. The stroke was not clarified,
and the status of the patient’s neurological status was not established.
After return from the hospital on 7/16/14, the patient started falling in his room. For a year,
from 7/24/14 until 7/13/15, the patient fell seven times. Although a doctor ordered x-rays on
one occasion, the doctor failed to perform an examination of the patient after any of these
falls. There was no documented attempt by the providers to protect the patient, who had a
history of stroke and dementia, from injury due to these falls. After return from the hospital on
7/16/14, the patient was on continuous oxygen therapy for unspecified reasons. The doctor
eventually documented on 8/27/14 that the patient was doing well without use of CPAP. The
doctor discontinued the CPAP and ordered CPAP use “PRN” or as needed. How would a
confused demented patient know when to use oxygen? It also appeared that the doctor used
the word CPAP when he probably meant BiPAP. CPAP is a device used in sleep apnea but BiPAP
is a form of oxygen delivery. There was no evidence that the patient had sleep apnea.
Beginning in July of 2014, after return from the hospital, the doctor again began writing notes
that were identical or near identical to previous notes. Many of these were verbatim identical.
These notes were similar to the note quoted above. This incompetent documentation
continued even when problems occurred, such as a patient fall.
Beginning in May of 2015, nurse documentation revealed that the patient’s status was
changing. The patient began experiencing diarrhea and became progressively more confused.
When nurses called the doctor stating that the patient was confused, the doctor gave a phone
order for long-term Ativan, a sedative and anti-anxiety agent. This occurred twice. This drug
carries a warning that it may impair mental abilities and must be used cautiously when
performing tasks requiring mental alertness. Use in an elderly demented patient with history of
falls was bad judgment at best and carries a manufacturers warning to use extreme caution
when using in patients at risk of falls. The patient was kept on Ativan for over a year despite
repeated subsequent falls. This placed the patient in direct risk of harm.
The patient’s confusion worsened. On 5/15/15, a nurse described the patient as unresponsive
and lethargic. On 5/23/15, the patient was described as walking unsteadily and appearing
agitated and confused. The doctor again prescribed Ativan by phone for 30 days without
examination of the patient. This was grossly and flagrantly unacceptable care. The patient
began complaining of stomach pains and the doctor ordered lab tests by phone twice, which
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were not done. Through all of these episodes the doctor continued to write nearly identical
notes, which did not represent symptom findings as documented in nursing notes. The doctor
never documented a thorough examination of the patient. Most of his examinations were
documented as “no change.”
By 7/11/15, a nurse described the patient as “very weak” and “declining.” On 7/12/15, a nurse
documented that the patient was not able to feed himself and was not eating. The doctor was
notified but took no action. Later that day the patient was incontinent, and a doctor ordered
blood tests, which finally were done. The laboratory called the prison because the labs were of
critical value, with hemoglobin of 6. The patient was sent to a hospital.
At the hospital, an intra-abdominal abscess was identified, and a laparotomy was done, and a
large invasive colon cancer was identified requiring a partial colectomy with an ileostomy. The
cancer was so advanced that it was not able to be resected. Given the patient’s dementia,
hospice care was recommended.
When the patient returned from the hospital, the doctor continued to write the same notes
with nearly identical words from July of 2015 until the patient died in April of 2016. These notes
stated, “No specific complaint. No change. Dementia, post colectomy for metastatic ca [cancer].
Continue same care.”
The patient did not appear to receive any specialized care or hospice care. The doctor made no
attempt to identify whether the patient was in pain or to assess the comfort level of the
patient. The patient fell six more times, based on documentation. The doctor’s notes were the
same even after patient falls and episodes of increased confusion or agitation. Despite repeated
falls, the patient was kept on Ativan, which carries a warning to use extreme caution in persons
at risk of falls. The doctor ordered no labs to monitor the clinical status of the patient.
Nutritional status was not documented as monitored by the physician. Comfort measures were
not documented by the doctor as taken. The patient soiled himself frequently and pulled off his
colostomy bag and soiled the bed and his clothes. During one of these episodes of fecal
accidents, a nurse documented that the patient was combative. The nurse wrote, “need more
staff to help change.”
The doctor wrote nearly identical notes over 30 times from July of 2015 until April of 2016,
giving no updated status of the patient. On 11/23/15, a second doctor was covering the
infirmary and diagnosed a pustular otitis media with a tympanic perforation, but on the same
day as this episode the doctor wrote his typical identical note without assessing the patient’s
ear.
In late November 2015, the patient became lethargic and had diarrhea. A nurse called a doctor
and the patient was sent to a hospital, where a urinary tract infection was identified. Blood
tests at the hospital indicated that the patient was significantly dehydrated (BUN 56), indicating

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lack of attention to nutrition and fluid consumption. When the patient returned from the
hospital, the same irrelevant, identical notes were written by the doctor.
On 4/18/16, the doctor wrote one of his typical identical, irrelevant notes. The following day, a
nurse noted that the patient was diaphoretic, listless, pale, and was lying in bed without sheets
or covers, and appeared to be in pain but was unresponsive. After about five hours and three
nursing evaluations, the patient was sent to a hospital. Although the hospital discharge
summary was not available, the patient died of sepsis. The autopsy describes the body as
having dirty finger and toenails and multiple scars on his extremities and back, apparently from
scratching himself.
In summary, this patient received insufficient nursing care likely due to lack of staffing. Nurses
were the only clinical staff paying attention to the patient and they appeared less than
adequately staffed in performing their tasks. This placed the patient at risk from falls,
infections, and lack of attention to nutrition. The Medical Director wrote nearly identical notes
over two years despite a changing clinical status of the patient. The notes were nearly identical,
even before and after hospitalizations. Significant clinical events (falls, ear infections, change in
mental status, alteration of bowel habits, etc.) were either ignored or not commented on by
the doctor. The patient’s actual clinical status, including nutritional status, was not monitored
by the doctors at all. The lack of attention to the patient’s pain status and comfort measures by
the physician were absent despite a recommendation for hospice care by the oncologist. We
identified 255 errors in the patient’s care over the two years of record review. Many included
failure to take adequate history, perform adequate physical examination, and make an
appropriate assessment, due to use of identical documented progress notes despite changes in
the patient’s status. The patient’s medical conditions, which included hypertension, chronic
kidney disease, dementia, COPD, and eventually colon cancer, were never monitored during
physician visits. Care was negligent. Careful attention to this patient would probably have
prolonged his life to a small extent but the death was not preventable. More important was
the lack of humane care by the physician, which was incompetent, and grossly and flagrantly
indifferent. The care of this patient also demonstrates the effect of lack of sufficient nurse
staffing on the Stateville infirmary.

Patient #10 Stateville
This 68-year-old inmate from Stateville had hypertension, diabetes, and back pain. He had
elevated lipids and carried above a 50% 10-year risk of cardiovascular events or stroke5 based
on American College of Cardiology criteria, yet this was unrecognized for the entire
incarceration and the patient remained untreated for this disorder. Blood pressure was not at
control (140/90) on six occasions, but doctors failed to adjust medications Failure to properly

5

The American College of Cardiology and American Heart Association guidelines on lipid therapy recommend that when the 10year risk of heart disease or stroke is over 7.5% that patients be started on statin medication. A simple calculator for identifying
risk is available at http://www.cvriskcalculator.com/.

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treat the hypertension and lipid disorder placed the patient at risk of cardiovascular events and
stroke.
The patient had back pain and was on ibuprofen, a nonsteroidal medication, for almost the
entire period of record review without adequate monitoring. This drug carries two black box6
warnings; one for increased risk of serious (and potentially fatal) adverse cardiovascular
thrombotic events, including fatal MI and stroke, and an increased risk of serious
gastrointestinal inflammation, ulceration, bleeding, and perforation (may be fatal). This latter
risk is increased in the elderly. The nonsteroidal medication can also exacerbate hypertension
or cause renal damage. Despite these serious and significant warnings, doctors routinely and
continuously prescribed this medication without considerations of the risk to the patient and
without discussing those risks with the patient.
On 4/15/16, the patient experienced an episode of emesis and nausea after awakening. An EKG
showed STT wave changes that could be consistent with ischemia. A doctor diagnosed possible
nonsteroidal gastritis or angina, both of which were possible in this patient. The doctor did stop
the non-steroidal medication and started omeprazole, an anti-ulcer medication, but the doctor
did not take action with respect to the potential for angina. The doctor ordered a hemoglobin
and it was 10.3, significantly lower that the last hemoglobin of 13.7, yet there was no follow up
of this abnormal lab. The patient should have been referred for endoscopy. Also, the doctor
stopped the ibuprofen and ordered only a single nitroglycerin tablet, and failed to order antianginal medication longer term. Because the patient had such high risk for cardiovascular
disease, a stress test or cardiac catheterization should have been done. Yet there was no follow
up of this problem. Endoscopy and colonoscopy should also have been done to evaluate the
recent anemia and abdominal symptoms.
A different doctor restarted the ibuprofen about two weeks after the episode of 4/15/16
without reviewing the abnormal hemoglobin and without recognizing the black box warnings or
the recent dramatic drop in hemoglobin. A week later, the ibuprofen was changed to naproxen,
another nonsteroidal medication with the same risks and same black box warnings. Doctors
ordered non-steroidal medications six times without consideration of the black box warnings
for gastrointestinal bleed, which the patient likely had as manifested by his acute anemia and
prior episode of vomiting “black stuff” as early as 2013. The doctors also ignored the potential
for cardiovascular thrombotic events with use of non-steroidal medication, likely because they
appeared ignorant of the patient’s high-risk cardiovascular status. This was likely incompetence.
On 2/5/17, the patient collapsed. CPR was initiated at the facility, but the patient died at the
hospital. An EKG done at the facility was consistent with an acute coronary event (MI). A
coroner listed the cause of death as atherosclerosis contributed to by gastrointestinal
hemorrhage.
According to the Food and Drug Administration website at
https://www.fda.gov/downloads/forconsumers/consumerupdates/ucm107976.pdf boxed warnings appear on a prescription
drug’s label and are designed to call attention to serious or life threatening risks.
6

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This death was preventable. Providers failed to evaluate for peptic ulcer even though the
patient had symptoms or signs of this condition (anemia, vomiting, and apparently bloody
emesis). The patient’s anemia was never properly evaluated despite being suggestive of peptic
ulcer disease. Despite potential for ulcer disease and cardiovascular disease providers kept the
patient on non-steroidal medication for years despite warnings from the manufacturer
regarding risk for gastrointestinal bleeding and myocardial infarction. Providers failed to treat
the patient for high blood lipids despite significant risk. Providers failed to manage blood
pressure to a level considered a goal for diabetics. Lipid therapy and adequate blood pressure
control are modifiable risks for cardiovascular disease. When a doctor on 4/15/16 documented
that the patient might have had a coronary event there was inadequate follow up. There were
signs on EKGs of ischemic cardiovascular disease (changing patterns of STT wave changes) that
indicate possible ischemic cardiac disease. There were multiple modifiable factors for
cardiovascular disease yet the patient did not receive evaluation for this disease. Although the
patient appeared to the provider to have had an angina episode, follow up stress testing or
angiography were not done, and the patient was not treated with anti-anginal medication. If
earlier interventions in these areas were undertaken the death would have been preventable.
We note that appended to the death summary was a Wexford Mortality Review Worksheet in
which the Medical Director who participated in care of the patient opined that earlier
intervention was not possible and that there was no way to improve patient care. We disagree
for the reasons cited above. We noted 50 errors of management in this patient’s care.

Patient #11 Stateville
The records sent for this patient consisted of 20 PDF files which were not in order and were
disorganized, making evaluation extremely difficult. This 73-year-old lost about 20 pounds from
2014 to 2015 without anyone noticing or initiating an evaluation. On 10/6/15, the patient
developed dysphagia to solid food and a right neck mass was identified. On 10/20/15, an
ultrasound showed a likely malignancy. The diagnosis of invasive squamous cell carcinoma of
the tongue was not made until 1/8/16, almost three months later.
Few offsite consultation reports were available. Some referral forms were present that had a
few scribbled notes by the consultant written on them. The patient started radiation therapy
sometime in late February, almost five months after symptoms started. The notes by the SCC
doctor were so poor that it could not be determined what the status of the patient was and
whether care was appropriate. Most of the doctor’s notes stated, “No specific complaint
[objective] no change [assessment] throat ca on radiation chemo [plan] continue same care.”
This identical note was repeated over and over, giving no update on the status of the patient’s
chemotherapy or radiation therapy. The patient had hypertension, hyperlipidemia, apparent
COPD, and head and neck cancer. Except for the head and neck cancer, none of the physician
notes over the last seven months of the patient’s life included mention of the patient’s other
conditions. Almost no notes over the same time period gave an updated status of the head and
neck cancer, and the existing therapeutic plan. The patient did not appear to receive care

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except by UIC consultants. Since not all of the consultation reports were in the medical record,
it was not possible to review whether the therapeutic plan of the oncologists was being carried
out. The patient apparently completed chemotherapy and radiation therapy, but a follow-up
PET scan was not in the record. The patient had episodes of shortness of breath in July that
were not diagnosed. The patient was found unresponsive on the toilet, apparently taken to a
hospital, and apparently died. We say apparently because there were no notes documenting
what happened to the patient.
The coroner listed the cause of death as hypertensive heart disease. A recent echocardiogram
was normal and did not show hypertensive heart disease. The coroner performed an autopsy
but the IDOC was unable to find it. The coroner made no mention on the death certificate of
the patient’s head and neck cancer. This appears to be a mistake.
There were insufficient medical records to determine if the death was preventable, as
consultation notes were not all available, SCC physician notes were poor, and the autopsy was
unavailable. We identified 170 separate errors. Most were combinations of failure to take a
history, perform a physical examination, make an assessment, and develop a therapeutic plan.
These occurred when the doctor who was the Medical Director wrote notes repeatedly that
contained the phrase quoted above. There were multiple errors of not having a medical report
available. However, we were unable to determine how many reports were not present, as it
appeared that the patient had many more consultations, radiation, and oncology treatments
than are documented in the medical record. It was not surprising that there were also multiple
episodes of failure to follow up appropriately after a consultation. Because so many
consultation reports were not in the record, many more of these were probably also not
followed up on. There were few episodes of care documenting review of the consultant’s care
noting recommendations. Documentation was so poor that it was not possible to determine
the course of care for this patient, even to determine whether death was preventable.

Patient #12 Stateville
This patient was incarcerated at Graham Correctional Center on 8/11/15. The patient was
transferred to Western Correctional Center. After the intake evaluation at Graham, there is a
gap, and medical records for the next year were missing. The record resumes in August of 2016,
when the patient was transferred from Western Correctional Center to NRC for a writ at UIC for
treatment of liver cancer. After transfer from Graham to NRC, most physicians treating the
patient were from NRC, but in February they were from SCC. It was unclear during this time
period where the patient was actually housed. The missing record documents from Graham and
Western were compounded by multiple missing record documents from NRC. At NRC, most
specialty referrals and specialty reports were not in the record, and it was not possible to
determine the course of care based on the available record. Also, there were no progress notes
for this patient from 1/20/17 until 2/15/17, almost a month. During this time, the patient had
life-critical laboratory results and it was not possible to review care for that period. To give a
final opinion on this patient with this chart is not possible because the chart is incomplete. We

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had asked for two years of the record but only received one year, and there were missing
documents in the record we received. Over the entire period at NRC/SCC, doctors did not
document understanding of the therapeutic plan of UIC consultants. Because of the lack of
reports in the record, it was not clear what that plan was. Despite providers, on multiple
occasions, stating that they were waiting for reports and expressing not knowing what the plan
was, these reports were not obtained. This took place between August of 2016 and February of
2017, when the patient died. This does reinforce our opinion about the medical record system
at NRC, which is completely broken.
The missing record from Western would be important to review with respect to an opinion on
preventability. A UIC consultant documented that hepatocellular carcinoma was identified on
CT scan in January of 2016, yet the patient was not referred for treatment until August of 2016.
It was unclear if earlier knowledge of the diagnosis was available. A biopsy done in May of 2016
showing apparent hepatocellular carcinoma was requested by UIC multiple times but was never
provided. This patient did not apparently have timely evaluation or treatment of his condition
and his death may have been delayed or prevented given timely and appropriate care. But we
will not make that designation without the ability to review the record, which was not present.
Because of these missing medical record documents, there is insufficient medical records to
determine whether this death was preventable.
Despite being unable to determine whether this death was preventable, we did note significant
problems with his care. We noted 40 errors; 15 were related to lack of available reports from
consultants, which resulted in at least five episodes of lack of follow up. It was not clear if the
patient ever went back to UIC for follow up after treatment of his hepatocellular cancer.
There were four episodes of medication error. In one case the patient was started on
spironolactone, but the patient had prior and recent hyperkalemia, which required kayexalate.
When the spironolactone7 was started, monitoring of potassium was not done, although
recommended by UIC. This was the first medication error. Almost three months later the
patient developed life-critical potassium elevation. This potassium (6.9) was reported by phone
by UIC at 5:30 a.m. on 2/11/17, but the patient was not evaluated with an EKG or clinical
evaluation, and kayexalate was not given until 2/12/17, in the evening. This was grossly and
flagrantly unacceptable practice. The second error was that it was not realized that the patient
was still on spironolactone until 2/14/17, when it was stopped. The third error was that the
patient had ascites and his diuretics expired and this was not noticed for almost four weeks, at
which time the patient had significant ascites and apparent anasarca. The fourth error related
to an abnormal laboratory result. At one point, a stat laboratory result was called in from a local
hospital. The platelets were 22,000. Thrombocytopenia is characteristic of cirrhosis and no
treatment is indicated except to prevent bleeding and to eliminate drugs that may cause
7 Spironolactone is a diuretic medication that can cause elevation of the potassium level. A potassium level above 6.5 is
considered critical and life-threatening. Immediate evaluation is indicated, along with an EKG to assess whether immediate
intravenous medication needs to be given. In this case, the patient was treated casually and not for a day and a half after
notification of the abnormality.

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bleeding. The Medical Director, who was a surgeon, receiving the report from a nurse by phone
incompetently ordered high dose injected steroids and a three-day course of high dose
prednisone, apparently thinking that the patient had immune thrombocytopenia, a different
disease. This placed the patient at risk of harm, as the drug was unnecessary and given the
patient’s, condition placed him at higher risk of bleeding and infection.
The patient developed severe ascites with decompensated cirrhosis. UIC had recommended
him to return if this occurred, yet doctors failed to know the therapeutic plan of UIC because
reports were unavailable, so the patient was not returned to UIC. Also, the patient was not
seen for about six weeks despite having new onset ascites and life-critical laboratory results,
including BUN 149, sodium 125, creatinine 3.88, and potassium 6.9. This lack of access to a
physician despite life-critical laboratory results was indifferent.
We note that despite UIC diagnosing and treating the patient for hepatocellular carcinoma, the
Medical Director at SCC, a surgeon, wrote the death summary and stated that the patient died
of cholangiocarcinoma, a cancer of bile ducts. This diagnosis was nowhere present in the
medical record and could not have reasonably been presumed based on a review of the
medical record. The coroner listed liver cancer, and UIC physicians documented that the patient
had hepatocellular carcinoma. Cholangiocarcinoma and hepatocellular carcinoma are different
cancers. This inaccuracy was not corrected as apparently no one reviewed the death critically.

Patient #13 Stateville
This patient was a 38-year-old man with a history of hypertension and on renal dialysis for
kidney failure. The reason for being on dialysis was not documented in the medical record and
was unclear, but it appeared to be from hypertension. This is a very young age to have kidney
failure from high blood pressure, yet the etiology of the renal failure was not documented in
the record.
The patient transferred from Graham to Stateville on 9/24/14. The patient was at Stateville 18
months. During that entire 18 months the blood pressure was not controlled. There were 16
episodes of care in the medical record during which a doctor (staff physician or contract
nephrologist) saw the patient. At all of these episodes the blood pressure was not at goal and
was sometimes significantly elevated. On only three occasions did a doctor modify or increase
blood pressure medication. During this time period the patient had only two chronic care visits.
The lack of attention to the patient’s ongoing high blood pressure was indifferent.
On six occasions, the serum potassium was above 6.7. Three of these values were above seven
(7.1, 7.2, and 7.6) and one of the values was extraordinarily high (8.5). All of these values are
critical values and require immediate intervention. When the potassium is above 7, the patient
is susceptible to cardiac conduction abnormalities (e.g. sinus arrest, idioventricular rhythms,
ventricular tachycardia or fibrillation, and asystole) which can cause death. Yet on all of these
occasions no actions were taken. On one occasion, when the UIC laboratory called Stateville at

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4:00 a.m. for critical potassium level of 8.5, the nurse took no action except to note that the
morning nurse would follow up. That did not occur. At 1:30 p.m. that same day, a nurse notified
a doctor and the plan was to have the patient followed up the next morning. There was no
documentation that this occurred. These were critical values that typically require immediate
attention, and the lack of attention to this was grossly and flagrantly unacceptable practice and
placed the patient at risk of harm.
Both a vascular surgeon and the nephrologist recommended work up of a murmur. The
Stateville doctor referred the patient to cardiology. Wexford denied the cardiology consult but
approved an echocardiogram. The patient had an echocardiogram consistent with significant
hypertensive heart disease and multiple abnormalities. When the doctor at Stateville saw the
patient after this test, the doctor did not review the test or take any action. No one followed up
on the murmur or the echocardiogram and the patient never saw a cardiologist. At the same
visit the blood pressure was 178/113, but the doctor took no action to improve blood pressure
control. The echocardiogram showed cardiac effects of prolonged poorly controlled
hypertension. A cardiologist should have been consulted because the Stateville doctor did not
review the test or appear to know how to manage the patient’s high blood pressure.
The patient was being dialyzed late evenings to early mornings. We do not consider dialysis in
the early morning appropriate, particularly when breakfast is also served early morning. Also,
when problems occur during dialysis there are no doctors present to evaluate the patient. At
about 2:00 a.m. on 1/9/16, the patient was brought by the dialysis nurse to the clinic with
nausea, vomiting, profuse sweating, and elevated blood pressure as high as 189/113. This
constellation of signs should have prompted a provider evaluation with immediate EKG and
laboratory tests or the patient should have been sent to a hospital. Acute coronary syndrome
should have been considered. Instead, the patient was given antacids, observed for several
hours, and sent back to his housing unit.
On another occasion, the patient had shortness of breath, lightheadedness, fast heart rate
(126), weakness, and diaphoresis. An EKG was done and did not have an automated reading on
it but appeared to have peaked T waves indicative of possible hyperkalemia. The EKG rate was
approximately 145-150. The patient should have been sent to a hospital. Instead, a nurse called
a doctor, who ordered a single dose of atenolol and sent the patient back to his housing unit
without any follow up. The patient was not evaluated for hyperkalemia. Care was grossly and
flagrantly unacceptable.
On another occasion, a doctor saw the patient for not feeling well. The blood pressure was
150/96 and the oxygen saturation was 88%, which suggests significant hypoxemia. These values
warrant hospitalization. The doctor referred the patient to the health care unit but there is no
documentation in the record that this visit occurred. This placed the patient at risk. There may
have been a problem with medical record paper work getting filed.

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On another occasion the patient had fever (101.4°F) with elevated blood pressure (170/95) and
felt nauseous with chills. The nurse called a doctor, who prescribed Tylenol and an anti-emetic
without provider follow up.
All of these cases demonstrate an indifferent attitude to the patient’s serious conditions.
On 3/22/16, the patient experienced shortness of breath, elevated blood pressure, elevated
pulse, and elevated respirations, and within minutes of being evaluated sustained cardiac arrest
and was taken to a hospital, where he was pronounced dead.
The Wexford Mortality Review Worksheet documented that earlier intervention was not
possible, there was no way to improve medical care, and the medical response could not be
improved.
This death was preventable. The coroner listed the cause of death as hypertensive heart
disease. The patient had long standing hypertension. His blood pressure at Stateville was
uncontrolled throughout his entire 18 month stay and the system was indifferent to his
uncontrolled blood pressure. He was seen in chronic clinic for his hypertension only twice,
which is not consistent with IDOC guidelines. Approximately 80% of the time, when a doctor
saw the patient with elevated blood pressure no action was taken to modify the patient’s
medication. According to a four-month sample of medication administration records, the
patient received only 60% of his medication. The reasons for this were not clear and there was
no counseling or history by providers to determine why this was occurring.
The patient was repeatedly placed at risk of arrhythmias due to hyperkalemia. The monthly
nephrology checks in dialysis clinic do document the nephrology prescription of Kayexalate, a
binding agent for hyperkalemia. But the episodes of extremely high potassium required
additional steps to lower the potassium. The lack of concern for extremely high potassium
levels was extraordinary and unacceptable, and appears to demonstrate a lack of basic primary
care medical knowledge or indifference to the patient’s critical need. The patient had an
echocardiogram showing significant hypertensive heart disease, but the test was not even
reviewed. The providers appeared indifferent to the patient’s serious medical condition, which
ultimately caused his death. It is our opinion that improved treatment of his high blood
pressure would have prevented or significantly delayed his death from hypertensive heart
disease. We do note that the patient’s phosphorous, BUN, and PTH were repeatedly elevated.
Because the dialysis records are not incorporated into the medical record, the course of dialysis
care was not clear. Given the continuously elevated blood pressure, high BUN, and
phosphorous, it is possible that the patient was not being dialyzed for sufficient time. We would
recommend that the IDOC have an outside nephrologist (from UIC) review this case to evaluate
the nephrology care to ensure that dialysis treatment times were adequate.
We noted 44 apparent errors in care for this patient. Most (16) related to not addressing out of
control hypertension. Twelve errors related to not timely reviewing abnormal labs (high
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potassium) and not instituting prompt action for critically elevated potassium levels. Three
errors related to not sending the patient to a higher level of care when apparently indicated.
Two errors related to the patient not receiving medication, including a survey of several months
of medication record indicating that the patient missed 40% of medication doses over four
months.

Patient #14 Stateville
This patient had 33 documented seizures over a four year period or about eight seizures a year.
This is not good control. It did not appear that the physician knew how to manage this
condition. There was no evidence of an EEG or CT scan, even though these should be done for
diagnostic purposes. We only reviewed two years of the record, so these tests may have been
done earlier. However, there was no reference to these tests. The doctors did not evaluate for
side effects of medication at chronic clinic visits. Failure to control seizures and to know how to
monitor this condition is an indication to refer the patient to a neurologist which should have
been done.
The patient had a presentation of atypical chest pain with an equivocal EKG, but was not
followed up for this. The patient had high blood cholesterol and in 2015 and 2016, his 10-year
risk for heart disease or stroke was 26% and 14% respectively. He should have been on a higher
dose of statin, but was not. This placed the patient at risk for coronary artery disease.
Shortly after one of the patient’s seizures, he became unresponsive. The patient sustained
cardiac arrest and died. The coroner listed the cause of death as coronary atherosclerosis,
although the autopsy was not available. The patient did not have a myocardial infarction,
apparently. Having died from coronary atherosclerosis during a seizure indicates that the
seizure may have precipitated an acute coronary event because of the rise in blood pressure
and pulse. This is difficult to be certain of and for that reason alone we determine that this
death was not preventable. However, patients with seizure are at risk for sudden death, a
condition known as unexpected death in epilepsy (SUDEP). This condition can have a
cardiogenic etiology. It was therefore a significant failure in not referring this patient to a
neurologist for accurate diagnosis and management of his epilepsy, because onsite physicians
were not able to bring the patient’s seizures under control, as evidenced by 33 seizures and
inability to obtain control.
We noted 57 errors of management. Most (14) were related to the patient having seizures,
with the nurse not consulting a physician. An additional 12 errors were related to not ordering
therapeutic drug levels after a seizure.

Patient #15 Dixon
This patient was a 24-year-old man with severe mental illness. He was incarcerated on 8/12/16.
He weighed 207 pounds. In the past he had multiple psychiatric hospitalizations. The patient

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became unstable when not on medication and would frequently refuse medications. These
refusals apparently did not result in referrals to mental health professionals. According to an
administrative review, when this patient did not take his medication he became more psychotic
with delusions, paranoia, and hallucinations. These episodes of psychosis resulted in multiple
crisis watches, often for self-harm. The self-harm included foreign body ingestion, which on two
occasions resulted in hospitalization.
On 7/12/17, a nurse documented that an officer observed the patient swallowing two sporks,
which are a plastic combination spoon and fork. The nurse documented that the patient “will
have no complication from swallowing a foreign object.” The nurse did not refer to a doctor.
This was grossly and flagrantly unacceptable care. On 7/13/17, another nurse notified a doctor
that the patient had swallowed a spork; the doctor ordered an x-ray but did not evaluate the
patient. The x-ray showed no radiopaque foreign body. On 7/16/17, the patient told a nurse
that he went on hunger strike “because no one cares about the spork I swallowed.” The nurse
did not consult a doctor. On 7/24/17, a nurse saw the patient on sick call for stomach pain. The
patient requested of the nurse, “Don’t put any pressure on my stomach.” The nurse assessment
was “ineffective coping” and abdominal pain of unknown etiology. The nurse did not refer to a
doctor.
On 9/27/17, a psychiatrist saw the patient. The psychiatrist documented that the inmate was
frustrated with “what he perceives to be indifferent medical attention.” The patient told the
psychiatrist that he had swallowed two sporks and was not receiving medical attention. The
patient was correct.
On 10/2/17, a nurse practitioner saw the patient, who told the NP that he had swallowed two
sporks and wanted them removed. The patient weight was 174 pounds, which was a 33-pound
weight loss since his incarceration a year ago; the weight loss was unrecognized. The NP
documented a soft abdomen. The patient had also embedded an object in his forearm. The NP
ordered an x-ray of the forearm but did not address the ingested spork. The NP assessment
included that the patient had a foreign body in his GI tract. To not evaluate for the swallowed
spork was grossly and flagrantly unacceptable care.
The patient complained to a licensed clinical professional counselor (LCPC) on 10/12/17 that he
had stomach pain and wanted to see the nurse practitioner. He said he was only eating snacks
because of stomach pain. There was no referral. This was indifferent.
On 10/18/17 the LCPC saw the patient, who again reported that no one was taking care of his
medical needs. He complained of vomiting, diarrhea, and weakness and was not eating because
he was nauseous. The LCPC documented that he would follow up the next day regarding a sick
call request, “given he still had not submitted one per medical.” It appeared that the medical
program was not going to see the inmate unless he submitted a request. The following day, the
patient did not show up for his mental health appointment. The note documented, “He is sick.”

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On 10/20/17 a nurse saw the patient, who complained of abdominal pain after swallowing
sporks months ago. The patient weighed 150 pounds, a 24-pound weight loss over the past
month and a 57-pound weight loss since incarceration. The nurse failed to acknowledge the
weight loss and appeared unaware that weight loss had occurred. The patient did not complain
of black tarry stool or bleeding, but had nausea, diarrhea, and abdominal pain, and it hurt when
he ate. The nurse noted pain on palpation in the center of the abdomen. The nurse did not
consult a physician. The patient was sent back to his housing unit. This was indifferent, and
grossly and flagrantly unacceptable care. The next morning, at morning medication pass, the
inmate was found dead in his cell.
On autopsy, the coroner found two sporks in the inmate’s duodenum, with deep lacerations of
the duodenum and superficial lacerations of the proximal esophagus with blood in the
stomach. The death was attributed to a gastrointestinal bleed from lacerations caused by a
foreign body.
An IDOC administrative review found no problems with medical care. The report noted that the
nurse on 10/20/17 had used the proper nursing protocol and that there was nothing in the
nursing assessment indicating an emergency. The review found problems with the inmate not
taking his medication and recommended that nursing staff notify a mental health professional if
an inmate refused medication on three consecutive days. However, no issues were found with
medical.
This death was preventable. On four occasions in July, nurses evaluated the patient for a
complaint of having swallowed a spork. Only once did a nurse consult a physician. On that
occasion, the physician ordered an abdominal x-ray but did not see the patient, and there was
no documented follow up of the x-ray. Three months later on 10/2/17, a nurse practitioner saw
the patient, who complained of swallowing a spork. The nurse practitioner took no action.
Notably, the patient had lost 33 pounds over the past year, which was unrecognized by the
nurse practitioner.
The patient complained to a psychiatrist and a licensed counselor that he had swallowed sporks
and was not receiving care. This did not result in referrals to a physician.
On the day before his death a nurse saw the patient, who complained of stomach pain, nausea,
diarrhea, and inability to eat because of the stomach pain. The nurse did not refer to a doctor.
At this point the patient had lost 57 pounds, which was unrecognized by the nurse. The next
day the patient died.
The most common features of an ingested foreign body are dysphagia, problems with eating,
and regurgitation of ingested food. The patient appeared to have all of these symptoms for
months. The patient had weight loss and multiple complaints of inability to eat normally. Pain in
the setting of an ingested foreign body suggests perforation and endoscopic evaluation is
indicated. The patient complained of pain repeatedly, yet these symptoms were not properly
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evaluated in the context of a foreign body ingestion. Endoscopic evaluation is often necessary,
even in the setting of negative x-rays. Plastic often does not show up on plain radiographs and
failure to locate an object on a plain radiograph does not preclude presence of a foreign body.
Since the spork has sharp prongs on the fork end, urgent endoscopy was indicated, but the
patient did not see a physician for over three months. In the only nurse practitioner evaluation,
the NP did not appropriately refer the patient. The NP also failed to recognize significant weight
loss. Care for this severely mentally ill patient was indifferent, and grossly and flagrantly
unacceptable.
We noted nine errors in this death review. Eight were related to either nurses or mental health
staff not referring to a provider for a serious medical complaint. Two were related to providers
not evaluating the patient related to significant complaints. And one related to failure of the
nurse practitioner to initiate a work up for an ingested spork that had not been eliminated for
over three months.

Patient #16 Stateville
This was a 54-year-old man with a history of hypertension and asthma. The patient was at
Menard. On 8/29/16, while at Menard, pulmonary embolism was diagnosed, and the patient
was started on warfarin with a recommendation to continue anticoagulation for six months.
While at Menard, providers failed to treat the patient with a statin drug despite an 8-13% 10year risk for heart disease or stroke. He also had seven episodes of chest pain while at Menard.
Some of these were typical for angina, but for most of these episodes of chest pain the history
was inadequate and it could not be determined if it was angina. Nevertheless, providers did not
start a statin despite the elevated cardiovascular risk, did not start antianginal medication, and
did not refer for possible stress testing.
In late December 2016, the patient was again hospitalized at Chester Memorial Hospital from
Menard for respiratory failure. Studies for pulmonary embolism were negative and no DVT was
present.
The patient transferred to Stateville on 2/4/17, still on warfarin anticoagulation. On transfer,
the patient had a pending sleep study and had diagnoses of hypertension, diabetes, asthma,
and pulmonary embolism on anticoagulation. On 2/23/17, a blood count showed anemia (HGB
9.3) and on 3/1/17, a doctor stopped the warfarin. A colonoscopy was ordered but there was
no evidence it was ever done. On 4/5/17, the patient asked for a breathing treatment, but the
nurse had a dispute with the inmate and no treatment was given. On 5/10/17, the patient
developed chest pain and the Medical Director noted that an EKG was normal, but there was no
EKG present in the record; it appeared to be missing. On 5/19/17, the patient again
experienced chest pain and an EKG showed subendocardial injury. The patient went into
cardiac arrest and died. The Medical Director’s report documented the cause of death as

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subendocardial injury. A death certificate listed the cause of death as pulmonary embolism and
documented that an autopsy was done, but the autopsy was not made available to me.
If the EKG apparently done on 5/10/17 was abnormal, the death may have been preventable.
The autopsy needs to be obtained. If the patient died from pulmonary embolism, the death was
likely not preventable. The determination of preventability cannot be made pending obtaining
the autopsy result and finding the missing EKG. The missing EKG of 5/10/17 is significant with
respect to evaluation of preventability.
We noted 30 errors in this patient’s care. Most had to do with failing to make an accurate
diagnosis and develop an appropriate therapeutic plan related to not starting statin drugs. This
appears to be a systemic issue in IDOC. The evaluation of chest pain was poor. Histories were
inadequate, risk factor analysis was not done to determine cardiovascular risk, and
management was not consistent with standards of care.

Patient #17 Dixon
This patient was a mentally ill patient. His problems were not monitored well. The patient had
Barrett’s esophagus, history of esophageal and duodenal ulcer disease, hepatitis C infection,
aortic valve replacement, and mitral valve prolapse noted on the problem list. Heart failure,
history of prior atrial flutter, history of thoracic aortic aneurysm, and possibly COPD were not
on the problem list and we could not find chronic illness clinics for these illnesses over the two
year period of review.
The problem list documented Barrett’s esophagus as early as 2002. This disease is an erosive
disease of the distal esophagus and has a propensity for malignant transformation. For this
reason, surveillance endoscopy is recommended. The timing of surveillance depends on the
histology of biopsy specimens, but it is recommended at least every three to five years. There
was no evidence that the patient was receiving this surveillance or that it was considered or
discussed with the patient. The patient was taking omeprazole to reduce gastric acidity, which
is necessary for persons with Barrett’s esophagus. During one hospitalization, the patient had a
life-threatening bleed from his esophagus and stomach, and hospital physicians noted that the
facility had stopped his omeprazole because the patient did not show up for medication on
several occasions. This should never occur. The medication records for the relevant month were
not present in the medical record. The patient had two episodes of gastrointestinal bleeding
since 2014. We reviewed two months of medication administration. During June and July of
2015, the patient refused 30 (25%) of 122 doses. Because he was mentally ill, doctors and
mental health staff should have met with the patient to determine why he was not taking the
medication. This did not occur.
The patient had a scheduled cardiology visit in March of 2014 which did not occur until May.
The patient had follow up gastroenterology appointments after the two serious and lifethreatening episodes of GI bleeding. Neither of these follow up gastroenterology visits were

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documented as having occurred. We did find a Wexford approval for one of these consults, but
could not find evidence that it occurred. The patient had life-threatening hyponatremia as low
as 114, but there was no attempt to determine why the patient had hyponatremia. It was likely
due to mental health medication, but there was no monitoring for this.
The patient weighed 193 pounds on 6/2/14 but began losing weight. The patient told a doctor
that he was losing weight on 9/21/15, but the doctor took no history and did not weigh the
patient that visit. On 11/5/15, the patient weighed 145 pounds, which was a 48-pound weight
loss over about 17 months, but the patient was being seen for weight gain because he had
weighed 133 pounds on 8/5/15. No one acknowledged the dramatic weight loss. When a
doctor saw the patient on 11/17/15 and the patient weighed 144 pounds, the doctor
documented that the “weight gain not a worry.” The weight loss was never worked up. Doctors
appeared indifferent to the patient’s weight loss.
The patient had mental illness and for uncertain reasons started a fast in late November 2015.
The patient weighed 133 pounds on 12/31/15 without any acknowledgement by medical staff
of the 60-pound weight loss. A telepsychiatry encounter occurred 1/11/16. The psychiatrist
restarted the patient on antipsychotic medication and ordered a follow up the following week,
but there were no further psychiatry notes that we could find in the record reviewed and there
was no evidence that the patient received the antipsychotic medication. Apparently, the
patient refused this medication. Despite the psychologist documenting that the patient was
unstable, there was no evidence of further psychiatrist’s notes. A request for enforced
medication was not initiated until 1/27/16, after the patient had been on his fast for well over a
month. There was reference to a request for enforced psychotropic medication on 1/26/16 and
a note by a psychologist that the patient was on the infirmary and was being considered for
forced feeding, but there were no medical notes or evaluations. On 1/28/16, a psychologist
documented that enforced medications were approved.
During more than a month of fasting, there was no blood testing or medical evaluations
documented in the medical record. A doctor wrote a note on 1/7/16, and documented that a
chaplain should talk to the inmate about his fast. There was one further physician note on
1/8/16 documenting that the doctor told the inmate that he might have to be force fed with a
gastric tube. This note was incomplete; the full note was not present in the medical record and
there were no further notes from physicians or nurses that we could find in the record we
reviewed. There were no further weights documented in progress notes after the weight was
documented as 137 pounds during a nurse practitioner evaluation on 12/31/15. The patient
weighed 193 pounds on 6/2/14 and had therefore lost 56 pounds, yet this was not
acknowledged. At this level of weight loss, blood tests to monitor his electrolytes, liver function
tests, and nutritional status were indicated but were not done.
On 1/27/16, stat labs were apparently ordered and sent to a local hospital. These labs indicated
severe sepsis, significant dehydration, infection, and included a serum sodium of 150, BUN 89,
creatinine 2.12, magnesium 2.8 (1.6-2.3), and WBC 16.7 with a left shift. These laboratory tests
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should have resulted in immediate hospitalization. The labs were signed as reviewed on
1/28/16, but the patient apparently was not sent to a hospital, as mental health notes
continued to be present in the medical record. The patient was apparently hospitalized on
1/31/16, although there are no medical progress notes present in the medical record that we
could find. On 1/31/16, two sets of blood cultures were obtained and subsequently grew gram
negative rods; these results were reported 2/1/16. The patient died 1/31/16 in the hospital. We
can only infer this because there was an x-ray evaluating an endotracheal tube placement after
intubation. There was no hospital report in the medical record. There was no death summary,
no death certificate, no autopsy, and no documentation in the medical record that the patient
died.
This death was preventable. Early and appropriate medical attention to the patient would have
prevented his death. As a result of the patient’s psychosis, the patient was engaging in a fast
that caused dramatic weight loss and eventually cause life-threatening metabolic changes.
Despite this medical staff appeared indifferent to his medical conditions. The patient had
dramatic loss of weight (60 pounds) dating from August of 2014, yet was not being monitored
for this. It was not until the patient began fasting and after the patient had already lost
approximately 50 pounds that weight loss was even recognized. During more than a month of
not eating, medical staff failed to timely and regularly monitor blood tests to determine the
health status of the patient and did not even evaluate the patient. After more than a month of
not eating, laboratory tests were done. These tests had life threatening laboratory tests values
showing extreme dehydration (sodium 150 and BUN 89), renal failure (creatinine 2.12), and
signs of systemic infection (WBC 16.7), which were signed as reviewed on 1/28/16. Yet the
patient did not appear to be sent to the hospital for three days. Care appeared to be
indifferent, incompetent, and inhumane.
We also note that many medical record documents were not sequentially filed and appeared
not to be in chronological order. Many documents appeared to be missing. We asked the
Attorney General to check for these documents, but have not received any new documents.
The IDOC needs an electronic medical record.
We also noted 35 five errors over the period of record review. The most common (six) were
related to lack of hospital records or records being disorganized. There were five medication
errors. Two of these were related to a provider prescribing an opioid without even taking a pain
history or examining the patient to determine if the patient had pain and whether the pain was
severe enough to warrant an opioid. Three were related to not receiving omeprazole,
medication for his ulcer. It was not surprising that the patient had two hospitalizations for
gastrointestinal bleeding, as he was not receiving/taking the medication, which was not being
monitored.

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Patient #18 Dixon
This Dixon patient was 70 years old. His problem list did not contain all of the patient’s medical
problems and the patient was not followed in chronic care clinics for many of his problems,
including his cardiac arrhythmias, pacemaker functioning, presumed heart failure, cirrhosis,
hyperlipidemia, diabetic nephropathy, or anticoagulation. The patient had a mechanical heart
valve and was on anticoagulation, but the anticoagulation goal was not noted in the record. If
the goal (typical for mechanical valves) was 2.5 to 3.5, then the patient had sub-therapeutic
anticoagulation for more than two years. Twenty-one of 27 INRs noted in the record showed an
INR of less than 2.5. The patient also had macrocytic anemia that was mistaken for microcytic
anemia, which is a serious and fundamental lack of primary care knowledge. The macrocytic
anemia, elevated bilirubin, and low platelets were not investigated for over two years. A B12
and folate level was eventually drawn after two years, but a diagnosis was not made. These
laboratory results suggested that the patient had alcoholic cirrhosis, which was never
identified. The patient also had chronic kidney disease which was unrecognized for over two
years. Failure to investigate these abnormalities was grossly unacceptable and demonstrated a
lack of primary care knowledge.
The patient had a serious cardiac arrhythmia (atrial fibrillation) with ventricular bradycardia
that required a pacemaker. After the pacemaker was inserted, a cardiology follow up was
recommended but never occurred. This failure to follow up with cardiology was never noted
and neither the pacemaker nor the arrhythmia was monitored in chronic care clinics. Typically,
pacemakers require a check which can be done remotely but needs to be done to ensure they
are functioning. In 2015, the patient began developing shortness of breath and edema that
were attributed to COPD, but the patient was not adequately evaluated for this. Later in 2015,
the patient developed chest pain. Doctors evaluating the chest pain failed to take an adequate
history and failed to evaluate the pacemaker function.
The patient had a 25% 10-year risk of heart disease and stroke yet was not placed on anti-lipid
medication. On 11/30/15, the patient experienced left-sided chest pain that felt like a pulled
muscle. The doctor did not initiate anti-anginal medication and failed to note that the patient
had failed to keep his cardiology appointment. The complaint was consistent with angina and
the patient should have had a higher level of investigation, including evaluation for coronary
syndrome. The following day a doctor evaluated the patient for nausea, but failed to take a
history of chest pain that may have been associated with the nausea.
On 12/17/15, a doctor saw the patient for chronic care follow up but failed to address the
arrhythmia, possible heart failure, or anticoagulation. Abnormal labs indicating chronic kidney
disease and possible alcoholic cirrhosis were not evaluated, except to order a B12 and folate
level after two years of having a macrocytic anemia. The arrhythmia and pacemaker function
were not addressed. The patient’s prior chest pain, shortness of breath, and nausea were not
addressed.

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A doctor saw the patient on 12/22/15 for a hypoglycemic episode (blood glucose 48),
orthopnea, leg edema, shortness of breath, and left chest pressure. The doctor ordered a
change in insulin and ordered lab tests with a week follow up. A chest x-ray and EKG were not
ordered. Although the doctor’s assessment was “COPD vs cardiac? Not exertional,” the doctor
took insufficient history. The patient should have been hospitalized, given his chest pain with
symptoms of heart failure or angina.
On 12/29/15, a doctor saw the patient for edema, shortness of breath, and orthopnea. The
patient had a heart rate in the 40s and the doctor questioned whether the pacemaker was
malfunctioning. The BUN was 42, creatinine 1.77 and BNP 712, indicating renal failure, possible
dehydration, and possible heart failure. The elevation of BNP could have been associated with
heart failure, renal failure, valvular heart disease, pulmonary hypertension, or coronary artery
disease. The doctor diagnosed exacerbation of heart failure and ordered a diuretic change and
blood tests. However, given his symptoms and underlying conditions, the standard of care
would have been to admit the patient to a hospital.8 Normal pacemaker functioning would
have kept the pulse above a set-point, which typically would be about 70 beats per minute.
When the heart rate falls below the set rate, it indicates that the pacemaker is not functioning.
Keeping this patient at the prison was grossly and flagrantly unacceptable.
On 12/30/15, a nurse at the prison did a pacemaker check that showed two alerts, one of which
was that the ventricular pacing was greater than the expected limit. No action was taken. The
patient had a pulse in the 40s, which should not occur with a pacemaker.
On 12/31/15, the patient saw a nurse for a nebulizer treatment and told the nurse, “it’s not my
lungs, it’s my heart.” A doctor saw the patient the following day but did not take a thorough
history and did not note the prior history of chest pain. The doctor assessed heart failure
exacerbation and re-started Aldactone. No chest x-ray was taken, and the pacemaker function
was not reviewed after the prior day’s pacemaker check.
The following day the patient was found dead in his cell. There was no death assessment, no
death certificate, and no autopsy in the medical record. The mortality list documented his cause
of death as cardiac arrhythmia.
This patient’s death was possibly preventable. Although the cause of death was not
determined, the death was possibly preventable had the patient been admitted to a hospital.
He had multiple conditions that were not followed. He had a pacemaker placed but no follow
up with cardiology. Prison doctors were not monitoring the pacemaker. A doctor believed that
the pacemaker was malfunctioning and it appeared that it was, since on a couple of occasions
the pulse was in the 40s, which is not expected with a functioning pacemaker. At that time, the
Heart Failure Society of America guidelines as found at http://www.hfsa.org/heart-failure-guidelines-2/ recommend that
patients with suspected heart failure should be hospitalized when they have decrease in renal function, a hemodynamically
significant arrhythmia, worsening congestion, comorbid conditions, and a pacemaker with repeated defibrillator firings, all of
which this patient had.
8

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patient had chest pain and symptoms of heart failure, yet he was not admitted to the hospital
for evaluation. It is likely that his death was preventable if he had been followed by cardiology
and if he had been admitted to a hospital for exacerbation of heart failure, bradycardia,
pacemaker check, and chest pain.
We identified 62 errors. Twelve were related to failure to follow up on abnormal laboratory
results. Twelve errors were related to failure to take an adequate history and twelve errors
were related to failure to develop an appropriate treatment plan. Notably, this appeared
related to failure to monitor many of the chronic diseases of the patient that were not in the
main categories of chronic illness clinics. Providers failed to follow any condition not related to
a major disease category. There were also seven episodes of nurses failing to consult a
physician for serious illnesses beyond the ability of a nurse to manage.

Patient #19 Dixon
This 75 year old man had underlying ulcerative colitis. He experienced weight loss and had
anemia and yet doctors failed to order a colonoscopy, which is below standard of care and
placed the patient at risk of harm. The patient had pancytopenia, and then anemia and
thrombocytopenia, but was never worked up for these problems except to order iron studies.
This was below standard of care. The patient also experienced weight loss, was underweight,
and had low albumin, which indicates malnutrition. Yet there was no evaluation for this.
This patient had a prosthetic leg due to an amputation from a prior episode of osteomyelitis.
The prosthetic leg did not fit well, and Wexford did not replace the prosthetic leg but tried to
repair it, and the patient was not able to use it due to developing ulcers on the stump. As a
result, the patient was confined to a wheelchair.
In using the wheelchair, the patient developed a pressure ulcer on his coccyx. A thorough
assessment of the patient’s activities of daily living was not done to determine how to prevent
the ulcer and promote healing. The ulcer was first noted on 6/17/16. At the time of first
noticing the ulcer, it appeared from the description to be a stage two ulcer with open blisters
and wounds surrounded by erythema. The patient initially was not provided adequate pain
medication. By 6/24/16, the wound appeared to be infected. Although a nurse practitioner
started antibiotics, the NP failed to order any blood tests or radiological tests to assess for
underlying osteomyelitis, which is standard of care. Because of frailty and debility, the patient
needed housing on a higher level of care. This could possibly have been an infirmary, but the
needs were so great that a skilled nursing unit was indicated, yet the patient remained in
general population.
The patient continued to lose weight and by 6/27/16 weighed 127 pounds, which was a 15pound weight loss over two years. Referral to a nutritionist was not done and the doctor did
not complete a nutritional assessment. Adequate nutrition is imperative for healing of pressure
ulceration, but this patient never had an adequate nutritional assessment. The doctor ordered

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blood tests, and these were abnormal (albumin 2.3; hemoglobin 10; platelets 145; and
sedimentation rate 60). This suggested possible osteomyelitis and the doctor reviewed these
tests, but apparently did not understand the implications of these laboratory tests and took no
actions on these abnormal tests. The doctor appeared not to know how to treat this patient’s
conditions. An MRI was indicated; blood and or bone cultures were indicated, and it appeared
that intravenous antibiotics were indicated. Yet, no action was taken. The patient should have
had osteomyelitis ruled out and should have been admitted to a hospital as early as 6/30/16.
This was not done. Care was grossly and flagrantly unacceptable.
The patient continued to deteriorate. Aside from adding Boost nutritional supplement, no other
action was taken. The wound worsened with tunneling, which was described as deep and was
indicative of stage 3 ulceration. The wound deteriorated with no change in treatment. There
was no referral for debridement. The patient remained in general population housing and
apparently was still in his wheelchair. Eventually, on 7/25/17, bone was visible to a nurse. On
8/2/16, a doctor, shortly after a nurse identified visible bone, described the wound as
“healthy.” Visible bone usually indicates osteomyelitis or significant infection, especially with a
sedimentation rate of 60. Yet the patient was still not sent to a hospital. The doctor’s
description of a wound with visible bone as “healthy” was grossly and flagrantly unacceptable.
By 8/8/16, the patient started developing altered mental status, first with memory loss. The
patient was unable to care for himself. On 8/11/16, the patient urinated on himself while
having a dressing change. Despite this and despite increasing evidence of sepsis, the patient
was kept in general population and not sent to a hospital. Ultimately a roommate told a nurse
that the patient had not eaten in two days and had not voided in days. The patient was so
dehydrated that an IV line could not be started. The patient was not responsive and was finally
admitted to a hospital on 8/13/16, five days after developing alteration of mental status.
At the hospital, the patient had bacteria and fungus growing in his blood thought to be due to
his decubitus ulcer. The patient was extremely dehydrated (BUN 92 and sodium 153) and
malnourished (albumin 2.7) on admission. In our opinion, the patient’s presentation at the
hospital was evidence of neglect at the facility in the weeks prior to admission. The patient was
discharged from the hospital on 8/19/16 as a hospice patient. The doctor placed the patient on
palliative sedation9 on 8/19/16 without documentation of a discussion with the patient’s family
about palliative sedation. The patient was not capable of making his own decisions. Criticism of
palliative sedation includes that it hastens death and can be perceived as a form or euthanasia.
Use of this practice should be done with an open and frank conversation with the patient,
which in this case was not documented as being done. In lieu of a discussion with the patient, a
discussion with the family is recommended. The IDOC should address this on a statewide basis
to ensure ethical standards of practice. The patient died on 8/21/16.
Palliative sedation is a measure of last resort used at the end of life to relieve severe and refractory symptoms. It is performed
by the administration of sedative medications in monitored settings and is aimed at inducing a state of decreased awareness or
absent awareness (unconsciousness). As quoted from Palliative Sedation section in UpToDate, an online medical reference. The
typical palliative sedation combination is a narcotic with a benzodiazepine, which is the combination this patient was on.
9

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This patient’s death was preventable. It appeared that doctors did not know how to manage a
decubitus ulcer, which is a primary care problem. This is especially problematic because Dixon
houses so many geriatric patients who are susceptible to decubitus ulcers. Care appeared
indifferent, neglectful, and incompetent, and on one occasion, grossly and flagrantly
unacceptable. It is our opinion that early management and treatment of the decubitus ulcer
would have prevented or significantly delayed his death.
We noted 68 errors in management of this patient. There were seven to eight errors each of
lack of appropriate history, examination, and development of an appropriate therapeutic plan.
There were seven errors of providers not ordering appropriate laboratory testing and nine
errors of not ordering imaging or other diagnostic testing. On eight occasions it was our opinion
that the patient should have been sent to a higher level of care for management. The ultimate
delay in hospitalization was mostly responsible for the patient’s death, in our opinion. Keeping
an 82-year-old patient with altered mental status, incontinence, and unable to care for himself
in general population prison housing challenges the boundaries of what it means to be a
professional.

Patient #20 Logan
This patient was a 62-year-old woman who had a pancreatic mass identified in 2015 while she
was in Iowa. She failed to follow up as a civilian. She became incarcerated and was in Cook
County Jail; she was hospitalized for a work-up in October of 2016. A large pancreatic mass was
identified. A stent was placed in the pancreatic duct. Unfortunately, a biopsy consisted of an
inadequate specimen. The patient was discharged with pathology pending. The patient was on
90 mg of morphine a day for pain management. When the patient left the hospital, the
diagnosis was likely pancreatic cancer. The patient was scheduled for a follow up with a
gastroenterologist at Stroger Hospital when she transferred to Logan.
Instead of completing the diagnostic work-up of the pancreatic mass, the doctor at Logan
initially did nothing, believing that the mass was benign despite the hospital documenting that
the mass was likely pancreatic cancer. Also, the doctor at Logan dramatically reduced the pain
medication from approximately 90 mg of morphine a day (15 mg SR BID and 15 mg IR Q 4 hour
as needed) to one Tylenol #3 pill three times a day. The patient suffered pain throughout most
of her incarceration with inadequate pain management.
After about a month after arrival at Logan, the doctor obtained a marker test for pancreatic
cancer and it was positive. The doctor referred the patient for an ERCP and biopsy. Wexford
denied this test; instead, they sent the patient to a gastroenterologist on a routine basis for
evaluation. There was no clinical justification for this denial as this served only to delay
evaluation. The patient went to the gastroenterologist in on 2/15/17, almost three months
after arrival to Logan. The gastroenterologist recommended a biopsy. This did not occur until
late April, approximately five months after arrival to Logan. The patient’s diagnosis was
therefore significantly delayed, largely as a result of the Wexford utilization process.

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In addition to the delay in diagnosis, treatment of the patient’s pain was indifferent and
bordered on cruelty. Pancreatic cancer is known to cause significant pain. When the patient
transferred from Cook County Jail to Logan, the patient was on up to 90 mg of morphine a day.
A doctor promptly and dramatically decreased the dose of 90 mg of morphine to one Tylenol #3
tablet three times a day. A Tylenol #3 has 30 mg of codeine, which has an equivalency of about
5.5 mg of morphine. Thus, the pain medication reduction was approximately 80%. Based on
nursing notes, the patient did not have adequate pain control, yet this was not adequately
monitored or addressed by physicians. When the patient saw a gastroenterologist consultant
on 3/21/17, the consultant prescribed a fentanyl patch for pain control. This was not authorized
by the Logan physician. The patient remained in severe pain. The doctor did not initiate narcotic
pain relief for about five months, until just before the patient died. Three days before the
patient died, the doctor prescribed palliative sedation using a combination of morphine every
two hours with a benzodiazepine every two hours. A criticism of palliative sedation is that it can
be perceived as a form of euthanasia10. This appears to be a legitimate criticism in this case
because of the lack of morphine use or adequate pain management until just before death and
because we could find no discussion of palliative sedation with the patient. This raises ethical
concerns, particularly because of the lack of pain medication in the preceding five months
before the patient died.
We also note in this case significant problems with the medical record. There were multiple
episodes of clinical care when identical vital signs were used repeatedly. The medical record
software defaults to use of the last recorded vital signs. But it appears to result in nurses and
physicians using vital signs from previous encounters even when vital signs are indicated. One
episode of using the same vital signs from a previous encounter lasted longer than a week. In
one series of episodes, the temperature was listed as 82.7°F, which is a temperature
incompatible with life. The patient was documented as having this identical temperature on
three separate clinical visits over a period of over a month. No one noticed this unusual
temperature. Vital signs should be recorded at the time they are done and only used for the
time period of the clinical event when the vital sign is taken. To do otherwise is a significant
patient safety concern. This medical record defect needs to be stopped immediately on the
basis of patient safety.
While this patient’s death may not have been preventable, there were serious concerns,
including unnecessary delays in consultation care, unacceptable lack of pain management in a
patient with an extremely painful condition, and possible inappropriate use of palliative
sedation without discussion with the patient. Use of palliative sedation is not governed by
policy but was used on patients in three of the 33 deaths we reviewed.11 Because of the
potential for misuse or perceived misuse, this practice should be strictly regulated within the
IDOC.

10
11

This is described in the article on palliative sedation in UpToDate.
Mortality Review Patients #19, 20, and 28.

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We noted 159 errors in the record review over a six month period. Fifty-two were related to the
medical record use of dated vital signs and nurses not using appropriate vital signs even when
the patient was being evaluated for a new problem. Twenty were related to nurses not
consulting a physician for a significant complaint (pain, vomiting, etc.). Eighteen were related to
physician therapeutic plans, mostly related to pain management, which appeared significantly
below standard of care. The lack of appropriate attention to nutrition, pain management, and
fluid and electrolyte management was so poor that during the last month the patient was
neglected, resulting in dehydration and electrolyte disturbances from lack of medical attention.
The patient should have been sent to a skilled nursing care unit for management because the
patient was not receiving appropriate care at the prison.

Patient #21 Menard
This patient had diabetes, hypertension, and prostate cancer, for which he took hormonal
therapy with an oncologist. The patient had a very high risk (as high as 47% 10-year risk of heart
disease or stroke) of heart disease, yet was not treated with a statin drug. This happened
repeatedly and is a systemic problem in IDOC.
From 3/13/16 until 11/3/16, the patient was evaluated five times for abdominal pain, for which
inadequate history and physical examinations took place. Although the patient was losing
weight, this was unnoticed. Weight loss with abdominal pain suggests a potentially serious
medical condition. On 11/3/16, the patient was sent to an emergency room, where a CT scan
showed a large retroperitoneal mass consistent with a lymphoma. The hospital called a Menard
physician to advise of this and to recommend follow up. The hospital report was not initially
available, and the abdominal mass was not addressed until the patient went for his scheduled
oncology appointment for his prostate cancer on 11/21/16. The oncologist noted the abnormal
CT scan and recommended a CT guided biopsy and CT scan of the brain ASAP with a three week
follow up. This follow up never occurred. Although the biopsy and CT scan of the brain were
approved, they were never done. By 12/5/16, a doctor noted that the patient had lost 50
pounds. On 12/29/16, a nurse documented that the patient had 3+ leg edema with a pressure
ulcer on his hip and could not walk on his own to the health care unit. The doctor did not admit
the patient to the infirmary even though it appeared that the patient was unable to care for
himself such that he was developing a pressure ulcer. This was grossly and flagrantly
unacceptable care.
The patient appeared lost to follow up until 2/2/17 when security officers complained to a
nurse about the patient being unable to care for himself in general population. The patient was
admitted to the infirmary by a nurse. The patient was unable to stand on his own without
assistance, did not respond appropriately, and did not know what time it was. The following
day, a doctor noted that the patient was confused. Nurses noted that the patient was
incontinent and appeared delirious as he was talking to people in his cell that were not there. A
doctor referred the patient to mental health but did not conduct an evaluation for medical
causes of delirium. This was grossly and flagrantly unacceptable care. For five days, the patient

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was kept on the infirmary even though he exhibited signs of delirium and should have been
immediately hospitalized. By 2/7/17, the patient had become lethargic and confused, yet a
doctor who saw the patient did not admit him to a hospital until later in the day when the
patient became lethargic with uneven respirations. There were multiple episodes of grossly and
flagrantly unacceptable care during the patient’s stay on the infirmary. The patient apparently
died in the hospital. There was no autopsy or death summary.
This patient’s death was possibly preventable. The patient had abdominal pain with weight
loss for seven months without adequate evaluation, including adequate diagnostic testing. The
weight loss was unrecognized. After an abdominal mass was finally identified on a CT scan, a
diagnostic work up was not initiated for three months. The patient died without a diagnosis.
The recommendation for an urgent evaluation as recommended by an oncologist was not done
over the remaining two months of the patient’s life. Though the patient appeared unable to
care for himself and had developed a pressure ulcer, the patient was kept in general population
and not monitored. Almost three months after the abnormal CT scan, the patient was brought
to the attention of a nurse by security staff because the patient could not care for himself. The
patient was confused, delirious, had significant edema, and had a pressure ulcer. Despite the
new onset of confusion, the patient was kept on the infirmary without adequate evaluation
until he became lethargic and was breathing abnormally. The patient was sent to the hospital
where apparently he died without a diagnosis. Earlier identification of the abdominal mass and
timely treatment of the likely lymphoma could possibly have prevented his death. Care for this
patient was grossly and flagrantly unacceptable and demonstrated neglect and indifference.
We identified 83 errors in his care. Most were related to failure to take adequate history,
perform adequate examinations, and develop adequate therapeutic plans. We noted that on
nine occasions the patient had a serious presentation (shortness of breath, confusion, delirium,
diarrhea, and inability to care for himself) and yet the nurse did not consult a physician. We
identified nine separate occasions when the patient should have been sent to a higher level of
care. A few of these related to not being housed on an infirmary unit when the inmate was
unable to care for himself. In other cases, the patient should have been immediately
transferred to a hospital but was not.

Patient #22 Menard
This patient was a 46-year-old man with a known history of hypertension, diabetes, and
obesity. The annual history and physical evaluation on 7/18/13 identified prior sexually
transmitted disease (gonorrhea) and the biannual evaluation on 10/26/15 identified blood
transfusions, multiple sexual partners, and prior history of gonorrhea as risk factors. The patient
had multiple risk factors for HIV, yet was not offered HIV screening, which is standard of care.12
That the histories were different on different biannual evaluations was also a problem.
Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement; Annals of Internal Medicine Volume 159,
Number 1; pp. 51-60; July 2, 2013. This was an A recommendation, which is that there is high certainty that the net benefit is
substantial.
12

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The patient then had low white blood count (1.8) with low lymphocytes (0.6) as early as 8/6/13
which were not followed up on. Low lymphocytes should have prompted evaluation, including
whether the patient had HIV infection. This was not done.
On 9/5/15, the patient developed altered mental status with fever. He was a 46 year old man
who was urinating on himself. The patient did not have an adequate evaluation for alteration of
mental status. He was not provided an adequate history or physical examination for his
condition. He should have had a CT scan and other diagnostic testing. Instead, the patient was
merely monitored on the infirmary with blood tests. The doctor made a diagnosis of fever of
unknown origin. This diagnosis presumes that causes of the fever have been ruled out, which
had not been done in this case, as little diagnostic evaluation was performed. The patient
should have been hospitalized for his condition but was not. Care was grossly and flagrantly
unacceptable.
The doctor presumed that the patient had lupus, but the patient did not have immunologic
criteria to qualify for this diagnosis. The providers failed to evaluate for HIV, a common
condition in this population and one that the patient had risk factor for (multiple sexual
partners, prior gonorrhea, transfusions) and blood tests suggestive for (low white blood count
with lymphocytopenia).
Lupus is an uncommon condition in this population as compared to HIV. The diagnosis of lupus
depends on satisfying multiple clinical and laboratory criteria which often require experienced
clinical diagnosis. Typically, a specialty referral is indicated. The patient did not satisfy
immunologic laboratory criteria for lupus; nevertheless, the doctor maintained this diagnosis
without searching for more obvious causes of the patient’s problem. The patient continued to
have high sedimentation rate, intermittent fever, weight loss, confusion, and low white blood
counts, sometimes including pancytopenia.13 Despite considering lupus, the doctor did not
refer the patient to a rheumatologist for five months. On 2/26/16, a rheumatologist would not
accept the patient for referral because the patient did not have immunologic criteria for lupus.
Still, the doctor failed to screen the patient for HIV, despite the patient having multiple risk
factors and suggestive laboratory and clinical findings. The doctor remained steadfast in
maintaining lupus as a possible diagnosis for over a year without obtaining immunological tests
required for the diagnosis and without excluding other more common diseases (e.g., HIV). This
was grossly and flagrantly unacceptable care.
The patient’s mental status deteriorated. From September of 2015 through October of 2016,
the patient exhibited altered mental status, but was inadequately evaluated for this and was
mostly housed in general population, where he appeared unable to adequately care for himself.
His care was neglectful and bordered on cruelty. On 3/15/16, a psychiatrist documented that
the patient was incontinent of urine and feces while wearing his clothes and noted delusional
Pancytopenia is low white count, low red blood cell count, and low platelets. These are the three cellular components of
blood. This is consistent with numerous conditions, many of which are serious and require immediate attention, sometimes
including referral to a hematologist for bone marrow biopsy. In this case, an HIV test would have been a first diagnostic step.
13

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thinking. The psychiatrist believed that the patient had psychosis from a medical condition. Yet,
doctors did not pursue further evaluation (CT scan or MRI of brain, possibly lumbar puncture,
exclusion of infection including HIV, etc.). No diagnostic action was taken except to monitor the
patient and obtain routine blood tests. The patient remained intermittently confused,
delusional, and delirious for the remainder of his life. The patient had disordered cognitive
function for approximately 13 months without having an evaluation for the cause. This was
grossly and flagrantly unacceptable care.
About a year after initially suspecting lupus, a rheumatology consult was finally obtained on
9/28/16. The rheumatologist found no obvious systemic complaints to suggest lupus but
ordered additional testing. By accident, apparently, the rheumatologist sent with the patient a
prescription for methotrexate with the wrong patient’s name on it. This was not identified by
staff and the patient received methotrexate inappropriately, which has side effects including
decreased blood counts, which already affected the patient. The rheumatologist’s type written
note did not include prescription of methotrexate. This may have harmed the patient, as shortly
after this the patient developed sepsis, a possible complication of using methotrexate in an
immune compromised patient.
The patient was admitted back to the infirmary in July of 2016 for inability to care for himself.
He was weak, incontinent, and unable to perform routine hygiene for himself. He also
developed fever on 7/22/16, yet there was little evaluation for the cause of fever except to
order a urine test and blood count. The patient was unable to walk without assistance, and
mostly lay in bed. He developed a large (6 inch by 6 inch) pressure ulcer which was identified by
nurses but not recognized or evaluated by physicians. He lost a significant amount of weight
(>50 pounds) yet the weight loss was unrecognized. Eventually, the patient became
hypotensive (90/66) and had hypoxemia, and was sent to a hospital, where he was found to be
in septic shock due to complications of HIV infection. The patient died in the hospital.
This patient’s death was preventable. The patient had multiple risk factors for HIV infection yet
was never screened for this infection. The patient had altered mental status for over a year but
never had a diagnostic evaluation for this. The patient had low lymphocytes and low white
counts since 2013 but was never evaluated adequately for this. The patient had fever but was
never properly evaluated for this. The patient’s confusion resulted in inability to take care of his
hygiene, but the patient was neglected, resulting in a large, unrecognized pressure ulcer and
significant unrecognized weight loss. Care was indifferent, neglectful, and grossly and flagrantly
unacceptable. Early diagnosis of HIV should have been made and this would have prevented his
death. We note that the physician caring for this patient was a surgeon without primary care
expertise. It is our belief that the doctor’s lack of training significantly contributed to this
patient’s death.
We noted 117 errors in care for this patient in slightly over a year of record review. Most were
related to inadequate history, examination, or development of a therapeutic plan. It is our
opinion that on 18 occasions the doctor should have sent the patient to a hospital but did not.
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We also noted that for long periods of time the patient was housed in general population status
when he was confused, incontinent, and unable to care for himself. When he ultimately went
to the hospital, he had evidence of neglect including severe malnutrition, significant weight
loss, multiple pustular sores, and pressure ulcers that were unrecognized at the facility. His care
was grossly and flagrantly unacceptable.

Patient #23 Menard
This patient had APRI14 scores indicating cirrhosis as early as 2012, but was not referred to UIC
hepatology for treatment of the hepatitis C in 2012 or 2013. In 2014 and in January of 2015, the
patient signed a refusal for care for hepatitis C, but it was not clear what explanation was given
to the patient. When he ultimately was evaluated by UIC in April of 2016, he did not even know
that he had advanced liver disease or cirrhosis, but he agreed to treatment of his hepatitis C. It
does not appear that effective communication with the patient occurred at Menard.
Though the patient had cirrhosis since 2012, he did not receive a screening upper endoscopy to
evaluate for varices until 8/7/15. He also did not receive every six month screening for
hepatocellular carcinoma until 5/8/15. These are standard recommendations for patients with
cirrhosis. That he ultimately died with likely hepatocellular carcinoma is problematic, as he was
improperly screened for this condition.
Despite having cirrhosis at least as early as 2012, the patient did not have appropriate
management of his ascites. Edema was evident as early as 10/4/12, when a doctor noted 2+
edema on a chronic clinic evaluation. The doctor did not initiate a diagnostic work up for the
edema. On 1/4/15, a nurse practitioner identified bilateral leg edema without taking action
except to order Ted hose. A CT scan on 5/28/15 documented ascites, which was not
documented as a problem, monitored, or treated. An MRI on 10/22/15 showed large ascites yet
this was not identified or monitored as a problem. The MAR shows that Aldactone was started
on 11/23/15 but discontinued on 11/30/15. There was no progress note on either date, so the
reasoning for these actions was not known. Despite evidence of significant ascites in October
2015, doctors did not monitor this or treat the patient. Doctors did not start a diuretic until
6/22/16 when the patient had tense ascites. It appeared that the providers did not know how
to manage cirrhosis with ascites.
Though the patient should have been screened for hepatocellular carcinoma every six months
beginning in 2012, the patient was not screened for hepatocellular carcinoma until May of
2015, when an ultrasound showed a mass worrisome for a malignancy which was confirmed on
a CT scan later that month. Although the ultrasound and CT scan showed a possible malignancy
in May of 2015, the patient was not referred for biopsy until 8/25/15. A Wexford utilization
14 APRI is an AST to Platelet Ratio Index. This score uses common blood tests to estimate the probability of fibrosis and cirrhosis
and is used as a means to identify persons with greater degrees of fibrosis. This is currently used for identifying persons at
higher need of treatment for their hepatitis C. IDOC does not initiate treatment for hepatitis C until the patient has a fibrosis
level nearly equivalent to cirrhosis and the APRI is used as a benchmark for referral.

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doctor initially denied the biopsy, instead recommending referral to Dr. Paul, the Wexford
hepatitis C doctor. She apparently referred the patient for an MRI, which was done in late
October of 2015, showing a wedge shaped fibrotic lesion in the liver. According to a subsequent
UIC note, the MRI was to include a liver biopsy, but this did not occur because MCC did not
send the ultrasound and CT scan results with the patient. Another liver ultrasound was done on
12/18/15 showing a 2.1 cm liver mass with a recommendation for follow up MRI or CT scan. No
action was taken. The patient appeared to have died with or because of possible cancer which
was never biopsied for over a year.
On 4/28/16, the patient was referred to UIC for hepatitis C treatment. We believe that the
patient should have been referred to UIC in 2012 for treatment, as providers at Menard did not
appear to understand the complications of cirrhosis or management of hepatitis C, and
treatment options should be explained by a person knowledgeable in treatment of the
condition. The UIC consultant documented that biopsy was not done in 2015 because prior
ultrasound and CT scans were not provided to the radiologist, and that the patient had a liver
lesion suspicious for cancer. The UIC consultant also noted that the patient did not understand
that he had complications of liver disease (cirrhosis, varices, and ascites). If the doctors at
Menard had not explained the complications of the patient’s liver disease to him, what
discussion took place with respect to treatment of his hepatitis C? The patient was willing to
accept treatment when the UIC doctors discussed treatment with him. Prior to initiating
treatment, the UIC doctors recommended a biopsy. This was not documented as done.
The patient was sent for an MRI on 6/22/16, but it was not clear if this was for a biopsy. Upon
return to the prison, the patient was noted to have fever (100.4°F), hypotension (96/64), and
hypoxemia (oxygen saturation 79%) with tense ascites. The patient had signs of sepsis and
should have been admitted to a hospital for paracentesis and blood cultures. Instead, a nurse
admitted the patient to the infirmary for observation, but a physician did not examine the
patient. This was grossly and flagrantly unacceptable care, as the patient had signs of sepsis.
The following day the patient had fever to 100.8°F with massive ascites. Instead of admitting
the patient to a hospital, the doctor only ordered Aldactone 25 mg BID, Lasix 40 BID, and an
oral antibiotic (Levaquin) without taking a history and performing only limited examination.
This was grossly and flagrantly unacceptable care, as the patient was at risk of death.
The following day the patient again became hypoxic (oxygen saturation 84%), hypotensive
(88/60), and had trouble breathing. The doctor sent the patient to a hospital, where he died.
This death was possibly preventable for the following reasons:
1. The patient was not screened for complications of cirrhosis for three years. This was the
likely cause of death. Hepatocellular cancer screening is recommended every six months
for persons with cirrhosis. Screening, early identification of complications, and
treatment for these might have prevented or significantly delayed the death.

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2. The patient had a liver mass suspicious for cancer identified in May of 2015 but until his
death in June of 2016, the mass was not evaluated with a biopsy and remained
undiagnosed. The delay in diagnosis of a possible hepatocellular carcinoma likely
contributed to his death and earlier diagnosis and treatment might have prevented or
significantly delayed the death.
3. The patient developed tense ascites, fever, hypotension, and severe hypoxemia on
6/22/16 and should have been immediately hospitalized. Instead, the patient was
placed on the infirmary for observation without any diagnostic testing on the first day.
This was grossly and flagrantly unacceptable care and placed the patient at risk for
death. On the second day the patient still had fever. Oral antibiotics and routine blood
tests were ordered when the patient should have been hospitalized. This delay may
have resulted in his death. Care was grossly and flagrantly unacceptable. On the
following day a doctor did not evaluate the patient, but the patient was sent to a
hospital for extremely unstable vital signs.
4. We note that the patient told a UIC consultant that he was unaware that he had
complications of hepatitis C (ascites, varices, cirrhosis). Although the patient signed a
refusal for treatment of hepatitis C, it is unclear how hepatitis C treatment was
explained to him if he did not even understand that he had cirrhosis. We question
whether effective communication occurred. The patient accepted treatment from the
UIC consultant but not the providers at Menard. It is our opinion that once cirrhosis was
evident in 2012, the patient should have been referred directly to UIC. The current
collegial process of using a Wexford doctor as a gateway for therapy and for testing
related to cirrhosis clearly caused delays in care (for treatment of hepatitis C and
diagnosis of the liver mass) that resulted in his death. Earlier treatment of his hepatitis C
would likely have prevented or significantly delayed death.
We noted 56 apparent errors in the care of this patient. Thirteen were related to lack of referral
for evaluation for hepatitis C treatment. We question the effectiveness of communication with
patients and believe that their hepatitis C treatment decision should be discussed with an
expert, not physicians and other providers in IDOC who do not apparently understand how to
manage cirrhosis or hepatitis C. Consent and refusal of consent needs to be informed and this
requires a physician who understands the treatment and the consequences. There were 17
apparent errors in not obtaining screening tests for cirrhosis (EGD and ultrasound).

Patient #24 Menard
This 46-year-old man developed abdominal pain. He was evaluated by a nurse on 5/17/17,
5/22/17, and again on 5/31/17. The nurse found no problems, but on 5/31/17 the nurse
referred the patient to a physician. The physician saw the patient on 5/31/17. The physician
took virtually no history. The doctor documented that the patient had an umbilical hernia and
said “it is small. He won’t let me touch it or push it back in.” Without any other evaluation, the
doctor prescribed Tylenol for six months. No diagnostic studies were done. This was not
appropriate follow up for a painful condition that was incompletely evaluated.

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A month later on 6/30/17, a LPN wrote that her supervisor asked her to evaluate the inmate
because his family had called concerned that he needed to see the Medical Director. The LPN
did an assessment using a diarrhea protocol stating that the patient had diarrhea four to five
times a day with abdominal pain and had lost his appetite. The abdomen appeared rigid and
distended to the nurse. The blood pressure was 150/118. The nurse apparently called a doctor,
who sent the patient to a local hospital.
At the hospital, an omental/peritoneal mass was identified. A biopsy was performed along with
colonoscopy and the patient was discharged on 7/6/17 with a diagnosis of carcinomatosis or
disseminated cancer in the abdominal cavity. On 7/10/17, the doctor referred the patient to an
oncologist, noting that final pathological reports were pending. During his infirmary stay the
patient had repeated pain, but the doctor notes did not address the patient’s pain adequately.
When the patient went to the oncologist on 7/26/17, inadequate information was sent, and the
oncologist did not understand why the patient was being referred. The oncologist asked for a
two week follow up with CT scan reports from the hospital, along with additional records.
The patient remained on the infirmary as a chronic admission but was infrequently examined or
questioned by doctors regarding his pain, which was complicated by constipation. Physician
evaluations included virtually no current history or examination and inadequately addressed
pain. Eventually, on 8/9/17 the patient became confused, unable to answer questions and was
sent to a hospital where, apparently, he died. There was no autopsy or death summary for this
patient.
This patient’s death was not preventable, yet there were a few problems. The initial evaluation
of the patient on 6/30/17 was indifferent. The patient had complained of several weeks of
abdominal pain, yet no history was taken, and little examination was performed. To give a
patient Tylenol without having a diagnosis is inadequate and indifferent care. No diagnostic
tests were ordered.
The patient’s pain on the infirmary was inadequately evaluated as evaluations seldom included
a history or physical examination. This also was indifferent.
When the patient went to the oncologist, inadequate medical records were sent with the
patient, resulting in a failed appointment. Communication with specialists is critical to
coordinated care.
We noted 10 apparent errors in care, mostly related to inappropriate therapeutic plans.

Patient #25 Menard
This 65-year-old patient was recently successfully treated for hepatitis C. During a dental
examination, the dentist found an abnormal lesion in his mandibular bone found on x-ray. On

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4/14/17, the dentist referred the patient for evaluation. A consultant saw the patient in midJune and did a biopsy, which on 6/22/17 was positive for B cell lymphoma.
The patient was referred to oncology and after some tests was started on chemotherapy in late
August. The chemotherapy regimen was CHOP, which included prednisone and also included
rituximab. This regimen can severely depress the white blood cells and platelets, and cause
severe life threatening infection. For that reason, the oncologist recommended a drug to
increase the white count. This drug, Granix, was to be administered after each episode of
chemotherapy. The manufacturer recommends that during the time Granix is used that white
counts be checked twice weekly. This was not done at Menard for this patient.
The oncology reports were not all present in the medical record and the blood work done at the
oncology office was not typically available to the site. On 11/22/17, the patient received
chemotherapy and on return became hypotensive; he went to a local ER and was diagnosed
with dehydration. The white count at the hospital was normal.
On 11/26/17, the patient developed a fever to 101.6°F and was too weak to stand up. The
nurse did not consult a physician but should have, as fever in a potentially neutropenic patient
can represent life-threatening risk. The nurse did place the patient on a special housing unit.
Not to call the physician was grossly and flagrantly unacceptable care. The patient should have
had immediate white count and/or immediate referral to a hospital for evaluation for infection.
A doctor did not see the patient for two days, until 11/28/17. The patient had fever to 101°F.
The patient should have been immediately hospitalized. The patient needed evaluation
unavailable at the prison. The patient needed immediate blood cultures, intravenous antibiotics
and diagnostic evaluation and monitoring for neutropenic infection. Instead, the doctor
ordered an oral antibiotic without identifying a source of infection. The failure to order a white
count or hospitalize the patient was grossly and flagrantly unacceptable care in a potentially
neutropenic patient on chemotherapy. The doctor also did not check to ensure that the patient
had received the Granix medication. We could find no evidence on MARs available in the record
that the patient received Granix, significantly increasing the potential for neutropenia.
The following day on 11/29/17, the patient developed hypotension, diarrhea, and felt sick. The
doctor stopped blood pressure medication and did order a white blood count, but it was not
ordered stat and was never done. Hypotension in the context of neutropenia, especially in
someone on prednisone which was part of this patient’s chemotherapy, can indicate infection.
Failure to immediately check for neutropenia or hospitalize the patient was grossly and
flagrantly unacceptable.
On 11/30/17, the doctor noted that the patient had pus coming from his ear and diagnosed
otitis externa and changed the oral Levaquin to intravenous Rocephin, another antibiotic. The
patient now had an infection and again should have been sent immediately to the hospital.
Care was grossly and flagrantly unacceptable.
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On 12/1/17, pus was still coming out from the patient’s ear and the doctor again did not send
the patient immediately to a hospital. The white count was never drawn. Care was grossly and
flagrantly unacceptable.
The patient was not seen the following day by a physician which is unacceptable in a potentially
neutropenic patient. On 12/3/17, the patient was found unresponsive with blood on his mouth
and draining from his penis, with a fever of 101.2°F; and in shock with blood pressure 96/60,
pulse 120, and respiration as high as 42. He appeared to be bleeding due to probable loss of
platelets likely due to chemotherapy related pancytopenia. The patient was sent to the
hospital. The hospital record was unavailable, but the doctor’s death summary stated that the
patient developed pancytopenia, sepsis, and pneumonia; and died due to sepsis and
pancytopenia on 12/12/17.
This death was preventable. Timely treatment with Granix would have prevented the
neutropenia would have prevented or significantly delayed death. Timely treatment of the
neutropenic sepsis would have, at a minimum, have significantly delayed death. The medical
record was disorganized, many consultation reports were not in the record, and information
was not available. It appeared that coordination with the consultant was poor. The patient was
at high risk for neutropenic infection and was to receive a medication, Granix, which it
appeared he did not receive. After developing fever, a sign of neutropenic syndrome, the
physician response over a three-day period was incompetent, demonstrated failure to properly
manage a potentially neutropenic patient, and was grossly and flagrantly unacceptable. We
noted 23 apparent errors in medical care. Seven errors involved not ordering timely blood
counts to monitor infection. Five involved inappropriate therapeutic plans, mostly involving
treatment of a potentially neutropenic patient.

Patient #26 Menard
This patient was incarcerated in 2008. He died in 2017 when he was 68 years old. He had no
medical problems. At annual health evaluations he was not offered colorectal screening,
though he did refuse a digital rectal examination, which is inadequate as colorectal screening.
He also was not treated for primary prevention with a statin for coronary artery disease for
years. In the 2008 reception screening and at every biannual screening dating from 2012 to his
death, he had greater than a 7.5% 10-year risk for heart disease and should have been offered
statin medication, but was not. This is a systemic issue, as providers under Wexford do not use
contemporary risk calculation to determine use of primary prevention for coronary artery
disease.
On 3/20/17, a doctor saw the patient for shortness of breath. There was no other history and
the doctor did not utilize a full set of vital signs. The only examination was that the patient was
very pale with cold hands. The doctor assessed anemia without having a blood count to make
that assessment. This was an inadequate evaluation without adequate history or physical
examination. The doctor ordered a stat CBC and CMP. Later that day, the doctor wrote that the

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labs were normal but that the patient was short of breath. Again, without adequate physical
evaluation or history, the doctor ordered a routine chest and abdominal x-rays, and urine test.
The following day a nurse practitioner (NP) noted that the patient had possible pneumonia. The
patient had a critical respiratory rate of 38-40 and blood pressure of 152/100. The NP ordered
an EKG and sent the patient to a hospital. The hospital was a very small (25-bed) hospital. Atrial
fibrillation with heart failure and pleural effusion was diagnosed. The patient had a chest x-ray
showing bilateral pleural effusions, possible pneumonia, and compression of the lungs by the
pleural effusions. The hospital called the NP, who accepted the patient back to the facility with
a plan to order a cardiology follow up. This, in our opinion, was not safe for the patient under
these conditions due to the age of the patient, the new onset of the fibrillation, possibility of
pneumonia, and significant pleural effusions and heart failure. Given the uncertainty, return to
Menard was a poor clinical choice. That decision was made apparently by a nurse practitioner,
according to the hospital record.
The patient was admitted to the infirmary. The following day the patient was incontinent of
stool and was in shock (86/60), with edema and high respiratory rate (30), and was sent to
another hospital.
The patient had myocardial infarction, heart failure, sepsis, ischemic colitis, and developed
hospital acquired pneumonia. Due to the heart failure and myocardial infarction, further
surgery could not be done. The patient returned to the facility after several weeks at the
hospital and died two days after return.
This patient’s death was not preventable. However, several errors were made. The patient
received no colorectal cancer screening, though contemporary standards recommend this for
persons over age 50. Since 2012, the patient had a consistent 10-year heart disease risk greater
than 7.5% and should have been on a statin. These are systemic problems in IDOC and should
be corrected.
The patient’s atrial fibrillation likely was responsible for the ischemic colitis. The initial
evaluation of the patient by a physician on 3/20/17 was inadequate. The patient had a serious
medical complaint (shortness of breath) yet received no history or physical examination
adequate for the complaint. Also, this patient should not have been taken back from the
hospital on 3/21/17, as his complicated medical condition (new-onset atrial fibrillation, large
bilateral pleural effusions, heart failure, possible pneumonia, and age >65) warranted
hospitalization.

Patient #27 Menard
This 48-year-old man had difficult to control blood pressure. For the entire two years of record
review, the blood pressure was uncontrolled. The blood pressure was significantly out of
control and as high as 260/130. The blood pressure was above 180/120 which is considered a

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hypertensive urgency on 15 separate occasions over a two year period. When the patient was
evaluated with hypertensive urgency, the evaluations were inappropriate as they did not
include evaluations for ongoing end-organ damage.15
The patient had HbA1C of 7.3, which was documented as known by a provider on three
occasions. This is diagnostic of diabetes, but the doctor did not enroll the patient in chronic
care, did not include diabetes as a problem, and did not initiate treatment. It was not clear if
the doctor understood that an HbA1C of 7.3 was diagnostic of diabetes.
The patient also had a persistent need for statin treatment which was unrecognized. In 2014, at
a chronic clinic visit, we calculated the 10-year heart disease risk was 28%, warranting a
moderate to high intensity statin, but no treatment was offered. At a 3/9/16 hypertension
chronic clinic, a statin was not recommended. We calculated a 10-year heart disease risk of
47%; the increased risk partly due to the new diabetes which was, however, unrecognized. The
untreated hyperlipidemia is a risk for cardiovascular disease.
The patient developed symptoms of episodic shortness breath on 2/4/15 and was admitted to a
hospital. At the hospital, the patient had an echocardiogram that showed thickening of the LV
and concentric hypertrophy but normal systolic function, verifying hypertensive cardiovascular
disease. The patient had a diagnosis at the hospital of hypertensive urgency and hypokalemia,
and blood tests were drawn to exclude hyperaldosteronism and pheochromocytoma. The
discharge summary included recommendations to follow up with a nephrologist and
cardiologist in two weeks to complete a work up for hyperaldosteronism and resistant
hypertension. The tests did show an elevated normetanephrine test that suggested
pheochromocytoma. This needed to be worked up but was intentionally not done.
Upon return to Menard, the Medical Director, who was a surgeon, did not refer to nephrology
or cardiology as recommended and did not undertake an evaluation for pheochromocytoma or
hyperaldosteronism. A month later, on 3/6/15, another doctor saw the patient and reviewed
the hospital summary, and noted that the hospital referred the patient to nephrology and
cardiology. This doctor also noted that the Medical Director made no referral. The doctor did
not refer the patient and the patient was never referred.
Notably, the patient had “anxiety attacks” on a number of occasions. On 3/5/14, a doctor noted
that the patient was short of breath, which he attributed to anxiety. This was sufficient for the
doctor to refer the patient to a psychiatrist. That appointment never occurred. A nurse took a
history on 3/27/14 that the patient thought his blood pressure elevations were related to
anxiety. The nurse also noted that the patient noticed skipped heart beats. On 4/22/14, the
End-organ damage in hypertensive urgent episodes includes neurologic symptoms such as delirium, agitation or visual
disturbances; focal symptoms consistent with stroke; hemorrhages of the retina; signs of increased intracranial pressure; chest
discomfort consistent with myocardial ischemia or dissection; symptoms of aortic dissection; and symptoms of pulmonary
edema. In addition to evaluations for these various symptoms, additional testing is indicated including EKG, chest radiograph,
UA, electrolytes including creatinine, cardiac biomarkers, CT or MRI of the brain or chest.

15

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patient told a nurse that he thought his elevated blood pressure was related to stress. On
8/30/14, a doctor noted that the patient had anxiety and referred the patient to a psychiatrist,
but this referral did not occur because the patient refused to be seen. On 10/22/14, a doctor
documented that the patient had anxiety and referred the patient again to a psychiatrist, which
did not occur. On 10/23/15, a doctor assessed anxiety and referred the patient to mental
health, which did not occur. We mention these many references to anxiety because this is
associated potentially with pheochromocytoma, which hospital laboratory tests in February of
2015 suggested that the patient might have. The referral to nephrology never occurred and the
patient was never worked up for this potential secondary cause of hypertension which he may
have had.
Also, the patient had long-standing low potassium, which in the context of difficult to control
high blood pressure suggests hyperaldosteronism. Hospital physicians recommended work up
for this condition as well, but this never occurred. The potassium was low on six separate
occasions. The lowest was a level of 3. Despite a low level of potassium, doctors at Menard
never worked up the patient for hyperaldosteronism. Toward the end of his life the patient was
on spironolactone, a diuretic that tends to increase serum potassium.
On 10/3/16, officers brought the patient to a nurse for unsteady gait and a near fall off his
bunk. The nurse referred to a doctor. The patient was a no-show to clinic twice; on the second
occasion he was described as refusing care, but we could not find a signed refusal in the record.
The patient died about a month after this. The patient was on five drugs in March of 2015, but
by November of 2016, the patient was only on three medications: diltiazem, metoprolol, and
spironolactone. The patient continued to have significantly elevated blood pressure.
The autopsy found atherosclerotic coronary arteries with 95% occlusion of one of the coronary
arteries. The cause of death was arteriosclerotic and hypertensive cardiovascular disease. There
were 113 errors we identified in the care of this patient. Most were related to failure to assess
a patient with hypertensive urgency16 and to ensure timely follow up. We noted that on
multiple chronic clinic visits for hypertension, the patient should have been referred to a
consultant to exclude secondary hypertension.
This patient’s death was preventable. It is our opinion that if the patient’s blood pressure were
controlled he would not have died from hypertensive heart disease. Part of this failure was a
failure to refer for evaluation of possible secondary hypertension and part was a failure to
manage hypertensive medication therapy. He had unrecognized and untreated diabetes for
over a year which increased his risk for cardiovascular heart disease. He had high risk for
cardiovascular disease and yet was not treated with a statin which increased his risk for
When blood pressure is above 180/120, the patient is said to have hypertensive urgency. When this occurs, the provider
should evaluate the patient for end-organ damage, and lower the blood pressure below 160/100. This can be done in
correctional facilities by observation on the infirmary with frequent checks of blood pressure and modification of blood
pressure medications. There should be follow up after this episode to ensure the blood pressure has improved. Tests should be
done to assess renal function and evaluation should be done to exclude heart failure.

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cardiovascular mortality. He had recognized hypokalemia, but it was not adequately
investigated. A hospital recommended referral to a nephrologist to rule out
hyperaldosteronism and secondary causes of hypertension, but prison doctors intentionally did
not act on this recommendation. A hospital test found elevated normetanephrines and the
patient had frequent episodes of anxiety and episodic shortness of breath consistent with
possible pheochromocytoma, yet the patient was not referred for work up. Medication
administration records were not all in the medical record, but those that were recorded that
the patient received his KOP medications. The medication compliance was not frequently
addressed. The patient appeared to have symptoms of unsteady gait and a near fall off his bed
in November, but was not evaluated and referrals to a doctor did not occur. He was said to
have refused a visit, but there was no signed refusal.

Patient #28 Western
This patient was an 81-year-old man with a history of hepatitis C, diabetes, mild heart failure,
prior amputation of the forefoot from osteomyelitis, peripheral vascular disease, and diabetic
neuropathy. He was being housed on the infirmary at Western Illinois Correctional Center.
The patient fell off his bed on the infirmary and sustained an open dislocation of the middle
finger. The patient was sent to a small local emergency room of a 22-bed hospital where full
services were unavailable. The laceration was sutured. However, the dislocation was not
corrected. The finger remained swollen, yet an orthopedic referral was not initiated. A doctor
referred the patient for an urgent wound evaluation, but this was denied by Wexford. This was
grossly and flagrantly unacceptable, as the patient had the equivalent of an open joint injury
and it needed to be repaired. By the second week after the injury, the wound was draining pus.
By the third week, the patient was unable to flex the finger, and finally the doctor obtained
approval from Wexford for orthopedic referral. The patient did not go to the orthopedic doctor
until 3/30/15, approximately a month after the injury. The orthopedic doctor wrote “I am
uncertain as to why this was not reduced prior to now but at any rate would recommend [the
hand surgeon] address this issue.” The patient had osteomyelitis and eventually had open
reduction and internal fixation of the open dislocation that was now infected. This delay
resulted in a non-functional finger. There was no orthopedic follow up after this delayed
surgery.
The patient had pancytopenia.17 This was not properly diagnosed. Yet the patient also had iron
deficiency anemia. The hemoglobin was as low as 7.7, which is very low. Iron studies showed
that this was iron deficiency anemia. This was evident as early as December of 2014. Even with
pancytopenia, iron deficiency anemia should prompt evaluation for colon cancer with
17 Pancytopenia is a condition when all three blood elements are low including red cells, white cells, and platelets. This is a
serious condition and typically requires a bone marrow study to determine the cause. This condition can be caused by cirrhosis.
On one episode a doctor mentioned that the pancytopenia was caused by cirrhosis. Yet the patient did have iron deficiency
anemia. This condition requires investigation as to its cause even when pancytopenia exists. The patient did not receive upper
or lower endoscopy to evaluate for this condition.

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colonoscopy. Also, because the patient had cirrhosis, the patient should have had upper
endoscopy to screen for varices and liver ultrasound to screen for hepatocellular cancer. None
of these tests was offered to the patient even though it is a standard of care.
The patient was evaluated four times in hepatitis C clinic (9/9/14, 12/22/14, 6/16/15, and
12/3/15). Despite the patient having cirrhosis at least as early as November of 2014 but
probably earlier, cirrhosis was not documented as a problem in the medical record during this
time period. We only started review of the record beginning in late 2014. Cirrhosis was not
identified as a problem until shortly before he died. The cirrhosis was not managed, including at
hepatitis C clinic visits. It is recommended that patients with cirrhosis receive a screening upper
endoscopy to rule out varices and semi-annual ultrasound or CT screening for hepatocellular
carcinoma. Providers also need to monitor the patient for complications of cirrhosis, including
ascites and encephalopathy. The patient did not receive management of any of these
conditions.
The patient had cirrhosis and a high level of fibrosis (F4), and was referred for interferon
treatment in 2010 but refused interferon. The newer hepatitis C drugs are much safer with
significantly less adverse reactions and are better tolerated. The patient should have been
offered treatment with the newer hepatitis C drugs as they became available,18 but was not. A
doctor on 6/16/15 documented that the patient was not to be treated because of frailty,
anemia, and because the Wexford infectious disease doctor decided that the patient was not a
treatment candidate. None of these are contraindications for hepatitis C treatment based on
newer agents and the patient should have been referred for treatment.
The patient also developed a diabetic foot ulcer on 12/8/15. Doctors allowed the patient to
walk on the foot, failed to probe the wound, did not evaluate footwear, and did not properly
evaluate for infection or osteomyelitis. The patient had known neuropathy and peripheral
vascular disease and had previously lost his fore foot to amputation with osteomyelitis. In a
patient with diabetes and known peripheral vascular disease, an ankle brachial index19 is
indicated, but was not done. The patient never had adequate evaluation to exclude
osteomyelitis and was never properly treated for a diabetic foot. The treatment of the foot
ulcer was not consistent with current recommendations for a diabetic foot. On 1/13/16, a
doctor started an oral antibiotic (clindamycin) and then, based on a wound culture, started
Rocephin and clindamycin by intravenous route. Unless the wound is debrided and cleaned, a
wound culture is not a useful test. The wound did not improve, and the doctor referred the
patient to a wound care specialist, which Wexford denied. This was grossly and flagrantly
unacceptable, as the facility doctor did not know how to manage this condition and apparently
neither did the Wexford UM doctor. An x-ray and another wound culture were recommended.
Within two days of the denial, the patient was admitted to a local hospital for shock (BP 74/35)
Newer hepatitis C anti-viral medications became approved by the Food and Drug Administration in 2013 and 2014.
An ankle brachial index (ABI) measures the arterial blood flow to the lower extremity to determine if it is adequate. In a
diabetic with a foot ulcer, an ABI gives an indication if surgery is necessary to correct insufficient blood flow, without which
diabetic foot ulcers fail to heal.

18
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and lethargy. Even though the patient had low albumin and low vitamin B12, the patient was
not evaluated for his nutritional status with pre-albumin or dietary history.
At the hospital, a 2 cm liver mass was noted with ascites. Colitis was diagnosed but a discharge
summary could not be located, and it was not clear what the hospital course was. The lack of
hospital records affected care of this patient, as the facility physicians did not understand what
had occurred to the patient in the hospital and neither did we. At this point, the patient’s
unmonitored cirrhosis eventually developed into decompensated cirrhosis and the liver mass
was consistent with hepatocellular carcinoma, although the hospital records were incomplete.
The patient returned to the prison and developed fever, weight loss, diarrhea, and severe
edema. The patient developed worsening swelling from the cirrhosis, fevers, decreased mental
status, and abdominal pain, and for a time refused hospitalization. However, it appeared that
during the time the patient refused hospitalization, his mental status was abnormal, and his
decision capacity was unclear. The patient was ultimately hospitalized again and returned with
a diagnosis of liver cancer, cirrhosis, and pressure ulcers. The hospital report was again
unavailable. The patient was given palliative sedation with Ativan and narcotics, and died.
There was no evidence we could find of a thorough explanation of palliative sedation with the
patient; nor was there informed consent. This appeared to be an inappropriate use of palliative
sedation and gives the appearance of hastening death without the patient being aware. The
death summary documented that the patient was diagnosed with liver cancer and had refused
treatment, which is not entirely accurate based on our interpretation of the record. An autopsy
showed the cause of death to be hypertensive cardiovascular disease and severe stenosis of the
LAD. The autopsy, remarkably, did not list cirrhosis or liver cancer even though cirrhosis and a
liver mass were evident on radiologic tests from the hospital.
There were numerous problems with the care of this patient. Many problems were related to
lack of appropriate referral for consultative services, including timely orthopedic referral,
referral for EGD for someone with cirrhosis, referral for biannual ultrasound for evaluation for
hepatocellular carcinoma, referral for ABI to evaluate vasculature in a diabetic foot, referral for
wound care, referral for nutritional consultation in someone with a healing diabetic foot, and
most important, referral for treatment of hepatitis C. We view this death as not preventable.
However, the basis of the not-preventable was based on the patient probably having dementia
which may not have warranted treatment of his hepatitis C. The patient should have been
screened for hepatocellular carcinoma and for varices as early as 2014, but since the patient
had symptoms of dementia in 2014, the need for treatment of hepatitis C was less certain and
it is on this basis that we determine it was not preventable.
We noted 140 errors in care over the two years of record reviews. Most errors were related to
the repeated failure to recognize cirrhosis and to thereby screen for esophageal varices and
hepatocellular carcinoma, the ultimate cause of the patient’s death. There were 13 episodes we
identified when the patient was not timely referred to a consultant and four episodes when he
was not referred to a hospital for significant deterioration of his medical status. Several of the
denials of care by Wexford were grossly and flagrantly unacceptable. We also note that the
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physician initiated palliative sedation in a demented patient without fully informed consent of
the patient or his family. This had the appearance of hastening death, which may or may not
have been the desire of the patient. This practice needs to be evaluated by the IDOC with
respect to its ethical and legal implications.

Patient #29 Taylorville
This was a 66-year-old man with known diabetes and asthma. He was followed in hypertension,
diabetes, and asthma chronic clinics. We asked for two years of the patient’s record but
appeared to receive only one year of record. Nevertheless, the patient was only seen three
times for asthma, hypertension, and diabetes. Based on laboratory data, the patient also had
diabetic nephropathy and hyperlipidemia. Though these were not documented or followed as
problems, the patient did receive treatment, though inadequate, for the hyperlipidemia and
was provided an ACE inhibitor.
Based on the January 2014 MAR, the patient was treated with 10 mg simvastatin at least from
January 2014 until 3/7/15, when the dose was changed to 20 mg simvastatin. In 2014, the
patient had a 10-year risk of heart disease or stroke of 46% (66 years old, diabetic, HTN,
smoker, African American) and on 3/4/15 the patient had a 10-year risk of heart disease or
stroke of 54%. Yet prior to 2015, the patient was on only 10 mg of simvastatin and after 2015
only 20 mg of simvastatin. His cardiovascular risk called for a high intensity statin, but the
patient was only prescribed a low intensity statin. He was not even on a moderate intensity
statin. This placed the patient at risk for heart disease.
Persons with diabetes and nephropathy, which this patient had, should have their blood
pressure controlled to 130/80. This was not done. Though the patient did not have significantly
elevated blood pressure, it was not controlled to 130/80 and medication was not adjusted
when it was above that goal. This placed the patient at risk for cardiovascular disease and for
further damage to his kidney function.
The patient also had diabetes. The diabetes was very poorly controlled. The HbA1C was 10.4 on
3/21/14 and remained at 10 or above, until it was 9.4 on 7/22/15. The HbA1C declined to 8.4
on 11/25/15, but even this was not good control. During this time, doctors made only minimal
changes to improve blood glucose control and the lack of control placed the patient at risk of
cardiovascular disease.
Thus, the patient had multiple risk factors for coronary artery disease (age, ex-smoker, high
blood lipids, diabetes, and hypertension). His controllable risk factors were not managed well
by prison physicians, thus placing the patient at increased risk for cardiovascular mortality.
The patient had asthma. However, the patient did not have evidence of spirometry or
pulmonary function tests, which are recommended on all patients with asthma. The patient had
several episodes of shortness of breath which were atypical of asthma. Since patients with

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diabetes can have asymptomatic or atypical presentations for angina, the shortness of breath
should have been considered as a possible angina equivalent. On 1/15/15, a doctor saw the
patient in asthma clinic and documented that the patient described shortness of breath. The
doctor wrote, “difficult to judge SOB [shortness of breath] etio [etiology] –likely multifactorial,
obesity? Sleep apnea?” Indeed, other causes should have been sought. The doctor’s
acknowledgement that the etiology of the shortness of breath was uncertain required
additional diagnostic testing. A stress echocardiogram and pulmonary function test or some
equivalents should have been considered. At a minimum, the patient should have had
pulmonary function testing at this point but did not. Angina should have been considered
especially in light of his diabetes and multiple cardiovascular risk factors but was not.
On 4/21/15, a doctor evaluated the patient for an episode of shortness of breath with exertion.
He had no chest pain. An EKG was done, but the tracing was of very poor quality and should
have been repeated. It showed non-specific STT wave changes, which can be consistent with
angina. However, the quality of the tracing was poor. The patient was not treated for angina;
nor was diagnostic testing done for this condition, even though the patient’s symptoms were
consistent with angina and even though the patient had multiple risk factors. At a minimum,
pulmonary function testing and a stress echocardiogram or equivalent tests should have been
done.
On 7/13/15, the patient again developed shortness of breath. The doctor wrote, “deteriorating
SOB [shortness of breath] but not so sure is asthma contributory.” The doctor ordered a chest
x-ray, which showed an enlarged heart. But the doctor did not order diagnostic testing
(echocardiogram) to determine if the patient had heart failure. Instead, the doctor added Lasix
presumably to treat for heart failure without determining if this was the patient’s diagnosis. An
echocardiogram should have been done.
The patient continued to have shortness of breath and dyspnea on exertion. On 1/28/16, the
patient developed chest pain at 4:30 a.m., with an order from a physician to see the patient
routinely in physician clinic during working hours. Someone with chest pain should be
immediately evaluated, not as a routine. At 9:00 a.m., a physician saw the patient. The blood
pressure was 169/94 and the pulse 100. An EKG was done. The doctor documented that there
were no acute changes. The EKG in the medical record for this date was a very poor tracing and
should have been repeated. One segment appeared to show ST segment elevation in V1-2 but
only for one portion. This test should have been repeated, but the existing tracing suggested
possible acute coronary syndrome, enough that with the symptoms the patient should have
been referred for diagnostic evaluation (e.g. stress testing). The doctor told the patient that he
would need a treadmill test when he was discharged. This was indifferent care. If the patient
needed evaluation of coronary artery disease, it should have been promptly done, as the
patient was at very high risk and EKGs seem to suggest this possibility.
Five weeks later on 3/6/16, the patient experienced acute shortness of breath at about 3:00
a.m. The oxygen saturation was 85% and decreased to the 60s. The nurse called an ambulance.
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About 40 minutes after the episode started the ambulance arrived but the patient experienced
cardiac arrest while transferring to the ambulance. The patient died at the hospital.
The coroner found that the patient died from acute coronary atherosclerosis with a right
coronary artery plague that showed rupture and hemorrhage consistent with acute coronary
syndrome. The patient also had hypertensive cardiovascular disease and kidney damage.
Pulmonary edema was noted.
This patient’s death was possibly preventable. He had very high risk for coronary artery
disease, yet his modifiable risks were not properly treated. His blood pressure was undertreated; his diabetes was never under control and poorly managed; and he was treated with
only a low intensity statin when he required a high intensity statin.
In addition, the patient had multiple possible atypical presentations of angina that were
unrecognized. During one episode of chest pain, the doctor ordered a routine next day visit
instead of sending the patient to an emergency room. At the subsequent day evaluation, the
EKG was an inadequate tracing but was nevertheless suspicious for acute coronary syndrome.
The doctor recommended that the patient get a stress test on discharge from prison, but he
took no immediate action to determine if the patient had angina and did not start anti-anginal
medication. This was indifferent to the patient’s serious medical need. If angina was suspected
enough to recommend treadmill testing on discharge from prison, the doctor should have
taken timely action to evaluate for cardiac ischemia and treated the patient presumptively for
angina. If the patient was treated appropriately for his cardiovascular risk factors and had
appropriate diagnostic evaluation of his angina, his death might have been prevented or
significantly delayed.

Patient #30 Hill
This 43-year-old patient had an incomplete problem list. The problem list documented seizure
disorder with a VP shunt,20 deep vein thrombosis (DVT), and cerebrovascular accident, although
there was no clear evidence for a cerebrovascular accident on subsequent notes. The patient
was being treated for hypothyroidism, which was not on the problem list. The history of his
problems could only be gleaned by piecing together strands from various notes, including
hospital discharge summaries. The patient apparently had a serious brain injury in 1993
requiring a ventriculo-peritoneal (VP) shunt and subsequently developed seizures from the
injury. Although the patient was described as having hemiparesis on an annual examination in
2012, there was no documented thorough neurological examination in the record that I could
find that confirmed this condition. The history of the DVT was never clearly documented, even
20 Normally, cerebrospinal fluid circulates in the ventricles of the brain. Due to injury or congenital abnormalities, there may be
defects which cause the cerebrospinal fluid to accumulate, causing excess pressure on the brain. In order to resolve this, a
drainage system is created to drain cerebrospinal fluid from the brain to the peritoneal cavity. This ventriculo-peritoneal (VP)
shunt is subject to blockage and when a person has a VP shunt, any alteration of mental status should prompt evaluation of the
shunt by brain imaging to ensure that excess fluid is not accumulating in the brain.

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on chronic illness notes. It was not clear when the DVTs started. The patient appeared to be on
life-long anticoagulation, but it was not clear why. Notably, the patient had an inferior vena
cava (IVC) filter for his DVT. Typically, patients on an IVC filter are not also anticoagulated.
When anticoagulated, the reason why should be clear. One can only speculate as to the reason
for the IVC filter and anticoagulation. Persons with severe seizure disorder are prone to injury.
In particular, a fall to the head during a seizure while on Coumadin can be life threatening.
While this may be why he had an IVC filter, it is not clear why he was still on Coumadin. Also,
the patient was on aspirin for an unknown reason. There was no documented reason to be on
aspirin, Coumadin, and have an IVC filter. The rationale for these prescriptions was not evident
in the medical record or in chronic clinic notes. Keeping someone on Coumadin and aspirin
together without indication places this type of patient at life-threatening risk. This evidences
incompetence on the part of the surgeon caring for the patient at Menard and the radiologist
caring for the patient at Hill.
The patient was seen infrequently for his chronic illness when at Menard. When seen, there
was often no history and few meaningful physical examinations. The status and rationale for
the continued anticoagulation was not made clear. The patient remained on aspirin and
Coumadin with an IVC filter throughout 2015 without explanation. Also, the patient had
breakthrough seizures despite being on three antiepileptic drugs. This patient was a very
complex patient because of his prior brain injury and VP shunt; and because he had repeated
breakthrough seizures on three medications, he should have been managed by a neurologist,
but there is no evidence of neurology consultation.
The patient transferred from Menard to Hill on 12/17/15. Before the patient transferred he was
living in population and appeared to be able to care for himself. The day of arrival at Hill, the
patient had multiple seizures and was evaluated only by a nurse. A doctor gave a phone order
for Ativan “for continuous seizure activity” and to “send out if unresponsive to therapy and
continuous seizures.” The patient apparently continued to have seizures and was sent to a local
hospital, intubated, and sent to a regional hospital where an electroencephalogram was
performed while in the ICU. The patient demonstrated presumed seizure activity without any
waveform on the EEG indicating epileptiform activity. The patient was discharged with
diagnoses of seizures and pseudoseizures.21 The medications were not changed.
When the patient returned to Hill Correctional Center, the patient was admitted to the
infirmary. Apparently, the patient was discharged from the hospital with a subclavian central
venous line, but this was never noticed by providers at Hill. Nurses did not bring this to the
attention of providers, apparently thinking it was necessary and began using the port to draw
blood from. This unnecessary intravenous line placed the patient at risk of infection and
moreover speaks to a significant lack of examination of the patient. How could a central venous
line be unnoticed for three weeks?
Pseudoseizures are episodes that resemble seizures but are psychological in origin as they have no origin in abnormal brain
activity.
21

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The patient was admitted to the infirmary after the hospitalization for ataxia22 and frequent
seizures. Nurses documented that the patient had ataxic gait. An initial NP infirmary admission
note documented that the patient had ataxia and unequal pupils. Unequal pupils are a serious
sign of central nervous system disorder and needs to be promptly evaluated. The patient had a
CT scan at the local hospital by report before transfer to the reference hospital. Nevertheless,
unequal pupils and ataxia in the context of a VP shunt requires immediate imaging studies with
CT or MRI. This was not done.
Over the course of the next two and a half months the patient continued to have unequal
pupils, had progressively deteriorating mental status, and became progressively unable to care
for himself. The patient could not walk without support. Instead of sending the patient to a
hospital for an evaluation of why he couldn’t walk, the NP ordered that his mattress be placed
on the floor. Over time the patient was unable to communicate effectively, did not consistently
respond to questions or commands, became incontinent of urine and feces, did not consistently
eat food or drink, and was unable to care for himself. Despite a dramatic deterioration of
neurological status in the context of a VP shunt, the patient never had a thorough neurological
examination or had an imaging study (CT scan or MRI) of his brain. The deteriorating condition
of the patient combined with the lack of physical examination or care by providers for the
patient was indifferent, and grossly and flagrantly unacceptable care.
Over time the patient developed bruising, first noted on his elbows but then on his back, thighs,
legs, and elbows. Despite being on Coumadin and aspirin and having bruising, the provider did
not order an INR to assess whether he had supratherapeutic levels of anticoagulants.
Supratherapeutic levels of anticoagulation would result in bleeding or bruising. This is a
dangerous sign and calls for immediate action to prevent life-threatening harm. The doctor did
not assess why the patient was on aspirin, as he had no clinical indication for this drug. Keeping
the patient on both drugs and failure to assess the INR was a life-threatening danger to the
patient and grossly and flagrantly unacceptable medical care. Eventually the patient began
passing frank blood from his urine and stool. The nurse told the doctor, who only ordered
ciprofloxacin for a presumed urinary tract infection without evaluating the INR to assess
anticoagulation status. This was grossly and flagrantly incompetent care.
During this two month period the patient had a significant deterioration in his mental status
and had evidence of bleeding. Despite unequal pupils and ataxia, deterioration of mental
status, and bleeding while on anticoagulants, the doctor never performed a thorough history or
a thorough neurological examination, including examination of his pupils. The doctor never
ordered an INR.
Eventually, the patient became unresponsive and was sent to a hospital. The patient had an INR
of 10, which is a life-threatening value. The patient also had a major intracranial bleed as a
Ataxia is a non-voluntary lack of coordination of movement that results in gait abnormalities. It is often a sign of central
nervous system disorder.
22

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result of the excessive anticoagulation that shifted the brain and caused herniation of the brain,
which caused the patient’s death. The death was attributed to supratherapeutic anticoagulant
levels.
This patient’s death was preventable. Care for this patient was grossly and flagrantly
unacceptable. The death summary was performed by the doctor caring for the patient and no
problems were identified. This doctor is a nuclear radiologist and clearly does not have
fundamental medical knowledge sufficient to practice general primary care medicine, and
should not be allowed to do so. This is a doctor identified on the First Court Expert report as
having performed poorly. Yet he continues to practice. Notably, the hospital notes document
questioning why the patient was on anticoagulation. The fact that the patient was at Hill for
almost three months and providers failed to identify that the patient had a central venous
intravenous line was remarkable. Apparently, this device was inadvertently left in the patient
when discharged from the hospital in December but no one at Hill even asked why it was
necessary. Also, no one at Menard or Hill apparently knew that the patient had an IVC filter.
The medical care was indifferent, and grossly and flagrantly unacceptable.
We noted 110 errors in the care of this patient. The most frequent error was the repeated error
of failing to identify the medical indication for the use of both aspirin and Coumadin. This was
particularly egregious because the patient had an IVC filter, which makes both Coumadin and
aspirin unnecessary. On 16 occasions, the patient had serious, even life-threatening
presentation, yet nurses failed to consult a physician. Physician history and physical
examination were frequently inadequate and, particularly in the latter stages of the patient’s
life, failed to further investigate obvious conditions such as bruising and altered mental status
that would have been obvious to a layman.

Patient #31 Illinois River
This patient had a history of diabetes, hypertension, and substance use. There were no progress
notes in the medical record from 5/27/15 until the patient was diagnosed with squamous cell
cancer of the tongue on 9/20/16. This record was incomplete. It was not clear if the patient was
not evaluated for a year and a half or whether the record was missing. It appeared that the
patient may have been in a transition center, but it was unclear. The initial diagnosis in
September of 2016 was squamous cell cancer of the tongue with multiple enlarged metastatic
lymph nodes in the neck, and locally invasive cancer. The cancer was stage IV on diagnosis. The
patient was admitted to the infirmary after the cancer was diagnosed and died in hospice on
12/2/16.
Based on the record, it was difficult to determine if the death was preventable or not
preventable, as there was a significant part of the record missing. If the patient was at a
transition center and had adequate care and access, then the death would be not preventable.
But this is based on speculation. We noted only two errors, both related to lack of medical
records.

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Patient #32 Pinckneyville
This patient was admitted to NRC on 12/6/16. The patient had hypertension, heart failure,
COPD, diabetes, and idiopathic thrombocytopenic purpura (ITP).23 The patient was on danazol
for his ITP. The patient had his spleen removed due to the ITP. The patient’s initial laboratory
results show that the patient had chronic kidney disease (creatinine 1.87) and low albumin,
indicating possible poor nutrition. The patient was incarcerated approximately five months
before he died. The diabetes was poorly controlled during the entire approximate five months
of incarceration.
The patient’s record of treatment of his ITP was not identified at NRC. Old records were not
obtained. His prior treating oncologist was not contacted. It was not clear what his therapeutic
plan was. The patient was on danazol for his ITP on transfer from a local jail. This drug has a
black box warning with respect to causing thromboembolism, some of which can be fatal, and
which ultimately apparently caused this patient’s death. This drug also is contraindicated in
patients with markedly impaired renal function and is noted to worsen diabetic control. This
patient had chronic kidney disease. None of these potential problems were monitored by IDOC
physicians.
The patient transferred to Pinckneyville from NRC on 1/4/17 without having had his therapeutic
plan verified. Doctors at Pinckneyville were unaware of how to manage his ITP. ITP causes
destructions of platelets, a blood element that is involved in clotting. His initial platelets were
60,000. Normal platelets are 150,000 to 450,000. The goal in chronic ITP is to keep platelets
above 20,000. When the patient arrived at Pinckneyville he was not on danazol, an off label24
medication used for ITP that he had been taking. On 1/9/17, the patient placed a health
request, complaining that he was not receiving danazol and had not seen a doctor yet for his
ITP. He was upset that his medication was discontinued without having spoken to a doctor
about this change.
A doctor saw the patient on 1/17/17, and restarted the danazol without noting a review of
contraindications which included markedly impaired renal function. The renal function was not
monitored, and doctors did not acknowledge the potential for worsening diabetes control from
this medication. While the patient’s renal function was abnormal, it was not clear if renal
function had deteriorated to a level that made the medication dangerous. Yet the doctor did
not initially refer the patient to someone expert in managing ITP, like a hematologist.
In early February, a doctor started large doses of prednisone for the ITP. A major problem with
this patient is that his prior treatment program was never identified. Typically, initial treatment
of ITP is different from treatment of chronic ITP. Initial treatment included steroids and
intravenous immune globulin (IVIG). Treatment of chronic disease utilizes splenectomy, which
ITP is a disease in which platelets are destroyed, often from unknown reasons. Platelets are necessary to properly clot blood
and lack of platelets can result in life-threatening bleeding. This disease is typically managed by a hematologist.
24 Off label medications are medications not approved by the FDA for the stated purpose. While these medications are often
useful, the FDA has not identified sufficient scientific evidence of their value.
23

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this patient already had, and other medications, sometimes in combination with steroids. After
the danazol was started, a creatinine was 2.05, a deterioration, and concerning with respect to
the potential for complications.
The patient was sent to a local hospital for an injection of IVIG, but at the hospital the patient
received no therapy and left with a recommendation to see a hematologist in his office. At
some point around this time, a doctor wrote an undated message to apparently the Wexford
Regional Medical Director asking, “What should we do?” There was no plan after return to the
prison to send the patient to a hematologist.
About a month later, the patient told a nurse “I’m going to die.” The nurse had brought the
patient to the health care unit because the platelet count was 6,000, a critical value that placed
the patient at risk of life-threatening bleeding. A doctor sent the patient to a hospital. The
patient was discharged from the emergency room on high dose steroids again with a
recommendation to follow up with a hematologist.
After this second hospitalization on 3/23/17, the Pinckneyville physician referred the patient to
a hematologist. The patient was evaluated by the hematologist on 3/30/17, but the report was
not in the medical record and it was not clear what the hematologist findings were. Brief
comments by the hematologist on the referral form recommended prednisone 100 mg daily
with a return in two weeks. It was not clear if the hematologist knew that the patient was on
danazol because the consultant note was not present. When a doctor followed up after the
hematology consult, the doctor did not document what the hematologist’s findings were or
what the therapeutic plan was.
On 4/5/17, the white count was 23,200, which may have been a result of the use of high dose
prednisone, but could also be from infection. No one evaluated this abnormal test. On 4/6/17,
the patient developed abdominal pain, had not been eating, and had not been able to have a
bowel movement for two days. The patient was referred to a local hospital, but transferred to a
tertiary hospital because he had an ischemic bowel with perforation. Ischemic bowel is often
caused by thromboembolism, which is one of the complications of danazol. It is unclear
whether the hematologist knew that the patient was on danazol and felt it was necessary.
Because the patient was so malnourished and weakened he was not a surgical candidate and
the patient also declined having an external ostomy placed. As a result, the patient was sent
back to the facility with a recommendation for hospice.
The patient returned from the hospital on 4/14/17 and died on 4/19/17. He was scheduled to
see the hematologist on 4/18/17, but the ADA van was unavailable and therefore the
appointment was rescheduled.
In summary, coordination of this patient’s complex medical condition with consultants was
extremely poor. For several months, the patient was not referred. When the patient was
referred, the consultation report was not available, and it was not clear what the patient’s
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status was. Because consultant reports are unavailable, there is insufficient information to
assess preventability.
We identified 20 errors on this record. The most serious ones were never understanding the
therapeutic plan for the patient’s serious medical condition or whether the danazol was
indicated. A side effect of the danazol likely caused the patient’s death, but it was not clear
whether the hematologist intended the patient to continue this drug. There were six errors in
lack of timely referral to a hematologist for management of a life-threatening condition.

Patient #33 Robinson
This 58-year-old man was at the Robinson Correctional Center and had hypertension and high
blood lipids, which were both untreated for eight months of record review. These are both risk
factors for heart disease. On 3/16/16, he developed chest pain with atrial fibrillation. The blood
pressure was 200/118 and the pulse was 129. The electrocardiogram also showed marked ST
depression indicating acute coronary syndrome, a life-threatening event portending a heart
attack. The automated reading recommended, “immediate clinical assessment of this individual
is strongly advised.” He should have been hospitalized immediately for cardiac catheterization
and management of his atrial fibrillation. Instead, a nurse evaluated the patient and consulted a
doctor, who only ordered 23-hour observation on the infirmary and gave one-time only doses
of clonidine and propranolol. This was grossly and flagrantly unacceptable care and placed the
patient at risk of death and demonstrated a profound deficit of primary care knowledge.
The following day, a doctor ordered aspirin and statin medication, but failed to refer to a
cardiologist and failed to refer for catheterization despite the prior day’s EKG result, which was
signed as reviewed. Aside from aspirin, anticoagulation due to atrial fibrillation was not
considered. These actions placed the patient at risk of death.
The doctor continued to fail to appropriately manage this patient’s life-threatening condition.
The doctor continued the patient on high doses of non-steroidal medication despite a box
warning25 regarding risk for cardiovascular thrombotic events including myocardial infarction
and stroke with use of this drug. The doctor eventually began treatment of the patient’s high
blood pressure with Norvasc, a drug that carries a warning of increased angina or myocardial
infarction in persons with obstructive coronary disease, which the patient appeared to have.
Eventually, the patient’s family called the HCUA because the patient was having chest pain
while walking to the dining hall and could not walk without chest pain. The HCUA wrote that
the patient was “not in any distress but complains he is unable to walk to dietary.” The HCUA
referred routinely to a doctor for an appointment five days later. This was indifferent as the
patient’s need was urgent not routine.

A box warning is the strictest warning put in the label of prescription medication by the Food and Drug Administration when
there is reasonable evidence of an association of a serious hazard with the drug.
25

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The patient again developed typical chest pain which was helped by nitroglycerin. An
electrocardiogram showed moderate ST depression consistent with ischemia. This is consistent
with acute coronary syndrome and the patient should have been transferred immediately to a
hospital. Instead, a nurse saw the patient and consulted a doctor, who ordered 23-hour
observation but no further treatment. At this point, aside from nitroglycerin, the patient was
not on antianginal medication. This was grossly and flagrantly unacceptable and placed the
patient at risk of death. This was the second episode of acute coronary syndrome which was
inappropriately managed.
The patient was seen after this second electrocardiogram verifying acute coronary syndrome
and a doctor referred the patient for an elective stress test. Wexford would not approve the
stress test and instead recommended as an alternative plan to refer the patient to a
cardiologist. This was done on an elective basis though the patient had an urgent need. The
cardiologist saw the patient a month after the referral and recommended a cardiac
catheterization “in the near future.”
The catheterization was ordered, but a week later the patient again developed chest pain. The
electrocardiogram showed atrial fibrillation. Our reading shows ST depression is several leads.
Chest pain with recurrent atrial fibrillation and acute coronary syndrome should have resulted
in immediate hospitalization for evaluation, catheterization, and consideration for
anticoagulation. Instead, a nurse consulted a doctor, who ordered 23-hour observation with a
next day electrocardiogram. Six hours later the patient was found unresponsive.
Cardiopulmonary resuscitation was started, and the patient transferred to a hospital, where he
died.
This patient had repeated episodes of acute coronary syndrome and two episodes of atrial
fibrillation, each of which should have resulted in hospitalization, which did not occur. The
angina was inappropriately treated and was never under control. Cardiac catheterization was
not done over three months despite the patient having three episodes of apparent acute
coronary syndrome. The atrial fibrillation was never appropriately assessed, and the patient
was not anticoagulated despite having atrial fibrillation and acute coronary syndrome on three
occasions. The patient’s cause of death was listed as coronary atherosclerosis and stroke, both
of which were preventable with timely and appropriate treatment. Therefore, this death was
preventable.
The death summary noted no problems and noted that earlier intervention was not possible.
We strongly disagree.
We noted 46 errors in the care of this patient from the time he was transferred to Robinson on
8/21/15 until his death on 6/10/16. These errors included not taking adequate history, not
performing a needed physical examination, and not developing an appropriate treatment plan.
Additional errors included not treating elevated blood pressure from August of 2015 until
March of 2016 despite continuously elevated blood pressure. Despite being 58 years old, this
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patient’s 10-year cardiovascular risk was apparently not calculated. The patient had blood in his
stool and was 58 years old but was not referred for colorectal screening. He had blood in his
stool but was kept on non-steroidal medication without investigation. The patient was also
prescribed medication that was likely to harm him (non-steroidal anti-inflammatory drugs and
Norvasc) without recognition of the potential for harm. The most serious errors, however, were
the failure to immediately hospitalize the patient after repeated episodes of acute coronary
syndrome and atrial fibrillation, and lack of awareness and acknowledgement of the
seriousness of these conditions.

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IDOC Mortality Error Classification
Error
type

Description of Error
Apparently did not obtain pertinent history and/or findings from examination.
Apparently did not make appropriate diagnoses and/or assessments.

1

Number
having
that error

2

276
249

Apparently did not establish and/or develop an appropriate treatment plan for
a defined problem or diagnosis which prompted this episode of care (excludes
laboratory and/or imaging and procedures and consultations).

3

228

Apparently did not carry out an established plan in a competent and/or timely
fashion (e.g. omissions, errors, of technique, unsafe environment).

4

44

Apparently did not appropriately assess or act on changes in clinical/other
results.

5

7

Apparently did not provide appropriate personnel and/or resources, including
getting hospital reports.

6

87

Apparently did not refer or timely schedule for a procedure that was indicated
(other than lab or imaging).

7

95

Apparently did not obtain timely appropriate laboratory tests and/or imaging
results.

8

119

Apparently did not develop and initiate appropriate discharge from infirmary
or failed to follow up after infirmary or hospital discharge.

9

4

Apparently did not follow up appropriately after consultation or health care
visit.

10

45

Apparently did not provide appropriate personnel and/or resources, including
getting hospital reports.
Apparently did not order timely, appropriate specialty consultation.
Apparently did not follow up on patient's noncompliance.

11
12
13

138
81
4

Apparently failed to timely refer to a higher level of care including
hospitalization, skilled nursing unit, or infirmary.
Apparently failed to follow up on significant findings.

14
15

93
28

Apparently, nurse failed to consult/refer timely to a higher level medical staff
(provider).

16

143

Apparently did not develop and initiate appropriate discharge from infirmary
or failed to follow up after infirmary or hospital discharge.
Failed to see a patient with potential serious illness.

17
18

79
37
1757

Total

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Patient #1

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1/2/2015 Cholesterol 194; TG 60; HDL 55; LDL 127.
1/5/2015 An annual history evaluation at WICC for this 56 year old. The
weight was 184. This nurse evaluation was not performed on
the same day as the physical examination.
1/6/2015 A nurse saw the patient because he passed out according to
his cell mate. The blood pressure was 162/93. The weight
was listed as 166 pounds. The nurse noted that the patient
had an appointment the next day so didn't refer the patient or
consult a doctor. An EKG was not done.

16

1/7/2015 The cholesterol was 194; TG 60; HDL 55; LDL 127.

1

Syncope is a critical sign and requires immediate
evaluation. The nurse needed to consult a provider
promptly.

Patient #1

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1/7/2015 An annual health examination showed BP 149/98, weight was
listed as 168, which is 16 pounds different from two days
before. The NP documented that the patient refused a digital
rectal examination for purposes of prostate screening but did
not offer colorectal screening (fecal occult blood tests or
colonoscopy). On the physical examination form, the rectal
examination is listed as a test of the prostate in males over 40
years old. Lack of colorectal screening is inconsistent with
contemporary standards of care. The refusal of the digital
rectal examination states he refuses performance of a
"prostate - digital rectal exam." There was no discussion of
colorectal cancer.

7, 15

1/12/2015 A doctor saw the patient and noted that the patient reported
a right testicle mass which was not appreciated on an NP
examination on 1/7/15. The doctor examined the patient and
documented an epidydimal cyst. The weight was 164.
2/9/2015 Cholesterol 201; HDL 56; LDL 135.
2/19/2015 The cholesterol was 201; TG 48; HDL 56; LDL 135.

2

The nurse noted the day before that the patient would
be seen for "passing out" but the NP did not address
this. Two days before a nurse documented the weight
as 184 pounds. At this visit the weight was recorded as
168 pounds, a 16 pound difference. The differences in
weight were so significant as to make weights
unreliable. The patient was 56 and should have had
colorectal cancer screening. The patient was offered
only a digital rectal examination. This examination was
offered for prostate screening. Current
recommendations of the American Cancer Society state
that digital rectal examination is insufficient as a standalone test for colorectal cancer. This type of cancer
screening will miss 90% of colon abnormalities. The
patient should have been offered fecal occult blood
testing (not from a digital rectal examination or
colonoscopy). This lack of colorectal screening was
significant. Care failed to follow generally accepted
guidelines or usual practice.

Patient #1

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 3 of 431 PageID #:12201

3/9/2015 The patient was evaluated for HTN clinic. The BP was 148/93.
Weight was listed as 170 pounds. No change in BP meds was
made; the doctor noted the patient missed his BP meds that
morning. The cholesterol was 201; HDL 56; LDL 135. The
patient was an ex-smoker. The patient had a 22% 10-year risk
of heart disease or stroke and should have been on a
moderate to high statin dose.
9/30/2015 A doctor saw the patient for HTN chronic care. The weight
was 164. Blood pressure was 124/73. Lipids were not
addressed.
2/11/2016 Lab showed normal metabolic panel except for albumin 3.3.
AST/ALT and alkaline phosphatase were normal. Cholesterol
was 161, TG 46, HDL 56, LDL 96.
3/1/2016 A doctor saw the patient in HTN chronic clinic. The weight was
164 pounds. The BP was 115/65. The doctor noted a
cholesterol of 161 and triglycerides of 46. The LDL was not
noted. The albumin was 3.3 which is low but the doctor did
not initiate any work up. The patient was on lisinopril, Zocor,
aspirin, Hytrin and another medication [illegible].

3

The statin dose probably should have been increased to
40 mg of Zocor. The BP meds should have been
increased. Care could reasonably have been expected
to be better.

6

The albumin was low yet the doctor took no action to
investigate. Care failed to follow generally accepted
guidelines.

1

Depending on which weight was used, based on the
history (1/5/15) and physical examination (1/7/15) the
patient had lost either 28 pounds or 10 pounds. In
either case the doctor was not monitoring the weight of
the patient. Presumably the purpose of taking weight is
to monitor it, but this wasn't done. Care could
reasonably have been expected to be better.

7/5/2016 BUN, creatinine and electrolytes were normal.
7/7/2016 This was to be the next physician visit after 3/1/16. The
patient weighed 158 pounds. The blood pressure was 119/77.
A rescheduled visit for 7/26/16 didn't take place.
9/2/2016 BUN, creatinine and electrolytes were normal.
9/13/2016 A doctor saw the patient for a hypertension clinic. The weight
was 156 pounds. The patient was 5 foot 5 inches tall. The
doctor checked the box that education was given regarding
weight loss. The blood pressure was 140/77. The patient was
on aspirin, lisinopril, Zocor, Hytrin and Proscar. No other
history was taken.

3

Patient #1

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 4 of 431 PageID #:12202

1/16/2017 The patient transferred from WICC to IRCC. Hypertension and
high blood cholesterol were listed as problems. The blood
pressure was 150/100 but not addressed. The weight was 152
pounds. On the 1/5/15 annual history the patient weighed
184 pounds. On a health request on 1/6/15, a nurse
documented that the patient weighed 166 pounds.

1,16

2/2/2017 The albumin was 3.1; AST, ALT, alkaline phosphatase and
bilirubin were normal.
2/10/2017 A doctor performed a general medicine clinic for high blood
lipids and prostatic hypertrophy. The weight was 155 pounds.
The doctor noted that the patient had nocturia twice a night
but took no other history related to the BPH or high blood
lipids. The cholesterol level was not documented. The doctor
ordered a fasting lipid panel. The doctor failed to address a
low albumin.

Nurses failed to address abnormal vital signs. On
transfer the nurse failed to appreciate a weight loss of
14 or 32 pounds depending on which weights from
January of 2015 were used. What is the purpose of
taking the weight? Care failed to follow generally
accepted guidelines, as intake screening should be a
summary screening of the patient's conditions including
weight, and the nurse should have referred abnormal
blood pressure to a physician.

1, 5, 6 The doctor failed to acknowledge an abnormal lab or
follow up. The doctor failed to acknowledge a 11 or 29
pound weight loss since the annual history and physical
examination from January 2015. Care failed to follow
generally accepted guidelines or usual practice.

3/14/2017 A NP saw the patient for an annual HTN clinic. The NP took no
history except to note "no complaints F/U altercation." The
weight was 155. Labs were not reviewed.

5

The NP failed to note weight loss. Care failed to follow
generally accepted guidelines.

3/26/2017 A nurse saw the patient for right sided flank and back pain that
was constant. The blood pressure was 152/94 and pulse was
119. The nurse assessed that there were no contusions or
swelling but there was pain to palpation. The nurse noted
"acute severe discomfort" and called a doctor who ordered
Toradol 60 mg IM and Ultram 150 mg BID for three days.

15

The patient had abnormal vital signs with back pain yet
there was no follow up with the primary care physician.
Care failed to follow generally accepted guidelines.

4/20/2017 The total protein was 5.7 (6-8); albumin 2.3 (3.4-5) and
alkaline phosphatase 167 (40-125). The hemoglobin was 6
(13.2-18).

4

Patient #1

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 5 of 431 PageID #:12203

4/21/2017 An LPN documented that the hemoglobin was 6 and the
patient had abdominal discomfort. The patient was
lightheaded and dizzy for the past month and had nausea and
vomiting for a month. The nurse referred to a doctor.
4/21/2017 A doctor saw the patient and noted weight loss, night sweats.
The doctor noted anemia, 19 pound weight loss over a month
and night sweats. The doctor ordered the patient transferred
to a hospital via state vehicle for evaluation.
4/21/2017 ER report from Graham Hospital from the 4/21/17
hospitalization showed hemoglobin of 7.5. The report
included a report of an EGD that showed extensive
inflammatory changes in the distal esophagus with some
ulceration suggestive of Barrett's esophagus. The stomach
was essentially normal. The biopsy reported 4/25/17 showed
mild reflux changes, chronic gastritis and helicobacter pylori.

This EGD should not have accounted for a hemoglobin
of 6.

4/22/2017 The patient returned from the hospital and was placed on the
infirmary.
4/22/2017 A doctor noted that the patient had a history of anemia and
received two units of blood The doctor took no other history.
The doctor failed to note the hospital diagnoses. The doctor
noted that the patient's hemoglobin was 6 in the ER but didn't
note what the current hemoglobin was. The doctor kept the
patient on aspirin, started iron, but ordered no laboratory
tests and no evaluation for a critical anemia. Despite the
patient just being diagnosed with a GI bleed and esophagitis,
the doctor kept the patient on aspirin and did not start a
proton pump inhibitor or H2 blocker medication.

1,3,17 The doctor failed to take a history of the current
hemoglobin and did not note the weight loss and
abdominal pain and failed to make an assessment of
what the patient might have. There was no plan for the
significant anemia and weight loss. The doctor
continued aspirin therapy in someone with recent GI
bleed, gastritis, and esophagitis. Care failed to follow
generally accepted guidelines.

5

Patient #1

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 6 of 431 PageID #:12204

4/24/2017 The patient told a nurse that he had constant pain below his
right rib with inspiration and when he laid on his right side.
4/25/2017 A nurse practitioner saw the patient, who weighed 138
pounds, which was somewhere between a 28 to 46 pound
weight loss over two years. The NP noted lower quadrant
abdominal pain and ordered a CBC and referred for
colonoscopy.
4/25/2017 A referral form from Illinois River documented that the patient
had a hemoglobin of 6 and a negative EGD in an ER and that
outpatient colonoscopy was recommended. This referral form
was not approved.
4/26/2017 The temperature was 100.6 at 4:00 am and 103.4 at 8:00 pm
on the graphic flow sheet.
4/26/2017 At 5:10 am a nurse documented that the patient had a fever
but did not document calling a doctor.
4/27/2017 The temperature was 103.6 at noon.
4/27/2017 At 8:30 am a nurse documented that the patient vomited and
had a temperature of 102.7 The nurse gave the patient
Tylenol but did not call a doctor.
4/27/2017 A nurse noted that the patient had abdominal pain but did not
refer to a doctor.
4/28/2017 The temperature was 101.4 at 4:00 pm
4/28/2017 At 4:00 pm a nurse noted that the patient had fever of 101.5
but only gave the patient Tylenol without consulting a
physician.
4/29/2017 The temperature was 100.4 at noon.
5/1/2017 The temperature was 102.4 at 4:00 pm.

6

16

The nurse should have consulted a physician.

16

The nurse should have consulted a physician.

16

The nurse should have consulted a physician.

16
16

16

The nurse should have consulted a physician.
The patient had weight loss, anemia, and fever and
should have been admitted to a hospital but the nurse
didn't even call a doctor.
The nurse should have consulted a physician.

16
16

The nurse should have consulted a physician.
The nurse should have consulted a physician.

16
16

The nurse should have consulted a physician.
The nurse should have consulted a physician.

Patient #1

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 7 of 431 PageID #:12205

5/1/2017 A nurse called the NP about whether the blood should be
drawn and received an order to draw the CBC in the morning.
The temperature was 102.4.

14

This patient should have had a stat CBC upon return
from the hospital and then a few days later to assess the
hemoglobin level. Because of the fever the patient
needed prompt evaluation for his anemia, weight loss,
abdominal pain and fever or should have been sent to a
hospital for evaluation. Care failed to follow generally
accepted guidelines or usual practice.

5/2/2017 The temperature was 101.4 at 4:00 am and 100 at noon.
5/2/2017 An NP saw the patient and noted that the patient had
abdominal pain, fever. Remarkably, the NP documented that
the patient had not been losing weight; the weight was not
documented but the patient had actually lost somewhere
between 28 to 46 pounds since January of 2015. The NP
ordered a stat CBC but should have referred to a hospital for
possible acute colitis or other condition causing weight loss,
fever, abdominal pain.

16
1, 14

The nurse should have consulted a physician.
The NP should have admitted the patient to a hospital
because of fever, weight loss, and abdominal pain. The
NP history was wrong that the patient did not have
weight loss. Fever, anemia, weight loss and abdominal
pain are indications for an immediate evaluation. Care
failed to follow generally accepted guidelines or usual
practice.

5/2/2017 A doctor noted that colonoscopy was approved in collegial
review. The doctor noted that a colonoscopy would be
scheduled after transfer to Danville. It wasn't clear why the
patient needed transfer to Danville for a colonoscopy.
Because the patient had fever, abdominal pain and weight
loss, a prompt colonoscopy and/or CT abdomen were
indicated. This may have required hospitalization.

12, 14 The delay in specialty care was significant and reflects
on the collegial review process. Care failed to follow
generally accepted guidelines.

5/2/2017 At 2:15 pm the patient was transferred to Danville. On arrival
at Danville the weight was 140 pounds or a 24 pound weight
loss over nine months and a 26 or 44 pound weight loss since
January 2015.
5/2/2017 Hemoglobin was 8.3 (13-16.9).

7

Patient #1

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 8 of 431 PageID #:12206

5/3/2017 An LPN noted that the patient came to the health care unit
inquiring about the decreased hemoglobin. The nurse talked
to a doctor who said that a CBC would be done on 5/5/17. The
doctor noted that unless the hemoglobin was less than 7 the
patient was to follow up next week.

5/3/2017 An approval for colonoscopy referral received on 5/2/17 from
Wexford UM.
5/10/2017 A nurse said that the patient would be rescheduled because
the labs were not yet done.
5/11/2017 The total protein was 5.8 (6-8); albumin 2.3 (3.4-5); alkaline
phosphatase 213 (40-125); AST 41 (10-40); hemoglobin 7.9.
5/17/2017 Last dated problem list: hypertension, high blood lipids and
prostatic hypertrophy.
5/17/2017 An NP saw the patient for semi-annual general medicine clinic.
The NP took a history of right leg swelling and pain in his
abdomen. The NP noted a hemoglobin of 6 on 4/20/17 with a
hemoglobin of 8.3 on 5/2/17. The NP noted that the inmate
weighed 150 pounds and was "very cyanotic" with right leg
swelling from the knee to the foot. The NP noted that
colonoscopy was approved. The only diagnosis was anemia.
The blood pressure was 121/79. The NP decreased the Zocor
and lisinopril without giving a reason. There were no
additional orders.
5/18/2017 A doctor wrote a brief note without seeing the patient stating
that a GI note from 4/22/17 documented that the patient had
chronic gastritis and possible Barrett's esophagus and started
triple therapy with follow up in 2-3 weeks with a repeat CBC
the next visit.

8

7

Danville did not understand the urgency of the patient's
problems. A nurse reviewing the patient on transfer
scheduled the patient for a routine PCP visit. The
physician ordered a routine CBC for a patient with
weight loss, fever and abdominal pain. Care failed to
follow generally accepted guidelines.

7

This was a delay in evaluating a serious medical
condition.
These were abnormal labs but were not addressed.
Care failed to follow generally accepted guidelines or
usual practice.

6, 8

Unilateral leg swelling is a significant finding. DVT
should have been excluded; this was potentially lifethreatening. Recent abnormal lab tests were not
acknowledged except for the anemia. Care was grossly
and flagrantly unacceptable.

4

The patient was over 50 with weight loss, fever, anemia,
and abdominal pain and needed an evaluation for this.
The doctor did not perform an adequate evaluation of
the patient and initiated a treatment plan without
evaluation of the patient. Care failed to follow
generally accepted guidelines or usual practice.

Patient #1

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 9 of 431 PageID #:12207

6/5/2017 Hemoglobin was 7.9.
6/14/2017 A doctor wrote that the patient's symptoms had improved
"tremendously" and that the patient was scheduled for
colonoscopy. The doctor did not note what the hemoglobin
was. The doctor noted that the colonoscopy prep was to be
started that day. The doctor diagnosed chronic gastritis.

1,2

6/15/2017 A colonoscopy report documented an infiltrative partially
obstructing large mass was in the ascending colon. The mass
was circumferential. Biopsies were taken. The endoscopist
recommended a CT scan, CEA, referral to a colorectal surgeon,
a recommendation to screen 1st degree relatives at age 40.
The consultant said to "watch for signs of bowel obstruction as
the mass was almost completely obstructing the lumen." The
consultant recommended a CT scan of the abdomen and
pelvis, tumor markers and referral to a colo-rectal surgeon
within two weeks.
6/15/2017 A pathology report documented invasive moderately
differentiated adenocarcinoma.
6/20/2017 A doctor noted that the colonoscopy results showed an
obstructing mass in the ascending colon. The doctor ordered
CBC, CEA, CMP, KUB, and follow up with colorectal surgery.
6/21/2017 A referral form on this date referred the patient to colorectal
surgery. This was checked as an urgent consult but was not
signed as approved.
6/22/2017 Wexford UM approved a colorectal surgery evaluation.

9

The doctor did not obtain an adequate history and did
not examine the patient. Previously abnormal labs
were not followed up. The weight loss, anemia, low
albumin, elevated alkaline phosphatase were
inconsistent with chronic gastritis. Care failed to follow
generally accepted guidelines.

Patient #1

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 10 of 431 PageID #:12208

7/5/2017 A doctor noted that the patient had swelling of the right lower 4, 8, 15
extremity and that oncology follow up was pending. The
patient had 2+ pitting edema of the right leg from mid-thigh to
"distal extremity." The doctor ordered a D-dimer, and other
tests and ordered ted hose and gave the patient a cane. The
blood pressure was elevated at 134/99 and pulse was 113.
The doctor still did not document the hemoglobin. The doctor
increased HCTZ. To treat suspect DVT with HCTZ was below
standard of care. The doctor ordered a "PRN" follow up.

7/5/2017 The nurse was unable to draw all labs and rescheduled the Ddimer test. The doctor was not notified.
7/5/2017 The BUN was 23 (6-20); albumin 2.2 (3.4-5); alkaline
phosphatase 301 (40-125); AST 82 (10-40); WBC 14.6 (3.9-12);
hemoglobin 9.1.
7/10/2017 An LPN documented that approval was needed for a D-dimer
test and did not draw it. The infirmary nurse was notified and
was asked to check with the infirmary doctor.

7/10/2017 Serum iron was <10 (50-180); transferrin 100 (200-400); iron
binding capacity 140 (250-450); INR 1.4 (0.9-1.2).
7/12/2017 A colorectal surgeon saw the patient. The patient told the
surgeon that he lost 50 pounds in the past 3-4 months. The
surgeon palpated a left upper quadrant mass suspected to be
his liver with a fluid wave consistent with ascites. This note
was incomplete and did not include the assessment or plan.

10

The doctor apparently thought of pulmonary embolism
or DVT because he ordered a D-dimer. If the doctor
believed the patient might have a DVT, immediate
transfer to a hospital for Doppler was indicated. The
doctor did not address the possible etiology of unilateral
leg swelling with an abdominal mass-known to be likely
cancer. To order a diuretic for unilateral leg swelling
without excluding DVT is incompetent. The doctor
ordered "PRN" follow up for a potentially lifethreatening problem. Care was grossly and flagrantly
unacceptable.

8

This was a significant test and the delay should have
resulted in a call to a physician.

8

A D-dimer test is a test for a potential emergency
condition (DVT or PE). This test had been delayed five
days due to bureaucratic obstructions. The patient
should have been admitted to a hospital for a Doppler
but even the D-dimer test was significantly delayed.

14

This visit was two weeks late. Care could reasonably
have been expected to be better.

Patient #1

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 11 of 431 PageID #:12209

7/14/2017 A CT scan showed small left pleural effusion; large metastasis
in the liver of 16 by 17 cm. There was a large mass involving
the ascending colon. There was a large amount of ascites
exerting a mass effect and suspicious for pseudomyoma
peritonei. There was a large metastasis in the anterior
abdomen with peritoneal nodules and a lymph node in the
area of the pancreas. The hemoglobin was 7.8. The CEA was
2185 (0-3)
8/3/2017 The patient was admitted to the infirmary for "severe LE
edema" to both legs over the past two weeks. The doctor
noted 3+ edema in both legs and in the penis and scrotum and
started Lasix and ordered CBC, CMP and elevation of the leg
and a Foley catheter. The patient was now unable to walk.
The provider failed to include in the history that the patient
had weight loss, and recent fevers. The doctor noted that the
patient had recently diagnosed colon cancer but did not
apparently associate the colon cancer with the edema. The
doctor provided only symptomatic treatment of the edema
without making a diagnosis. It did not appear that the doctor
reviewed the hospital record.

8/3/2017 A nurse noted that the Foley catheter could not be placed due
to penile edema. The doctor was also unable to insert the
Foley catheter but was able to insert a straight catheter.
Ultimately, doctor and nurse gave up and gave the patient a
urinal.
8/4/2017 The patient vomited approximately 100 CC of yellow bilious
vomit with bloody streaks. The nurse called a doctor who
advised to send the patient to a hospital.
8/4/2017 A chest and abdominal x-ray showed basilar atelectasis and
gas overlying the rectum.

11

1, 2,3

Starting a Foley catheter without indication can lead to
infection. It was not made clear that the penile edema
was causing difficulty urinating. As well, the doctor
failed to associate the colon cancer recently identified
and the edema. The doctor was treating the patient
without having a diagnosis for a potentially lifethreatening problem. This failure placed the patient at
risk of harm. Care was grossly and flagrantly
unacceptable.

Patient #1

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 12 of 431 PageID #:12210

8/7/2017 A therapeutic paracentesis was performed at Carle Clinic. 6
liters of serosanguinous fluid was drained. A PET scan showed
metastatic involvement of right lower abdomen involvement
with adjacent lymph nodes, liver involvement with central
necrosis.
8/7/2017 A hospital note documented that the patient was admitted for
severe ascites, nausea, vomiting and abdominal pain with
malnutrition and hypoalbuminemia. The assessment was
noncurable metastatic colon cancer. The colorectal surgeon
was consulted as was an oncologist. Palliative surgery was
suggested but because of malnutrition, he was a surgical risk.
He had ascites from the low albumin from malnutrition.

8/17/2017 There were no further notes we could locate. But the patient
was listed as dying on 8/17/17 of metastatic colon cancer.
There was no death summary or autopsy.

12

Patient #2

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 13 of 431 PageID #:12211

8/26/2015 A letter to a nurse at the Stephenson County Jail in Freeport
Illinois from a Pediatric Cardiologist from UI @ Peoria in
Rockford IL stating that the patient had repair of Tetralogy of
Fallot during childhood and had residual defects. A case
conference recommended that he obtain a magnetic
resonance angiography of the heart and pulmonary vessels at
St. Francis Medical Center in Peoria and a Holter monitor. If
the studies confirm their impression they would recommend
replacement of his pulmonic valve to resolve his severe
pulmonary regurgitation. Next to the inmate's name was
written his IDOC number indicating that the IDOC probably
had this letter. On the bottom of the letter dated 9/18/15 is a
brief note stating "Reviewed PLS schedule tests as
recommended." The patient obtained the Holter monitor, but
the scheduled MRI was not done as ordered.

This patient had a serious congenital heart disease and
his cardiologist was planning to replace his pulmonic
valve when the patient became incarcerated.

10/13/2015 The patient had a Holter monitor for a preoperative evaluation
at the Children's Hospital. The patient had right bundle branch
block. 1509 supraventricular ectopic beats. There were 1.4%
premature atrial contractions.
11/5/2015 Intake labs included bilirubin 1.5; ALT 9; AST 25; Alk phos 65;
hepatitis C negative; syphilis non-reactive; INR 2.1; an EKG
showed NSR with possible left atrial enlargement, right bundle
branch block, possible inferior infarct and T wave abnormalityconsider lateral ischemia.
11/5/2015 The patient arrived at NRC. A nurse took a history of past
cardiac surgery as a child and "pending surgery for leak in
heart;" blood clots in the past and currently on coumadin. The
patient told the nurse that he was on Plavix since July. The
patient was 6 foot tall and weighed 135 pounds.

13

Pulmonic regurgitation associated with Tetralogy of
Fallot is a diastolic murmur.

Patient #2

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 14 of 431 PageID #:12212

11/5/2015 A PA saw the patient in NRC for his reception physical
1, 2, 12 The patient was in the midst of a valve replacement due
examination. The PA noted that the patient had a prior stroke
to complications of his pulmonic regurgitation and the
in May of 2015 and was on Plavix but switched to Coumadin
PA failed to take an adequate history to uncover this.
and that he had cardiac surgery as a child. The PA did not take
a more in depth history but did note that the cardiac surgery
was in the 1980s at Swedish American Hospital in Rockford
and the CVA was treated at Freeport Memorial Hospital in
Freeport IL. The PA documented a systolic murmur II-III/VI.
The assessment was history of childhood cardiac surgery, prior
stroke, and rule out aortic stenosis. The PA started Coumadin
5 mg and ordered a physician follow up. The PA discussed the
case with a doctor who recommended the doctor follow up
urgently. The PA did not request old records.

11/18/2015 The patient transferred from NRC to Sheridan. The transfer
document listed rule out aortic stenosis and post stroke as his
two medical conditions. No follow up care or specialty
referrals were indicated. The Sheridan nurse scheduled the
patient for a routine general medicine clinic and noted that
the patient gave a history of having a small valve in his heart
with a hole in his heart.
12/3/2015 The patient was scheduled for an MRI at Children's Hospital of
Illinois in Peoria.

14

15

The transfer did not include that the patient had
pending cardiology work up.

Patient #2

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 15 of 431 PageID #:12213

12/10/2015 The patient was seen in chronic care at Sheridan for cardiology 1, 4, 7,
clinic. The blood pressure was 118/80, which is normal. The
12
doctor listed warfarin as the only medication. The doctor
noted that the patient had childhood cardiac surgery and a
prior stroke in 2015 which the doctor wrote was "due to likely
embolization of blood clot in heart." The doctor failed to
contact the patient's pediatric cardiologist. The doctor failed
to obtain a prior record or call the cardiologists. The doctor
did write that the history was uncertain and that the patient
was not clear on dates. The doctor noted that the patient was
supposed to have surgery for balloon valvuloplasty prior to
incarceration. On physical examination the doctor
documented an irregular heart rhythm with a murmur but did
not order a stat EKG. The doctor wrote in the examination
space "suspicious for A fib" with aortic stenosis. Despite
knowing that the patient was supposed to have surgery, the
only plan was to continue warfarin, order a routine EKG, start
metoprolol for a year; drew labs, submitted a referral to UIC
cardiology and ordered a follow up after the cardiology visit.
The indication for metoprolol was not stated. The patient had
elevation of blood pressure. Metoprolol is known to increase
conduction disorders when they exist and can cause heart
block. The patient had known conduction abnormalities due
to his pulmonic regurgitation. This unnecessary medication
placed the patient at risk of harm. The doctor did not call the
patient's cardiologist or continue the plan the patient had
prior to incarceration and the doctor made no attempt to find
h noted
i
h the
d patient was
l approved
d
12/15/2015 A doctor
that
inlicollegial for
UIC cardiology.
12/16/2015 Wexford UM approved a cardiology consult at UIC.

15

The doctor presumed the patient had aortic stenosis
with atrial fibrillation without verifying with an EKG or
echocardiogram. The doctor should have contacted the
patient's cardiologist to determine the status of the
patient. Instead, the doctor presumed that the patient
was stable. The doctor did not refer the patient to the
correct consultant (pediatric cardiothoracic surgeon)
which would ultimately delay the surgery. The doctor
started metoprolol, a beta blocker, which can increase
the potential for conduction disorders in a patient at
significant risk for conduction disorders which this
patient had as a result of the pulmonic valve disease.
This may have been responsible for the patient's death.

Patient #2

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 16 of 431 PageID #:12214

12/18/2015 A doctor evaluated the patient for Coumadin clinic. The
doctor noted significant cardiac disease. The doctor's heart
examination was regular rate and rhythm with no murmur.
The doctor noted that the patient had a cardiology
appointment in 2-3 weeks.
12/23/2015 The patient was evaluated by a physician after a code 3
[emergency] for sudden onset of mid-sternal chest tightness.
The patient had dizziness. An EKG showed RBBB with possible
inferior infarct, left atrial enlargement and T wave abnormality
consistent with ischemia. The doctor's only examination was
documented as "CVS - chest-" implying no findings, yet the
patient had a known significant murmur. The doctor assessed
angina vs [something illegible]. The doctor ordered ibuprofen
and noted that the patient had a UIC appointment in 2-3
weeks.

16

14

For symptoms consistent with angina in a person with
dizziness and a known valvular heart condition and with
an EKG suggestive of ischemia, the patient should have
been referred to a higher level of care. Instead the
patient was not treated with antianginal medication but
was noted to have a routine appointment. The care was
grossly and flagrantly unacceptable.

Patient #2

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 17 of 431 PageID #:12215

1/13/2016 The patient was seen at UIC cardiology. The UIC cardiology
fellow did not know what the patient had. The patient had
DOE and told the cardiologist that he had two surgeries, one
to fix a hole in his heart and the second to correct a
dysfunctional valve. The patient didn't know if the valve was
stenotic or regurgitant. In May 2015 the patient had a stroke
treated at Freeport Memorial hospital. He was started on
warfarin. The patient knew his cardiologist (Dr. Foran) at
Rockford Children's Hospital. The patient told the cardiologist
that he was supposed to have repeat surgery on his valve. The
doctor wanted the records from Rockford Children's Hospital
and Freeport Memorial hospital and ordered an
echocardiogram to evaluate which valve was involved. A fourmonth follow up was recommended. On the referral form,
the cardiology fellow recommended obtaining the records
from the prior cardiologist, obtaining an echocardiogram, and
to return to the clinic after the echocardiogram.

1/14/2016 A doctor at Sheridan saw the patient after the UIC cardiology
visit. The doctor noted that the patient had sinus rhythm at
UIC and documented that UIC recommended getting old
records and to get echocardiogram. The patient had
occasional episodes of dyspnea, palpitations, and presyncope
and had irregular rhythm with III/VI systolic murmur. The
doctor submitted a referral to UIC for echocardiogram. The
doctor did not attempt to get the old medical record or to
attempt to find out which cardiologist had cared for the
patient.
1/14/2016 A referral to UIC cardiology for follow up was ordered on this
date but cancelled on 4/28/16, the day the inmate died.

17

Patient #2

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 18 of 431 PageID #:12216

1/19/2016 A doctor noted that the UIC echocardiogram was approved in
collegial review.
1/19/2016 Wexford UM approved an echocardiogram.
2/9/2016 An echocardiogram was done showing normal LV, ejection
fraction of 55-60%, diastolic flattening of the septum, mild to
moderate enlargement of the right ventricle, moderately
reduced RV systolic function and severe pulmonic valve
regurgitation with PA systolic pressure not assessed due to
inadequate tricuspid insufficiency. An EKG treadmill was
recommended to assess exertional capacity and if poor would
refer for surgical correction of the pulmonic valve.
2/10/2016 A doctor wrote a note that the patient had congenital heart
disease with prior surgery and had a history of stroke with
cardiac arrhythmia. The doctor noted that the patient had a
pending echocardiogram which had been approved.

10

The doctor did not have the echocardiogram report and
failed to note the abnormality.

2/18/2016 A doctor wrote a note without seeing the patient stating he
received a communication from a clinical pharmacist regarding
a potential drug interaction between Coumadin and ibuprofen.
The doctor stopped the ibuprofen and ordered a FU after the
echocardiogram at UIC.

10

The doctor did not have the echocardiogram report and
failed to note the abnormality. This was a week after
the test. The doctor wasn't even aware that the patient
had the test already.

10

Almost a month after the echocardiogram, its results
were not reviewed. The results, recommending surgery,
were unnoticed.

2/19/2016 INR was 2.3.
3/7/2016 A doctor wrote a note without seeing the patient, noted that
the patient was on Coumadin for anticoagulation because of a
congenital heart defect and post stroke. The INR was 2.4.
There was no evaluation of the patient. The doctor continued
the Coumadin.
3/21/2016 INR was 3.0.

18

Patient #2

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 19 of 431 PageID #:12217

3/24/2016 A doctor saw the patient and noted that the patient was
requesting follow up of his cardiology visit. The doctor noted
that the patient had his echocardiogram at UIC but that the
report was unavailable. The doctor documented that UIC
cardiology would follow up on the results. The patient had
irregular rhythm with a II/VI systolic murmur. The doctor
made no assessment other than that the patient had a UIC
cardiology appointment for follow up of the echocardiogram.
The doctor ordered a follow up with UIC and continued the
metoprolol. The patient weighed 144 pounds and had a blood
pressure of 98/62. The patient asked for a low bunk saying he
loses his grip and couldn't pull himself up and has "near falls."
The doctor ordered a low bunk but did not address the
hypotension, and continued metoprolol.

4/11/2016 INR was 3.6
4/12/2016 A doctor wrote a note without seeing the patient and noted
that the patient was on coumadin for a prior stroke secondary
to a blood clot in his heart since 12/31/15. The doctor noted
the most recent INR on 4/11/16 was 3.6. The doctor held the
Coumadin and restarted the next day with an INR in a week.
4/18/2016 INR was 1.9.
4/25/2016 A doctor wrote a brief note without seeing the patient, stating
to schedule the patient for cardiology and ordered an EKG
ASAP with an addendum to cancel the EKG.

19

3, 10

The patient had near syncope, low blood pressure, and
valvular heart disease yet there was no urgency in the
evaluation despite alarming signs (low blood pressure
and irregular heart rate). The referral to cardiology was
routine. The echocardiogram, which was abnormal,
was not obtained. Almost two months after the
echocardiogram, the report was not present in the
record. The doctor was therefore unaware of the
diagnosis or the recommendation for stress test and
surgery. Care was grossly and flagrantly unacceptable
as the system was indifferent to the patient's serious
medical need by not even providing to physicians a
critical test (echocardiogram) for almost two months.
During the four months in IDOC the diagnosis of the
patient or the impending need for valvular heart surgery
was unknown to IDOC staff.

Patient #2

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 20 of 431 PageID #:12218

4/25/2016 A doctor referred the patient to UIC cardiology for a treadmill
test as recommended presumably by the echocardiographer.
The doctor did document a note on this date but didn't
document review of the echocardiogram.
4/25/2016 A notice of furlough in the medical record indicated that the
patient had a cardiology appointment at UIC on 5/3/16.
4/27/2016 Wexford UM approval for exercise stress EKG and Echo at UIC
scheduled for 5/3/16. The patient already had the
echocardiogram.
4/29/2016 An autopsy was done for the death, which occurred on
4/28/16. The autopsy showed an enlarged heart, there was a
patent foramen ovale and no valvular abnormalities. There
was minimal atherosclerosis. The diagnoses were pulmonary
edema, pulmonary anthracosis, post repair of congenital
anomaly, endocardial fibrosis, and patent foramen ovale. The
death was determined to be from cardiac arrythmia.
6/1/2016 These labs were from the wrong patient: total cholesterol 176;
TG 94; HDL 61; LDL 96.

20

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 21 of 431 PageID #:12219
Patient #3
8/14/2015 The 47 year old patient had reception history at NRC. A nurse
documented that the patient had hypertension, and was on
Norvasc, aspirin and HCTZ. The BP was 133/87. The provider
physical examination included no further history. The doctor
said that the patient refused a DRE. The doctor started the
patient on his medication. The weight was 200.
8/14/2015 Intake labs included a total protein of 8.1; bilirubin of 1.7;
hepatitis C was negative. Reactive syphilis titer. The syphilis
EIA was unconfirmed. The lab recommended to retest in a
month.
8/28/2015 The patient was transferred to IRCC. On arrival the BP was
146/80.
9/7/2015 AST 90 (10-40); alt 77 (10-50); calcium 9.2; sodium 138.
9/16/2015 Total cholesterol 267; TG 132; HDL 32 and LDL 209,
hemoglobin was 14.1.
9/23/2015 At chronic care clinic the doctor noted that the patient had
cholesterol of 267; TG 132; HDL 32; and LDL of 204. The
doctor ordered zocor and continued HCTZ, Norvasc, aspirin.
The weight was 200 pounds.

12/30/2015 A nurse saw the patient for back pain. The blood pressure was
148/90. There was no referral.
2/9/2016 The bilirubin was 0.7; total protein 7.3; total cholesterol 232;
TG 97; HDL 38; and LDL 175.

21

6

There was no follow up of these abnormal tests. Care
failed to follow generally accepted guidelines.

4

The patient had a 10-year cardivascular risk of 9.7% and
should have been placed on a moderate to high
intensity statin. Instead, the doctor ordered a low
intensity statin, which the patient never received. Over
the following two years, no one recognized that he
wasn't receiving the statin medication.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 22 of 431 PageID #:12220
Patient #3
3/17/2016 An NP saw the patient for HTN chronic clinic. The patient was
on HCTZ, Norvasc, and aspirin. The NP did not mention Zocor.
The weight was 205. The NP documented that the inmate
wanted to try lifestyle modification instead of using a statin
drug, although zocor had already been prescribed in 2015.
4/14/2016 The patient asked about his medications. The blood pressure
was 140/90.
7/25/2016 The patient saw an RN and asked to see the NP because he
had headaches on and off with "pressure behind his eye"
leading him to take the Norvasc twice a day instead of once.
The BP was 128/80. The nurse took no action and charged the
patient $5.
8/16/2016 Bilirubin 1.1; potassium 3.3; total protein 7.3.
9/19/2016 An NP saw the patient at IRCC for HTN. The weight was 200
pounds. The BP was normal. No changes were made.
2/8/2017 The patient transferred to East Moline CC. The transfer form
listed hypertension as his only problem. He was on Norvasc
10, aspirin, HCTZ and KCL.
2/15/2017 Blood glucose 156; bilirubin 1.4; anion gap 13; total
cholesterol 216; TG 132; HDL 38; LDL 152.
2/16/2017 A doctor noted that the blood sugar was 156 so he ordered an
A1c and RBS. But the doctor failed to note the elevated
bilirubin or cholesterol.
2/27/2017 A1c 5.2 and glucose 100.
3/9/2017 A doctor saw the patient for HTN clinic at EMCC. The weight
was 212. BP was 144/84. No changes were made.

22

6

The doctor failed to act on elevated bilirubin.

5

The blood pressure was elevated but the doctor took no
action.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 23 of 431 PageID #:12221
Patient #3
6/6/2017 A nurse saw the patient for upper respiratory symptoms. The
patient had headache, cough, and stuffy nose. The
temperature was 100.1; pulse 109; and BP 112/60. The nurse
gave the patient cold tablets and did not refer.
6/19/2017 The patient saw the nurse for a persistent cough that he had
for about 10 days. The temperature was 98.6; pulse 102; BP
126/78. The nurse scheduled a physician visit for the
following day.
6/20/2017 A doctor saw the patient for cough and headache. Some of
the note was illegible. The pulse was 108 and temperature
99.9 with an oxygen saturation of 94%. Parts of the physical
examination were illegible. The doctor did not order follow
up.
7/18/2017 A nurse saw the patient for headache, sore throat, cough, and
runny nose. The pulse was 104, temperature 98.4 and BP
124/86. The nurse advised salt water gargles but did not refer
to a provider.
8/1/2017 A nurse saw the patient for cough, chest pain and cold sweats.
The temperature was 99.1; pulse 100; and blood pressure of
126/58. The weight was 200. The nurse referred the patient
to doctor sick call on 8/3/17.
8/4/2017 A doctor saw the patient and ordered a chest x-ray for the
chronic cough. The physical examination was normal. The
chest x-ray returned and the doctor diagnosed pneumonia and
started azithromycin for five days.
8/4/2017 A chest x-ray showed linear atelectasis in lung bases with no
consolidation or heart enlargement.

23

1, 3

Chronic cough with previous low grade fever should
have prompted a better history and evaluation including
a chest x-ray. The doctor did not evaluate the TB status
of the patient. Care did not follow generally accepted
guidelines.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 24 of 431 PageID #:12222
Patient #3
8/11/2017 A doctor saw the patient for FU. The patient had complained
of night sweats and cough. The doctor documented that the xray was reported as clear with atelectasis. The doctor
assessed cough and cold sweats and ordered a CBC, CMP, ESR
with a follow up.
8/16/2017 The hemoglobin was 10.9; with microcytic indices. The ALT
was 8 and AST 9 which were both low. The sedimentation rate
was 69.
8/18/2017 A doctor didn't see the patient but noted that the hemoglobin
was 10.9 with a sedimentation rate of 69. The doctor ordered
a RF, ANA, iron panel, ferritin and stool for occult blood x 3
with a follow up.

8/21/2017 The patient refused the stool for occult blood.
8/22/2017 The doctor saw the patient, who refused blood tests and stool
tests. The doctor's note was partly illegible. The patient felt
the cough was better.
9/6/2017 The sodium was 133; glucose 115; anion gap 122; CO2 was 23.
9/14/2017 A doctor saw the patient for HTN chronic clinic. The patient
was on aspirin, zestoretic (combination of lisinopril and HCTZ),
and amlodipine. Weight was 191 and BP was 138/66 and
pulse 110. The doctor noted cough and weight loss and noted
that the patient refused further testing.
10/3/2017 The hemoglobin was 8.9 with microcytic indices. The platelets
were 357 and WBC 8.

24

7, 8

The patient had significant anemia with elevated
sedimentation rate. Endoscopy should have been
considered and CT scan of the chest and abdomen were
indicated because the reason for the elevated
sedimentation rate and anemia were not known. FOBT
was appropriate.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 25 of 431 PageID #:12223
Patient #3
10/13/2017 A nurse saw the patient for flank pain. The pulse was 109;
respiratory rate 24; BP 120/48 and the weight was 181, a 19
pound weight loss. The nurse also saw the patient for upper
respiratory symptoms. The patient complained of cough, SOB,
yellow phlegm. The patient had PEFR of 325/350/400 with a
oxygen saturation of 97%. The nurse referred to a physician
that day.
10/13/2017 A doctor saw the patient who said he "can't breathe." The
patient had cough and dyspnea on exertion. The doctor noted
that the patient had lost about 30 pounds in five months. But
the doctor took no history with respect to the weight loss,
such as whether he was able to eat, swallow, had diarrhea,
constipation, and normal bowel movement or whether he had
abdominal or any other pain. The patient permitted a digital
rectal examination that was negative for occult blood. The
doctor ordered a chest x-ray; CBC, CMP, RF, ANA, TSH, T4, and
urine culture and analysis. The doctor placed the patient on
the infirmary for 23 hours observation.

10/13/2017 A chest x-ray showed enlarged heart in a globular shape;
pericardial effusion could not be excluded.

25

1, 7, 8 The doctor took inadequate history. Given symptoms,
weight loss, and elevated sedimentation rate, a CT scan
of the chest and abdomen were indicated due to a lack
of a diagnosis. Endoscopies were still indicated.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 26 of 431 PageID #:12224
Patient #3
10/14/2017 A nurse saw the patient on the infirmary and noted that the
pulse was 116 with a blood pressure of 132/58. The weight
was 179 pounds. The nurse documented talking to the doctor
who ordered the patient released from the infirmary with
instructions to complete the stool for occult blood. The
doctor asked for the laboratory tests for 10/16/17 with FU the
same day and to notify staff if any changes occurred. On the
same day, a nurse documented one stool was negative for
occult blood.
10/16/2017 A doctor saw the patient. The pulse was 107; BP was 122/46
and temperature 98.4. The patient felt better. The doctor
took no history. The patient had a 2/6 systolic murmur. The
doctor didn't know what the patient had except for iron
deficiency anemia. The blood tests had apparently not
returned. Given the murmur, further work up
(echocardiogram) was indicated. Because the doctor didn't
know what the patient had, he should have been admitted to
a hospital for evaluation. The doctor started iron supplements
and ordered follow up in a week.
10/16/2017 The PSA was 0.1; T4 8.9 (5-12); TSH 1.24 (0,35-4);
sedimentation rate 98 (0-10); ANA non-detectable and RF <10.
10/19/2017 The doctor noted that the PSA was 0.1; the TSH, T4, ANA, and
RF were all negative. The doctor didn't see the patient but
ordered a CBC and CRP.
10/20/2017 The CRP was 43.8 (<8). WBC was 9.6 with hemoglobin 8.3.

26

14

The patient should have been referred to a hospital. He
had possible pericardial effusion, significant weight loss,
elevated sedimentation rate, new murmur, and anemia.
A stat echocardiogram was indicated. Additional testing
CT scans and endoscopies were also indicated as the
patient had serious illness and no diagnosis.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 27 of 431 PageID #:12225
Patient #3
10/23/2017 The doctor saw the patient. The weight was 178 pounds. The
pulse was 119 and temperature 97.3. The only history was the
doctor statement that the patient felt fine. The doctor was
not tracking any symptoms of the patient. The patient has a
systolic murmur and anemia. The doctor noted that the
patient had anemia and "possible pericardial effusion,"
although it wasn't clear how the doctor came to that
conclusion. The doctor wanted to admit the patient to an ER
but the patient refused.

1

The history was poor but the decision to admit to a
hospital was appropriate, but the patient refused.

11/3/2017 A doctor saw the patient, who had pulse of 118; BP 154/82
and weighed 174 pounds. The only history was that the
patient wasn't eating because he had no appetite. The patient
had a 3/6 systolic murmur. The patient again refused to go to
the ER or have blood work done. A mental health referral was
submitted.
11/3/2017 At 10:30 am the patient was diaphoretic with pulse of 114 and
BP 80/40. The heart rhythm was irregular.
11/3/2017 At 8:17 pm the patient was unresponsive. CPR was initiated.
The patient died at 8:20 pm.
11/3/2017 The death certificate documented that an autopsy was not
done.

1

The history was poor but the decision to admit to a
hospital was appropriate. This patient should have been
sent to a hospital and allowed to refuse at the hospital.

27

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 28 of 431 PageID #:12226
Patient #4
5/27/2016 The patient had his NRC history. The patient had prior pelvis
surgery after a motorcycle accident in 1992. The patient had
no identified problems except for mental health problems.
5/27/2016 A psychiatrist note documented that the patient was on
Depakote, Risperdal, and Remeron.
5/27/2016 The creatinine was 1.51; the other components of the
metabolic panel were normal.
6/8/2016 Total cholesterol 164; TG 151; HDL 41; LDL 93. CBC was
normal.
6/13/2016 The patient was transferred to BMR.
11/15/2016 The patient had reception history but the location wasn't
documented. The patient had no problems identified except
for mental illness. This was an apparent re-incarceration.
11/15/2016 CMP was normal. Creatinine was 1.22 (0.5-1.5).
11/17/2016 The patient had a reception physical examination. No
additional medical history was taken except for drug use. The
patient had no medical problems identified except for mental
health with a prior suicide attempt.
11/29/2016 The patient transferred from NRC to EMCC. The patient was
on Remeron.
12/2/2016 Total cholesterol 196; TG 100; HDL 43; LDL 133.

28

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 29 of 431 PageID #:12227
Patient #4
3/22/2017 A nurse assisted the patient at 4:23 pm. He said he was dizzy
and had just collapsed. The patient was responsive to
questions. The nurse didn't take the patient's vital signs and
noted that the patient was able to respond. While the nurse
started to take vital signs the patient began seizing. The
patient had foam coming out of his mouth and the nurse
turned the patient on his side. The patient became combative
and seized again. The patient was again rolled on his side.
The nurse told custody to call an ambulance. The patient then
said he couldn't breath and oxygen was initiated. The BP was
80/40; pulse 82 and respirations 24 and saturation 90%. The
patient tried to remove the oxygen mask when paramedics
arrived and the patient again began seizing. The nurse
checked for a pulse but could not obtain one so medics began
CPR and continued until the patient left for the hospital.
There was no timeline for the terminal event.

3/23/2017 A death summary noted that the patient died on 3/22/17 at a
hospital. The patient suddenly collapsed, got up, then
collapsed again, going into seizure like activity. CPR was
initiated after the ambulance arrived but the patient was
pulseless. The patient was pronounced dead at the hospital.
3/24/2017 The autopsy showed large bilateral pulmonary emboli with
pulmonary congestion. Death was due to pulmonary emboli.

29

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 30 of 431 PageID #:12228
Patient #5
8/8/2017 A nurse completed a reception history. The reception form is
defective. It has only a few diseases and nurses do not record
problems in the explanation section and only list problems in
the assessment. The age of the inmate was not on the form.
The CBG was 148. The only history boxes checked were for
cardiac. The patient was noted to be on metformin and
glargine but the diabetes box wasn't checked. The nurse gave
no explanation of his cardiac/HTN problem. In the surgery
section, the nurse noted that the patient had history of
unspecified open heart surgery in 2012 and had a stent "L
side" (it wasn't clear what this meant). In the assessment the
nurse documented IDDM, sleep apnea, and glaucoma but did
not state what his heart condition was. The patient weighed
220 pounds yet the nurse listed the patient as an IDDM, which
did not appear accurate. The patient most likely had type 2
diabetes. The blood pressure was 119/67. The nurse noted
that the patient was oriented x 3. This was a very poor
history. The nurse made no entries commenting on any
alteration of mental status.

30

1

The history was inadequate as it did not identify all of
the patient's problems.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 31 of 431 PageID #:12229
Patient #5
8/8/2017 A doctor performed the reception physical examination. The
doctor took no history and given the lack of nursing history,
the patient ultimately receive inadequate history. The doctor
recorded a totally normal examination, mostly checking boxes
as normal. The doctor did not assess mental status. The
assessment was IDDM, HTN [illegible but looks like HTN], CAD
with open heart surgery for unspecified reasons in 2013; post
stent placement; glaucoma; asthma; sleep apnea; umbilical
hernia. The doctor started a number of medications but they
were illegible. The MAR documented that the patient received
KOP meds including Ventolin, oxybutynin, folate, omeprazole,
atorvastatin, hydralazine, and Brilinta. On a different MAR the
patient was started on NPH insulin 14 units BID with a sliding
scale regular insulin. The MAR includes eight refusals over a
13 day period for the NPH. The regular insulin was only given
twice a day (to accommodate custody) and the patient refused
seven times. The reasons for use of oxybutynin was not
documented in the record and none of the listed problems
were an indication for oxybutynin. The reason for the Brilinta
was also unclear. It wasn't clear that the patient had a STEMI
in the past, which is an indication for Brilinta. It is clear that
the patient was on this medication because of prior stent
placement or possibly CABG. This was an extremely poor
history and assessment, as it wasn't clear why the patient was
using some of his medications.

31

1, 3

The doctor took an inadequate history of the patient's
conditions and did not develop an adequate treatment
plan for the patient's problems. Specifically, the doctor
documented medication (oxybutynin and Brilinta)
without an indication. The doctor modified an
established treatment plan (diabetes) without
appropriate documentation of the reason for the
change or discussing the change with the patient. Care
failed to follow generally accepted guidelines or usual
practice.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 32 of 431 PageID #:12230
Patient #5
8/8/2017 A doctor different than the one who performed the physical
examination ordered Coreg, Norvasc, Zestril, hydralazine,
atorvastatin folate, and aspirin. A month supply of aspirin,
Coreg, Norvasc and Zestril were given to the patient but these
were not documented on the MAR.
8/8/2017 BUN was 26 (6-20); creatinine 1.79 (0.5-1.5); these abnormal
tests were not evaluated at NRC.

6

8/22/2017 The patient wasn't seen again at NRC and on 8/22/17 at 8 pm
the patient transferred to EMCC. The problems listed on the
transfer sheet included IDDM, HTN, CAD, glaucoma, and
asthma. The patient was listed as being on albuterol, NPH and
regular insulin, atorvastatin, latanoprost, ticagrelor and an
illegible eyedrop, Coreg, Norvasc, Zestril, metformin,
oxybutynin. The blood pressure was 150/an illegible number.
The patient was referred to chronic care.
8/22/2017 At 8:30 pm a nurse documented that the patient was placed
overnight in the HCU because the patient was confused. The
patient answered questions with "obscure answers" and was
unable to walk to the health care unit by himself. The nurse
wrote he was "very confused on where he is and why." The
medication that was issued as KOP were removed from his
control for his safety. The nurse didn't call a physician.

The doctor did not follow up on this abnormal lab result
indicating renal disease which was not a current patient
problem.

14, 16 A new diagnosis of confusion in a patient without any
condition that includes confusion as a symptom should
have resulted in an immediate consultation with a
physician and referral to a hospital for evaluation.

8/23/2017 At 4:40 am the patient refused to have an AccuChek and
refused his insulin. The nurse referred the matter to the HCUA
and DON but did not call the doctor. The nurse returned later
and the inmate accepted insulin.

32

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 33 of 431 PageID #:12231
Patient #5
8/23/2017 A doctor saw the patient. The temperature was 97.5; pulse
53; BP 140/74, and oxygen saturation 99%. The doctor noted
that the patient was 75 years old with a history of DM, CAD,
sleep apnea, asthma/COPD, glaucoma, GERD, HTN. The
doctor noted that the patient used to use a CPAP machine but
hadn't use one for two weeks. The doctor noted that the
patient had been confused for the past week but took no
other history of this problem. The doctor documented that
the patient used albuterol twice a week. There was no other
history remarkably. On examination the doctor documented
that the patient was somewhat forgetful and documented the
patient was "A + O" presumably meaning alert and oriented
but the doctor didn't perform a mental status examination.
The doctor did not perform a neurological examination,
examine the cranial nerves or an in depth mental status
assessment. The doctor assessed asthma/COPD, HBP, CAD,
glaucoma, DM, and OSA, and ignored the confusion. There
was no history, physical examination, or evaluation for the
recent onset of confusion. The doctor housed the patient in
the health care unit without ordering any diagnostic testing.

8/28/2017 BUN 23 (6-20); B12 283 (181-914); creatinine 1.53 (0.5-1.5);
A1c 6.4; cholesterol 122; TG 97; HDL 33; LDL 70; T3 (80-178);
hemoglobin 11.2 (13.2-18).

33

1, 2, 8, The patient had relatively new onset of confusion. The
14
doctor failed to take adequate history or perform
adequate examination. The patient should have been
referred for diagnostic testing including possible CT
scan, and prompt laboratory testing including for
toxicology. This did not occur for five days. Care failed
to follow generally accepted guidelines.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 34 of 431 PageID #:12232
Patient #5
9/2/2017 A nurse wrote that the inmate was bleeding from his mouth.
The patient had a laceration of the left side of his tongue.
There was a flap still attached with gross swelling. The inmate
was unable to speak secondary to the swelling. The patient
was unable to swallow. The nurse wrote "confusion present
as normal for inmate." The patient was sent to an ER. On
9/2/17 the facility was notified that the patient died.
9/2/2017 A nurse wrote an incident report documenting that the patient
bit his tongue and that it was lacerated and swollen with gross
bleeding. There was no evidence of assault. The patient had
difficulty swallowing.
9/2/2017 A nursing progress note from the hospital documented that
the patient was able to state his name and birthdate but that
it was difficult to understand what the patient was saying. The
BP was 160/90 with pulse between 90-100. Photos were
taken of the swollen tongue and lips. The doctor attempted to
intubate the patient but was unable to visualize the vocal
cords. The patient suddenly stopped breathing. An ICU doctor
assessed that the patient had ACE related angioedema.
9/2/2017 Unfortunately, there was no autopsy for this patient. The
recent new onset of confusion is troubling and was not
thoroughly worked up with history, physical examination, or
CT scan. It is not clear if this contributed to the patient's
death.
9/5/2017 The death summary documented that the patient was on the
medical unit and developed a swollen tongue for which he was
sent to the hospital, where he died suspected of having
angioedema from lisinopril.

34

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 35 of 431 PageID #:12233
Patient #6
1/6/2016 A doctor wrote a brief note noting that the patient had multiple scratches on the
skin from the inmate scratching herself. The doctor wrote an order to schedule
the inmate to come to clinic Tuesday for a femoral phlebotomy that he would
perform. There was no evaluation of the inmate. The doctor re-ordered minerin
creme.
1/8/2016 Hemoglobin 11.1; platelets 91.

1/9/2016
1/11/2016
1/20/2016
2/3/2016

INR 1.4.
A1c 7.6.
Optometry exam for retinopathy.
The patient complained bitterly about her treatment. She said that she had the
skin problem for months and "I already done the cream you put up inside you once
and I have had this problem for months and no one will do anything about it… I
have been complaining about it for months and I come over here and pay and
nothing gets done." Apparently the patient was going to the HCU for her skin
cream.

35

This patient had likely cirrhosis and should
have had screening endoscopy and
screening for hepatocellular carcinoma on
a semi-annual basis.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 36 of 431 PageID #:12234
Patient #6
2/9/2016 A doctor noted that the patient had back "boils." The patient was asking for pain
medication. The patient had a raised indurated area on her back with scarring
from previous lesions. The doctor noted that the patient could stand and sit
without difficulty. There was no other examination. The doctor assessed a "back
boil with a few smaller indurated red spots in a diabetic patient." The doctor
started minocycline. There was no follow up ordered. The doctor failed to
evaluate recent laboratory results indicating that the patient had cirrhosis and
anemia.

2/12/2016 A nurse noted that the patient had a rash that was unchanged with multiple sores
in various stages of healing with no active drainage but with bloody spots on her
shirt. Her clothes appeared filthy and had odor and the inmate was unkempt.

36

1, 2, 3 The doctor did not take an adequate
history or establish a coherent treatment
plan for the rash. The doctor had not
established a diagnosis for the problem.
With respect to the skin disorder, without
a diagnosis, the doctor should have
referred to a dermatologist. The patient
had cirrhosis but the doctor did not refer
for an EGD to screen for varices or an
ultrasound to screen for hepatocellular
carcinoma. These screening tests are
recommended for persons with cirrhosis.
Those patients with varices are
recommended to start a beta blocker to
prevent variceal bleeding. Care failed to
follow generally accepted guidelines as
the doctor had been trying various creams
without effect.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 37 of 431 PageID #:12235
Patient #6
2/26/2016 Albumin 2.4; bilirubin 2.8; alk phos 429; AST 116; ALT 57; hemoglobin 12; platelets
96; total cholesterol 54 (100-200); TG 89; HDL 10; LDL 26 (50-129).

37

These labs were not followed up. The
APRI score was 3.021 indicating likely
cirrhosis. The patient had a significantly
elevated alkaline phosphatase and it
wasn't clear if this was due to liver or gall
bladder disease. The cholesterol levels
were so low as to be of concern. This may
have been due to malabsorption,
malignancy, chronic infection, or severe
illness. Yet none of these abnormalities
were evaluated. The liver functions
yielded fibrosis scores that warranted
hepatitis C treatment but there was no
evidence of referral to UIC for evaluation
for treatment. This care failed to follow
generally accepted guidelines or usual
practice.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 38 of 431 PageID #:12236
Patient #6
3/3/2016 A doctor saw the patient in hypertension chronic clinic. The blood pressure was
1, 6, 7
117/77; weight 139 pounds; pulse 98. The doctor took no history. Problems listed
included cirrhosis, chronic hepatitis C, diabetes, weight loss, HTN, amenorrhea,
and dermatitis. The only medications listed included lisinopril and NPH and regular
insulin and minerin cream. Compliance was listed as poor without any explanation.
The "pulses" were listed as "wnl." The entire examination was "lungs wnl, heart
wnl and edema none; fundoscopy not seen; others multiple spots from dermatitis
and micro infected sites- just finished antibiotics; BMI 24." The patient was listed
as in good control. The doctor started minocycline apparently for the infected
dermatitis. The doctor took no history of the skin problem, no history of the
cirrhosis. No labs were evaluated. The diabetes and cirrhosis were not addressed.
The hepatitis C was not addressed and it wasn't clear if the patient was treated
despite the patient having advanced fibrosis qualifying for treatment. Recent
blood tests were not reviewed.

3/16/2016 A doctor wrote a note that the patient had diarrhea while on an antibiotic. The
doctor took no history and wrote that the patient was not seen. The doctor
ordered stool for ova and parasites and for c difficile.

38

1

The doctor did not act on the recent
laboratory tests which had significant
abnormalities. This included not taking an
adequate history or making an
appropriate diagnosis or acting on
abnormal lab results. Because of the
history of cirrhosis the patient should have
had an EGD to screen for varices, liver
ultrasound to screen for HCC, which were
not done. Because of the elevated
alkaline phosphatase the patient should
have had evaluation of the gallbladder and
pancreas by ultrasound or CT scan. The
care failed to follow generally accepted
guidelines.
The doctor took action based on anecdote
and did not take a history of the patient.
It wasn't clear how the doctor obtained
the information that led to the change in
therapy. The doctor did not inform the
patient of the change in therapy.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 39 of 431 PageID #:12237
Patient #6
3/23/2016 A doctor saw the patient in hypertension chronic clinic. The blood pressure was
122/79 and pulse 102. The patient said that she had loose stools from the
antibiotic. The doctor took no other history. The examination was brief and
consisted of the lungs being "wnl" fundoscopy "not see" and edema "non" with a
note "BM was solid light brown and difficult to produce...C dif is not a
consideration." The doctor's assessment in its entirety is given verbatim with
formatting and spelling mistakes included "Bp is good control and IM stopped
taking the minocycline stating trthat someonetold her she might have C. Diff.
stool collections set were for ova and parasites and cdiff was not formulary and
md wanted to see a specimen today which did not remotely resembel a c diff stool
nor did th patient history so no specail non formulary will be done to look for c
diffe. the IM was told to restart the minocycline but her skin lesions have
improved already so if she refuses again there wil be no further orders for this at
this time." This assessment was not coherent. This assessment does not include
evaluation of the patient's diabetes, cirrhosis, or hepatitis C. There was no
examination of the patient's skin. The patient was documented as having no
edema. The doctor noted that the stool was solid light brown inconsistent with C
difficile. The doctor did not address any of the patient's other problems.

4/1/2016 A1c 6.8.

39

4

Based on the documented note, it
appeared that the physician either has a
typing problem or was incoherent for a
different unexplained reason. The
therapeutic plan was not competently
described.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 40 of 431 PageID #:12238
Patient #6
4/7/2016 A doctor saw the patient for diabetes chronic clinic. The pulse was 109 and blood 1, 2, 6,
pressure 120/82. The weight was 138 pounds. The problems listed included a
12
number of symptoms which were not problems including "screening for
depression," "pruritis," and other events which were not problems, including "well
woman examination." Other listed problems were unqualified items such as "loss
of weight" and "Np boils." The boxes hypo/hyperglycemia were checked both yes
and no without explanation. There was no history for any of the patient's medical
conditions. The A1c was 6.8. The examination documented multiple
hyperpigmented areas from scratching without open lesions. The fundus was not
examined. The remaining examinations were documented as "wnl." Aside from
the A1c, no laboratory values were addressed including for blood lipids or liver
function tests. The doctor did not address the hepatitis C, cirrhosis, the skin
disorder, and ordered a four-month follow up. The doctor noted that the patient
had annual diabetic eye screening in January of 2016. The doctor did not address
the fast pulse.

The doctor again documented skin lesions
but took no history, performed
inadequate examination, and made no
attempt to diagnose or establish a
thorough therapeutic plan. The doctor
failed to address the patient's other
problems. The care failed to follow
accepted guidelines, as an undiagnosed
skin lesion would normally be referred to
a dermatologist. The lack of history was
striking and also fails to follow usual
practice. The doctor did not evaluate CBG
test results which were not available or
not done.

4/9/2016 A nurse saw the patient two days after the chronic care visit of 4/7/16. The vital
signs of the nurse were identical to the vital signs on the chronic care visit and it
appeared that the vital signs defaulted from the prior note. This is improper, as it
does not represent an honest representation of what occurred. The identical vital
signs were documented on a 4/10/16 nursing note; a 4/12/16 nursing note; a
4/13/16 nursing note; a 4/17/16 nursing note; and a 4/18/16 nursing note.

This is a problem in that the medical
record permits false vital signs to be
incorporated into the medical record.

4/19/2016 A nurse saw the patient for a progress note. The vitals recorded at this visit were
identical to vital signs used on the subsequent note of 4/20/16.
5/13/2016 INR 1.4.

40

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 41 of 431 PageID #:12239
Patient #6
5/13/2016 Bilirubin 1.7; BUN 9; glucose 57 (65-110); albumin 2.5; bilirubin 2.8; alk phos 445;
AST 123 (10-40); ALT 69 (10-50). Hemoglobin 12.6 (11.7-16) platelets 78 (150450).

41

These labs were mostly abnormal. The
low blood glucose was significant, as
hypoglycemia occurs frequently in liver
disease. Since this patient had cirrhosis,
the hypoglycemia should have prompted
reduction of insulin so that her glucose
was above 65. Failure to do this can result
in significant hypoglycemia. The abnormal
liver function tests demonstrated cirrhosis
and the patient should have been treated
for hepatitis C but was not. The patient
should also have been screened for
varices and HCC but was not. The care
failed to follow generally accepted
guidelines or usual practice.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 42 of 431 PageID #:12240
Patient #6
5/31/2016 A doctor saw the patient because she had "sores" over her body and had pruritis
and that the hydroxyzine helped. The doctor took no history of the patient's
condition. The only examination was that the patient was oriented, walked and
stood without difficulty, and had many hyperpigmented spots mixed with open
sores. The assessment was patchy eczema which the doctor attributed to the
advanced liver disease. The doctor also documented that the diabetes could be
contributing "some yeast component. a mixed dermatitis." The doctor
documented he would evaluate the patient "next month" in hepatitis C clinic and
ordered hydroxyzine, hydrocortisone cream, and athlete foot cream presumably
all for the skin condition. Patient had a pruritic diffuse skin condition which
apparently resulted in scratching and excoriations. Whether this was due to her
liver condition or to psoriasis, which the coroner surmised, is unclear. But she did
not have adequate evaluation for the condition. The doctor did not competently
evaluate the skin condition and did not refer to a dermatologist. The doctor also
did not evaluate recent abnormal labs.

6/9/2016 A doctor wrote a note to renew a low concentrated sweet diet for six months. The
doctor did not see the patient. Vital signs for this visit were identical to a 6/7/16
nurse note.

42

1, 2, 6, The patient was not responding to
treatment and the doctor was not
12
obtaining appropriate history, performing
adequate examination, or making
apparent adequate diagnoses. The
patient should have been referred to a
dermatologist but was not. The doctor
also did not act on abnormal laboratory
results recently obtained which should
have resulted in radiologic studies of the
upper abdomen. The care failed to follow
generally accepted guidelines or usual
practice.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 43 of 431 PageID #:12241
Patient #6
6/21/2016 A doctor saw the patient for hepatitis C clinic. The doctor did not document
1, 2,5,7,
whether the patient had received hepatitis B or A vaccines. The only examination
8
was to document multiple laboratory values without dates. The doctor performed
no examination, listed labs without dates, and concluded that the patient had
advanced cirrhosis. His comment about treatment was "advanced cirrhosis in a
patient with other unstable issues (DM) and who was consistently noncompliant
during her sentence and is not stable with her itching dermatitis has not been a
candidate for treatment prior and shows little interest in treatment even as i try to
talk to her today about follow up at Stroger." The doctor wrote Harvoni on a piece
of paper and gave it to her and told her to ask Fantus clinic to treat her for her
hepatitis C. The doctor documented that the patient was to be discharged in three
months. The doctor stated that the patient was more interested in cream for her
dermatitis. The doctor performed no examination, did not assess for edema, did
not order typical studies for someone with cirrhosis including ultrasound of the
liver to screen for HCC, EGD, use of beta blocker for variceal control, or
assessment of complications of cirrhosis. The doctor documented that the patient
was not a candidate for Interferon-Ribavirin but gave no reason even though the
electronic form requested a reason.

43

The patient had cirrhosis and needed
hepatitis C treatment but was not
referred; apparently because of discharge
within a year. A refusal was not evident.
There was no documentation that
treatment was discussed with the patient.
The doctor documented that the patient
was non-compliant but it wasn't clear
what the patient was non-compliant with.
As well, the patient had cirrhosis but was
not referred for EGD, HCC screening, and
did not have a beta blocker started as
prevention for varices. The doctor
seemed unprofessional. The patient was
upset with a persistent skin condition for
which there was no clear diagnosis. The
doctor took inadequate history, failed to
examine the patient or make an adequate
assessment of the skin condition, failed to
act on laboratory values indicative of
cirrhosis, failed to order EGD, and failed to
order screening ultrasound for
hepatocellular carcinoma. The care failed
to follow generally accepted guidelines or
usual practice.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 44 of 431 PageID #:12242
Patient #6
7/18/2016 A doctor saw the patient for her skin rash. The doctor noted that the patient was
to parole in 1-2 months and had a chronic rash being treated with steroids. The
main problem was a chalazion of the left eyelid. The doctor noted an extensive
rash over the trunk "likely eczema" and diagnosed "chronic rash" and prescribed
hydrocortisone cream, minerin cream, and hydroxyzine.

7/29/2016 A1c 5.9.

12

The patient had rash for at least over
seven months with resolution. The doctor
was not successful in treating the patient
yet continued the same care that wasn't
working. He failed to establish an
adequate treatment plan as the plan being
used was not working. The patient should
have been referred to a dermatologist.
Care failed to follow generally accepted
guidelines or usual practice.

This A1c was normal but for this person
indicated that the patient was possibly
being overtreated due to complications of
her liver disease. The insulin doses should
have been decreased.

8/10/2016 A doctor saw the patient for diabetes chronic clinic. The doctor noted an A1c of
5.9 with no date and noted hypoglycemia 1-2 times per month. There was no
history except to document hypoglycemia. The only examination was to state that
the patient was alert, had normal pulses and had clear lungs. The patient was
documented as in good control. The patient had an A1c of 6.8 at the prior
diabetes clinic now at 5.9 and had cirrhosis. The doctor did not express concern
that the cirrhosis was affecting the diabetes and did not consider lowering the
insulin dosages especially since the patient was experiencing hypoglycemia. The
doctor did not review CBG results.

44

1, 4, 6 The history of hypoglycemia with an A1c
of 5.9 warranted decreasing the insulin
doses as the patient's cirrhosis (liver
failure) was apparently making the patient
hypoglycemic. The doctor failed to review
any CBG results. The doctor failed to take
adequate history. Care failed to follow
generally accepted guidelines or usual
practice. This placed the patient at risk of
harm including mortality.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 45 of 431 PageID #:12243
Patient #6
8/23/2016 At 5:20 pm a nurse evaluated the patient who had malaise and fever and was not
feeling good. The temperature was 101.8; pulse 120; and BP 88/50. The nurse
noted periorbital swelling such that the patient was unable to open eyes fully. The
nurse called a doctor and received orders to admit the patient to the infirmary,
push fluids, give Tylenol, perform a urine dipstick, and start Bactrim after the urine
dipstick. The doctor indicated that he would consider labs and a chest x-ray in the
morning.

2, 14

8/23/2016 A nurse wrote an infirmary admission note at 6:53 pm. The patient had abdominal
distention and fever.

16

8/23/2016 At 6:57 pm a nurse documented that the patient had fever of 100.7; pulse 112;
and BP 88/58.

16

8/23/2016 At 9:00 pm a nurse noted that the pulse was 96 and BP 94/56.

16

8/23/2016 At 11:34 pm a nurse documented the patient complaint that "I just don't feel good
at all." The BP was 88/52 and the nurse documented a distended abdomen and
abdominal pain.
8/24/2016 At 1:48 am a nurse documented moderate periorbital swelling.

16

45

This patient had fever, tachycardia,
periorbital swelling, and hypotension
indicative of sepsis yet the doctor, without
evaluating the patient, started oral
antibiotics for a presumed infection
(urinary tract infection) that had not yet
been diagnosed and for which there was
no basis. This patient should have been
referred to a hospital. The patient was
also on lisinopril for hypertension and it
should have been discontinued as the
patient was hypotensive. Care was grossly
and flagrantly unacceptable.
The nurse should have consulted a
physician because of the additional
component of abdominal distention.
The nurse should have consulted a
physician. The patient appeared to be in
septic shock.
The nurse should have consulted a
physician. The patient appeared to be in
septic shock.
The nurse should have consulted a
physician. The patient appeared to be in
septic shock.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 46 of 431 PageID #:12244
Patient #6
8/24/2016 A doctor documented an infirmary admission note documenting that the patient
had fever, malaise, and right upper quadrant pain. The doctor documented a
moderately distended abdomen tender in the RUQ without rebound. The doctor
diagnosed advancing liver failure. The doctor did not review any labs including the
elevated alkaline phosphatase previously recorded. The doctor ordered a CMP and
CBC for a PM pickup. The doctor diagnosed fever without any other assessment.

8/24/2016 BUN 13; creatinine 1.38; albumin 1.9; bilirubin 4.4; alkaline phosphatase 376; AST
78; and Alt 37. WBC 14.7; hemoglobin 10.9 and platelets 67.

8/25/2016 At 3:06 pm a nurse documented a temperature of 98.6, pulse 92 and BP 94/56.
The patient apparently was transferred to DMH ER.
8/25/2016 At 3:13 pm a doctor wrote a referral to a local hospital ER documenting that the
albumin was 1.9; alkaline phosphatase was 376; ALT 37; AST 78; bilirubin 4.4. The
doctor was unable to get access for IV fluids and the patient's blood pressure was
dropping to 60 systolic. The doctor sent the patient to the hospital for
hypotension. Notably the patient's ALT was 56 and AST 99 with a bilirubin of 2.2 in
November of 2015. She should have been treated for hepatitis C at that point but
apparently was not.
8/27/2016 The patient had returned from the hospital but there was no report. It wasn't
clear what the status of the patient was; this was dangerous. At 5:35 am a nurse
documented no temperature but a pulse of 115 and BP of 72/48. The nurse didn't
refer to a physician.

46

5, 14

The doctor now knew that the patient had
fever and right upper quadrant pain with
hypotension. Immediate hospitalization
was indicated. Instead the doctor ordered
labs that would not be available until the
next day. Care was grossly and flagrantly
unacceptable.

Because of the patient's complaint of right
upper quadrant pain with fever these labs
indicate infection, blood loss, and possible
biliary obstruction, which is a lifethreatening. These labs should have been
immediately addressed.

This was a significant delay in referral to
an ER. The patient was sent to an ER two
days after developing fever, abdominal
pain, and hypotension. Care was grossly
and flagrantly unacceptable. The patient
went to the ER but there was no hospital
report in the record.
16, 18 The nurse should have consulted a
physician as the patient was hypotensive.
This was dangerous and placed the patient
at significant risk of harm.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 47 of 431 PageID #:12245
Patient #6
8/27/2016 At 1:32 am a nurse documented that the patient vomited more than 300 cc of
reddish brown emesis. The blood pressure was 78/52 but other vitals were not
taken. The nurse did not contact a physician.

16

The patient with cirrhosis had apparent
bloody emesis with hypotension but the
nurse did not call a physician. This was
dangerous and placed the patient at
significant risk of harm.

8/27/2016 At 2:20 am a nurse documented pulse of 110 and BP of 75/48 and noted that the
patient vomited more than 500 cc of dark red color emesis. The nurse
documented calling the physician. But received no orders except to "CPM"
[continue present management].

14

The patient was in shock and had bloody
emesis yet the doctor did not send the
patient to a hospital. Care was grossly and
flagrantly unacceptable.

8/27/2016 At 2:51 am a nurse documented that the patient had a large amount of bloody
emesis of approximately 300 cc. The blood pressure was 75/48 and pulse 110.
The nurse assessed "throat cancer."

16

The nurse made an inaccurate assessment
but bloody vomiting with shock needs to
be referred to a physician. This was
dangerous and placed the patient at
significant risk of harm.

8/27/2016 At 3:58 am a nurse documented that the patient had a fourth bloody emesis "this
shift." The nurse called the doctor who asked to be called if the patient vomited
blood again. The vital signs of pulse 115 and BP 72/48 were identical to prior
other nursing encounters on this night.

14

The patient was in shock and had bloody
emesis yet the doctor did not send the
patient to a hospital. Care was grossly and
flagrantly unacceptable.

47

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 48 of 431 PageID #:12246
Patient #6
8/27/2016 At 5:28 am a doctor at DCC wrote a referral to the ER stating that the patient had
advanced liver disease with esophageal varices and DM and was recently sent to
the ER on 8/25/16. The patient was vomiting frank dark blood. The patient was
hypotensive and the doctor documented he asked the patient if she wished a
living will DNR. The doctor documented that the patient was oriented x 3 and
declined. The patient was then sent to the hospital. The document that the
patient signed had a signature that was disorganized and unlike her prior
signatures. Given that the patient was in shock, it is not appropriate to obtain
consent for no intervention unless the patient is coherent. This consent was
questionably obtained.
8/27/2016 At 8:48 am a note was entered stating that at 6:15 am the patient left by
ambulance to the hospital.
8/27/2016 The patient asked for morphine instead of being sent out to the hospital.
8/27/2016 At 6:02 am the doctor wrote a brief note. The patient's vital signs were 72/48 with
pulse of 115. The doctor noted that the patient signed a living will "tonight" and
was vomiting blood and needed sclerosing of her varices and sent the patient to
the ER.

48

This transfer was significantly delayed.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 49 of 431 PageID #:12247
Patient #6
8/27/2016 The patient was sent to the hospital. According to hospital records the patient was
sent to the hospital to evaluate for end-of-life care to be placed in hospice. The
hospital noted that the patient had a history of psoriasis, hepatitis C, DM, and HTN
and had "continued" swelling and ascites. The hospital physician documented that
the facility physician told the hospital that the patient was DNR with a living will.
The facility physician documented that the patient would accept morphine and
fluids but no invasive procedures. The history was limited given the condition of
the patient. The patient was initially alert but became obtunded. The hemoglobin
was 6.2 and INR 3.4. The hospital record documented that the patient had been in
the hospital two days previous. The hospital noted that two days ago the patient
was seen in the ER with RUG pain and diarrhea. A CT scan showed cirrhosis,
hydrops GB with cholelithiasis and cholecystitis, but surgery said the risk of surgery
was too great and the patient was sent back to DCC for comfort measures. At the
current ER visit the hospital doctors talked to the DCC physician who clarified the
full supportive measures should be attempted unless she codes because she was
DNR, DNI. The patient had vomited blood several times at the facility since
Tuesday. The patient needed levophed at the hospital to sustain blood pressure.
The blood pressure was 47/22 with pulse of 110. The patient had ascites.The
patient was arousable and oriented to person place and time. The patient was
deemed to have cirrhosis with hypotension and was DNR. The doctor at the
hospital documented that the patient had a living will at DCC and was DNR. This
was discussed with the physician at DCC. The patient died at 12:55 in the hospital
without interventions except fluids. The hemoglobin in the hospital was 6.3 with a
WBC of 16.

At this point and even two days previous
the patient had such end-stage liver
disease that interventions were unlikely to
significantly prolong life. However, earlier
interventions including treatment of
hepatitis C and particularly screening for
varices (which is indicated for persons
with cirrhosis) should have been done and
may have prolonged her life. In this
respect her death was possibly
preventable.

8/27/2016 The patient signed a living will but the signature is so disorganized and different
from other signatures of the patient that it does not appear that she was capable
of physically signing at the time of signature. Whether she was of sound mind is
not clear as she was in shock. The will was cosigned by a nurse and a doctor.

This appears to be an inadequately
obtained informed consent. The patient
should have been treated but was not.

49

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 50 of 431 PageID #:12248
Patient #6
8/28/2017 Autopsy showed that the patient experienced a gastrointestinal bleed filling the
stomach. The patient also had evidence of end-stage cirrhosis, ascites, pulmonary
edema, congestion of the spleen, cerebral edema, anasarca, diffuse psoriasis,
history of HIV, and diabetes. The patient was said to have died from a ruptured
esophageal varices.

50

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 51 of 431 PageID #:12249
Patient #7
9/30/2003 The patient had increased liver enzymes documented on the
problem list without more specificity. The patient also had a
history of obesity, alcohol abuse, peptic ulcer disease, and
sickle cell trait.

3

The patient had a history of alcoholism and elevated
liver functions documented but these were not followed
up regularly and this problem was lost to follow up.
Care failed to follow generally accepted guidelines or
usual practice.

7/16/2014 An NP saw the patient for an annual evaluation. The weight
was 262 pounds. The patient was 49 years old. The NP noted
problems as high blood lipids and HTN and noted that the
patient had elevated liver function tests but wasn't more
specific. The NP did note alcoholism. The patient was noted
to be deaf. The NP documented that the patient voiced no
problems but the patient couldn't hear and it wasn't clear how
a history was taken. The patient did not have investigation
regarding the elevated liver function tests.

3

The patient had a history of alcoholism and elevated
liver functions documented but these were not followed
up regularly and this problem was lost to follow up.
Care failed to follow generally accepted guidelines or
usual practice.

11/7/2014 The patient was deaf and asked for headphones. The NP
wrote "headphones NSD" but it wasn't clear what that meant.

11

The patient was deaf. His deafness was not
accommodated with respect to obtaining history and
physical examinations. The patient did not receive
functioning hearing aides or sign translators who could
assist in obtaining an adequate history. Care failed to
follow generally accepted guidelines or practice.

11

The patient was deaf. His deafness was not
accommodated with respect to obtaining history and
physical examinations. The patient did not receive
functioning hearing aides or sign translators who could
assist in obtaining an adequate history.

11/12/2014 A doctor saw the patient. The blood pressure was 120/70.
High blood pressure and high blood lipids were listed as
problems. The patient was on HCTZ 25, metoprolol 100 BID,
Lisinopril 40, Zocor, and aspirin.

51

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 52 of 431 PageID #:12250
Patient #7
11/17/2014 Someone wrote that interpreter services with provider would
be scheduled for the inmate to address his medical concerns.
11/19/2014 An NP saw the inmate with an interpreter in the "blue room."
The inmate stated that his knee gives out. The inmate also
had cough with an irritated throat at night. The NP ordered a
knee brace and cough syrup.
2/24/2015 Glucose 112 (65-110), potassium 3.4; cholesterol 188;
triglycerides 204; HDL 35; LDL 112.

3/16/2015 A doctor documented that the patient walked out of the clinic
during the encounter and documented that the patient does
not want to listen to advice. But the patient was deaf and
probable did not hear the doctor. The blood pressure was
128/89. The potassium was 3.4 and the doctor added
potassium.
7/9/2015 A nurse saw the patient for athlete's feet. The nurse noted
that the patient was taking diabetic medication and blood
pressure medication. The weight was 255 pounds.

7/28/2015 Someone [title not provided] wrote that the patient had
bilateral hearing aids and was given a permit to purchase
headphones for use indefinitely. The weight was 247.
9/30/2015 Potassium 3.7.

52

8

The patient had an elevated glucose and a risk factor
(obesity) and should have received a hemoglobin A1c.
Care could reasonably have been expected to be better.

11

The doctor failed to document that appropriate
accommodation was provided to the patient, given his
deafness.

4

The nurse documented that the patient was on diabetic
medication but the patient was NOT on diabetic
medication. This raises the concern that the patient
could not hear the nurse, leading to an inaccurate
history.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 53 of 431 PageID #:12251
Patient #7
10/13/2015 At HTN chronic clinic the patient complained of back pain and
requested pain medication. The doctor prescribed Naprosyn
375 BID as needed for three months. There was no other
history. The blood pressure was 120/68. The doctor
documented the patient in good control and continued
current medication, stating that high blood lipids were also in
good control.
11/9/2015 An NP saw the patient for a low bunk renewal. The patient
weighted 264 pounds.
2/18/2016 Glucose 98; potassium 3.4; cholesterol 149; TG 126; HDL 37;
LDL 87.
3/8/2016 A doctor saw the patient in HTN clinic. The blood pressure
was 124/86. The weight 240. The doctor took no history.
The doctor did a brief examination and documented the
hypertension and high blood lipids in good control. The doctor
continued the same medications. The doctor did not note any
labs.
4/28/2016 A nurse practitioner saw the patient with an interpreter. The
patient had cough. The lungs were clear. The NP said the
cough might be from the ACE inhibitor but ordered cough
medication. Weight was 265.
6/23/2016 The patient was evaluated in the "blue room" and complained
of sore throat and cough. The patient said the hearing aid
didn't work well. The throat was red. The NP ordered
amoxicillin without a culture or other tests. The NP requested
a repair of the hearing aids. Vital signs were not taken even
though the patient was treated for an infection.

53

1, 3

1

The history was inadequate and treatment was
therefore based on a symptom without establishing a
diagnosis.

The history was inadequate.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 54 of 431 PageID #:12252
Patient #7
7/6/2016 Glucose 113 (65-110); potassium 3.8; cholesterol 148; TG 186
(45-150); HDL 30; LDL 81.

7/27/2016 An NP did another annual evaluation. Again, a nurse obtained
history, noted elevated liver enzymes but nothing more
specific. The weight was 277 pounds. The NP took a history of
drinking "a lot." Even though the patient was 51, colorectal
screening was not done. The NP did write that the inmate
declined a digital rectal examination. No laboratory tests were
evaluated. The patient's prior elevated liver function tests had
not been evaluated for two years even though the patient had
a history of alcoholism.
8/23/2016 Glucose 105; potassium 4.1.
9/9/2016 A nurse practitioner saw the patient for hypertension clinic.
The NP documented that the patient had a cough. The BP was
148/100. The patient said he had just taken his medication
and didn't want to change medications. The NP did not
evaluate lipid values. The NP made no changes in medication.
The NP ordered BP checks two times a week for three weeks.
9/11/2016
9/13/2016
9/14/2016
9/18/2016
9/21/2016
9/25/2016
9/28/2016

Blood pressure was 152/88.
Cholesterol 155; TG 131; HDL 29; LDL 100.
Blood pressure was 148/90.
Blood pressure was 152/98.
Blood pressure was 158/98.
Blood pressure was 150/100.
Blood pressure was 158/98.

54

The elevated glucose and triglycerides should have
prompted a hemoglobin A1c test to screen for diabetes.
Care failed to follow generally accepted guidelines or
usual practice.
7, 8

The patient was over 50 and should have received
colorectal screening but did not. The patient had a
history of alcoholism with elevated enzymes but there
was no follow up. The glucose was previously elevated
and the NP should have ordered an A1c. Care failed to
follow generally accepted guidelines or usual practice.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 55 of 431 PageID #:12253
Patient #7
10/5/2016 An NP saw the patient and noted that the blood pressure was
high (186/106) The patient weighed 292 pounds. The NP
increased lisinopril to 40 mg BID and scheduled a follow up for
11/1/16.
10/9/2016 Blood pressure was 150/82.
10/12/2016 Blood pressure was 158/88.
10/16/2016 Blood pressure was 162/100.
10/19/2016 Blood pressure was 140/80.
10/23/2016 Blood pressure was 138/88.
10/26/2016 Blood pressure was 130/80.
10/27/2016 An NP saw the patient. The BP was 160/96. The weight was
255. This would have been a 37 pound weight loss over three
weeks. The patient complained that his headphones were
broken and he couldn't afford a second set. The NP sent the
patient to the ADA coordinator about the headphones. The
NP continued naproxen for six months without a clear
indication despite the HTN and without addressing the high
blood pressure.
11/1/2016 An NP saw the patient for elevated blood pressure. The blood
pressure was 148/88. The NP ordered a PRN follow up but
took no action regarding the elevated blood pressure. The
weight was listed as 265, a 10 pound weight gain in four days
but a weight loss over the past month.

55

1, 4

Based on weights in the medical record, the patient had
a 37 pound weight loss over three weeks. While this is
probably due to a malfunctioning scale or inaccurate
weights, the NP should have inquired about this but no
history was taken and the patient's weight was not
checked. Also, the blood pressure was elevated but the
NP did not modify treatment. Care failed to follow
generally accepted guidelines or usual practice.

1, 4

The blood pressure was elevated but the NP took no
action. The patient had documented weight loss but no
history was obtained. Was the patient's deafness an
issue? Care failed to follow generally accepted
guidelines or usual practice.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 56 of 431 PageID #:12254
Patient #7
11/11/2016 A nurse saw the patient for "upper respiratory infection." The
patient had cough. The pulse was 112 and the blood pressure
was 98/62 without change in medication. The oxygen
saturation was 93%. The nurse did not refer the patient
despite the patient having tachycardia and low blood pressure,
especially given the patient's recent elevated blood pressures.
A provider should have been consulted. The nurse
documented that the patient would be referred to the NP in
the "blue room" apparently where sign language assistance
could be provided. However, this referral didn't take place.

16

The patient had abnormal vital signs and given the
patient's complaint, a provider should have evaluated
the patient. The blood pressure had been elevated and
had dropped significantly and was now hypotensive
without any intervention. This should have prompted
consultation with a physician but this didn't occur. Care
failed to follow generally accepted guidelines or usual
practice.

11/13/2016 A nurse saw the patient at 1:25 pm but the nurse couldn't take
an adequate history. The nurse wrote, "patient deaf, does not
speak, communicates by writing notes, short words, does not
understand all the nurses questions." The patient was
vomiting. The patient had a "musty" odor from his mouth
with sore throat for four days. The patient was drinking "lots"
of water. The temperature was 96.3, pulse 116; BP 120/70
and oxygen saturation 98%. The patient hadn't eaten in 4-5
days. The nurse told the NP about the patient's condition.

11

The patient was vomiting, had tachycardia, and hadn't
eaten in 4-5 days. The nurse appropriately referred the
patient to a provider but the inability to take an
adequate history because of the deafness needed to be
addressed or referred to a higher level of care.

56

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 57 of 431 PageID #:12255
Patient #7
11/13/2016 An NP saw the patient at 2:00 pm who complained of being
1, 8, 14
sick for several days. The patient had headache, fever, and
vomiting. The NP used the nurses prior vitals. The throat was
beefy red. The NP diagnosed pharyngitis and dehydration and
placed the patient on the infirmary. The NP ordered IV fluid of
500 cc bolus and then 250 cc per hour, with vital signs every
four hours and intravenous Ancef 1 gram every six hours for
five days. The NP did not order any labs.

11/13/2016 The NP ordered a 500 cc bolus followed by 250 cc/ hour for
two hours then at 125 cc hourly for 1 liter then to just
maintain the IV.
11/13/2016 At 9:00 pm the patient said he was thirsty. The patient had
"abdominal distress" at 4:00 pm and refused medication. The
patient had a large liquid BM and then took oral meds. The
temperature was 97.9; pulse 85; BP 118/64. The patient had
voided 700 cc of urine.

57

16

The patient had fever, vomiting, unrecognized weight
loss, low blood pressure, tachycardia, and hadn't eaten
in days. It is not clear how a diagnosis of pharyngitis
was made given the patient's symptoms and
presentation. This appears incompetent. Pharyngitis is
not generally treated with intravenous antibiotics. Since
the NP diagnosed dehydration and started IV antibiotics,
laboratory tests were indicated to assess the degree of
dehydration (particularly since the patient hadn't eaten
in 4-5 days) but were not ordered. This patient should
have been sent to a hospital. Care was worse by virtue
of being unable to obtain a history because the patient
was deaf and staff as documented by the nurse earlier
were unable to obtain a history. Care was grossly and
flagrantly unacceptable.

The patient was known to be dehydrated and told the
nurse he was thirsty. In addition to abdominal distress
the patient had diarrhea. The nurse should have
referred the patient to a provider or consulted a
provider.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 58 of 431 PageID #:12256
Patient #7
11/14/2016 The patient had sore throat and was admitted to the infirmary 1, 2, 14
the evening before for observation. The doctor wrote that the
patient had headache, fever, and vomiting for several days
and documented that the exam was consistent with
pharyngitis and dehydration. The doctor did not obtain a
history with respect to the vomiting, or clinical course. This
may have been due to the patient being deaf. The BP was
120/70; pulse 116; respirations 18; and temperature 96.3. On
examination the throat was described as red with tender
submandibular area but no other abnormalities. The doctor
diagnosed pharyngitis, hay fever, and dehydration. The doctor
noted that the patient was on intravenous antibiotics (Ancef)
and had received 2 liters of intravenous fluid. The doctor
ordered a CBC, CMP and ESR in the morning. These
apparently were not done.

Vomiting, fever, not eating, and dehydration are
inconsistent with pharyngitis. This diagnosis was not
competently made. Notably, the patient was deaf and
couldn't give a good history. The doctor failed to take a
history of the patient's problems. Stat labs were
indicated because the patient hadn't eaten in five days
and had vomiting. Orthostatic blood pressure should
have been obtained. Since the patient had recent
elevated blood pressure, the low blood pressure should
have been cause for concern. The patient should have
been referred to a hospital because of lack of ability to
obtain a history and need for immediate blood tests
(metabolic panel, CBC, lipase, amylase). Care was
grossly and flagrantly unacceptable.

11/14/2016 At 8:25 am a nurse described the patient as lethargic with
temperature of 95.9. The nurse documented stated that the
blood pressure was faint and difficult to hear and that
"possible reading 118/78." The assessment was "weakness."
The nurse consulted a doctor, who didn't feel that the patient
needed to be sent out.

Altered mental status with the patient's other
symptoms of vomiting, diarrhea, dehydration, and fever
warranted hospitalization. The doctor should have sent
the patient to a hospital. Care was grossly and flagrantly
unacceptable.

11/14/2016 At noon the temperature was 94.9, pulse 68, and blood
pressure 114/68.
11/14/2016 At 4:00 pm a nurse wrote an admission note to the infirmary.
The patient wasn't responding to questions. The temperature
was 94.9. The patient was still on aspirin, HCTZ, Lisinopril,
metoprolol, KCL, Ancef and Tylenol.

58

14

14,16 The patient now had hypothermia in addition to
lethargy, dehydration, fever, and diarrhea. The patient
needed hospitalization. The nurse failed to refer to a
provider and the patient should have been sent to a
hospital.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 59 of 431 PageID #:12257
Patient #7
11/14/2016 BUN 32; sodium 130; calcium 8.2; albumin 2.3; bilirubin 3.3;
alk phos 472; AST 165; ALT 119.

14

An unresponsive patient with lethargy, dehydration,
vomiting, hypothermia, diarrhea, and low blood
pressure is consistent with sepsis. Because the nurse
was having trouble recently obtaining a blood pressure,
the patient may also have been in shock. The patient
should have been immediately transferred to a hospital.
Care was grossly and flagrantly unacceptable. Giving
the patient additional fluid without having immediate
lab access placed the patient at significant risk of harm.

16

If the patient wasn't talking and unable to communicate,
a physician should have been consulted. The patient
should have been referred to a hospital.

11/14/2016 A doctor ordered IV fluid NS at 125 cc per hour for 4 liters.
This was equivalent to about two and a half liters a day.
11/14/2016 At 11:50 pm a nurse noted that that the patient was lying in
bed but did not document vital signs.
11/15/2016 A nurse noted that the patient was not talking but "no s/s of
distress." The assessment was weakness without being more
specific. Vital signs were not noted.
11/15/2016 At 4:00 am the temperature was 95.2, respiratory rate 14, and
BP 116/90.
11/15/2016 At 8:30 am a nurse noted that the patient wasn't talking. The
nurse documented temperature of 95.2. The nurse took no
action despite the low temperature.
11/15/2016 At 6:20 pm a nurse noted that the patient wasn't talking.

59

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 60 of 431 PageID #:12258
Patient #7
11/15/2016 At 8:40 pm a nurse noted that the patient's cell mate said that
the patient was kneeling on the floor and laid on the floor.
The patient was placed back in bed but the nurse didn't take
the inmate's vital signs.

14, 16 This gives an impression of disorientation or delirium.
Despite significant deterioration on 11/15/16 with
respect to the patient's mental status, a doctor did not
evaluate the patient. The lack of physician evaluation
was grossly and flagrantly unacceptable.

11/16/2016 At 7:20 am a nurse noted that the patient opened his eyes to
severe stimulus. The patient took fluids with "coaching" and
swallowed AM med. The patient was unable to eat his
breakfast on his own and was waiting for a porter or CNA. The
nurse assessment was "weak."

14, 16 The patient was unable to eat independently. He was
dehydrated, hadn't eaten in days, was vomiting, had
diarrhea, and was hypothermic. Why was he not sent
immediately to a hospital. Care was grossly and
flagrantly unacceptable.

11/16/2016 A nurse wrote that the inmate was unresponsive at 7:53 am.
An apical pulse was 52 and the BP 68/palpable and the blood
sugar was "high" times two. A second IV line was started by a
nurse practitioner. An ambulance was called and the patient
left grounds at 8:25 am, unresponsive.
11/16/2016 At the hospital the patient had rales bilaterally, 1+ edema and
a small RLL infiltrate. The initial assessment was DKA, ARF,
hyperkalemia, and respiratory failure due to pneumonia. The
patient was in septic shock and unresponsive. The initial blood
work included WBC 11.9; hemoglobin 12.2; platelets 102;
glucose 606; potassium 6.8; BUN 106; creatinine 5.01; albumin
2.3; ALT 650; ALT 1441; INR 1.6; and CPK 1404. The
bicarbonate was 12. Later the glucose rose to 790 with a CO2
of 8. The patient was intubated.

60

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 61 of 431 PageID #:12259
Patient #7
11/17/2016 The Medical Director from Dixon wrote a death summary
stating that the patient was admitted to the infirmary with
sore throat, headache, and vomiting for several days. The
doctor noted that the patient was hypothermic on admission
and that the patient developed increased weakness,
recurrence of hypothermia, and decreased responsiveness on
the night of the 15th and was sent to the hospital on the
morning of the 16th. The doctor noted that the patient was in
DKA and had prior normal fasting blood sugars [which is not
accurate]. The patient died on 11:20 pm on 11/16/16 with
presumptive cause of death diabetic ketoacidosis. The doctor
said an autopsy wasn't available.

61

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 62 of 431 PageID #:12260
Patient #8
1/23/2015 The patient had an annual history and physical examination.
The patient was a smoker and had mental illness. His weight
was 159 pounds. The patient was noted to weigh 165 in 2013
but 160 in 2010. The patient was noted to have a "good" oral
examination.
6/26/2015 The patient weighed 160 pounds on a nurse evaluation.
2/5/2016 An NP saw the patient for an enlarged lump on the neck. The
weight was 157 pounds. The lump was tender. The NP
diagnosed parotiditis and prescribed antibiotics for seven
days. Lymphadenopathy was a consideration.

2/10/2016 The NP saw the patient in follow up of the neck mass. The
patient still had a hard lump about 3 cm in size. The NP took
no action and ordered a two week follow up.

2/23/2016 A doctor saw the patient for the left sided neck mass. The
doctor noted a "likely enlarged 2 x 2 cm non-tender LN [lymph
node]." The doctor took no action and ordered a six month
follow up to "monitor likely a chronically enlarged lymph
node."

62

12

The parotid gland is on the face in front of the ear.
When infected, swelling can occur from the preauricular area to the angle of the jaw. The parotid gland
is not in the neck and it is incompetent to diagnose
parotiditis based on neck swelling. The patient should
have been referred to an ENT surgeon for biopsy.

12

Neck masses in adults can be congenital, inflammatory,
or neoplastic in origin. In adults, the potential for
malignancy should be excluded before a benign
diagnosis is given. A 3 cm sized hard mass suggests
malignancy and should be referred to an ENT specialist.

4, 12

The patient had a neck mass for at least a month. The
doctor did no evaluation to identify a source of infection
which should have been present if this was a lymph
node. Malignancy should have been excluded in an
adult with a neck mass. A six month follow up for a
neck mass was indifferent and incompetent or both.
Because of the size the patient should have been
referred to an ENT doctor. Care was incompetent.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 63 of 431 PageID #:12261
Patient #8
3/29/2016 The patient saw a doctor. The weight was 152 pounds which
was an eight pound weight loss. The doctor took no history
regarding the neck mass except that it resolved according to
the patient. The doctor examined the neck and indicated that
there was no further mass noted. The doctor did not address
the weight loss.

The doctor failed to take history of weight loss. It is
unlikely that a 2-3 cm mass in the neck resolved and
likely that the doctor incompetently examined the
patient but based on the documented examination

4/9/2016 A nurse saw the patient who complained of a sore throat
especially when he swallowed. The nurse noted a right sided
neck mass. The nurse called a physician who ordered
prednisone by phone.

4, 12

The doctor started prednisone tapering over 10 days.
There was no diagnosis and we could not even imagine
what the doctor might have been thinking by
prescribing prednisone for painful swallowing with a
neck mass. The patient should have been referred to an
ENT specialist or to a hospital for evaluation. Care was
incompetent.

4/29/2016 A nurse saw the patient for an upper respiratory infection.
The patient complained of cough, headache, fever, and
swollen glands. The weight was 150 pounds, a 10 pound
weight loss. The nurse noted a swollen uvula and a swollen
lymph node on the right. A doctor saw the patient the same
day. The doctor started antibiotics and 10 day follow up. The
weight loss was not addressed.

12

The patient had a neck mass noted for over two
months. Moreover, the patient was losing weight.
Weight loss with a neck mass is most likely malignancy.
Neck masses in adults may be infectious but malignancy
need to be excluded before other diagnoses are
maintained. The doctor should have referred to an ENT
consultant. Care was incompetent.

5/9/2016 An NP saw the patient in follow up. There was increased
swelling of the right side of the throat. The weight was 148
pounds. The patient was afebrile. There was "notable
swelling to the [right] pretonsillar area." The NP diagnosed
tonsillitis. The NP started a different antibiotic and ordered a
follow up visit.

12

This patient had neck swelling for three months with
weight loss. This was very unlikely to be tonsillitis. A
swollen lymph node or mass is unlikely to be trivial
when it is present for three months. The patient should
have been referred to a surgeon for biopsy. Care was
incompetent.

63

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 64 of 431 PageID #:12262
Patient #8
5/11/2016 An NP saw the patient in follow up. The right neck was
described as firm and was painful. The NP documented that
the tonsillitis was worsening and admitted the patient to the
infirmary. The doctor's infirmary admission history and
physical documented starting clindamycin and Levaquin, two
antibiotics. Ironically, the nurses documented that the patient
had a mass on the right side of the neck the size of a golf ball.
The doctor only documented a firm nodule at the angle of the
right jaw. The patient's weight was not taken on admission to
the infirmary and the weight loss was unrecognized.

8, 12

A firm neck mass is unlikely to be tonsillitis. A golf ball
sized lesion is unlikely related to tonsillitis. The patient
should have been referred to an ENT specialist. Because
the mass was worsening a prompt CT scan should have
been performed. Care failed to follow generally
accepted guidelines or usual practice.

5/13/2016 A doctor saw the patient and noted that the patient didn't feel
better. The doctor noted no fever yet the diagnosis was
peritonsillar cellulitis vs. abscess. The doctor ordered salt
water gargle, increased Naprosyn, and added tramadol.

8,12

A firm neck mass is unlikely to be tonsillitis. A golf ball
sized lesion is unlikely related to tonsillitis. If an abscess
was considered the patient should have had a CT scan or
referral for incision and drainage. The presentation was
not of an abscess as there was no fever. The doctor also
did not order a white count. The patient should have
been referred to an ENT consultant. Care failed to
follow generally accepted guidelines or usual practice.

5/15/2016 The patient asked a nurse, "are you going to let me die?" The
nurse referred to a NP. The NP saw the patient and diagnosed
bilateral peritonsillar abscess despite that there was no fever.
The NP sent the patient to the ER for "airway management
and management of the peritonsillar abscesses."
5/15/2016 The patient returned from the hospital the same day.

64

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 65 of 431 PageID #:12263
Patient #8
5/15/2016 A hospital WBC 4.8 and hemoglobin 14 (14-18). Sodium was
131; BUN 7, a CT of the neck showed a neck mass likely a
cancer. The mass was 4 by 2.4 by 2.8 cm. The mass was
worrisome for metastatic lymphadenopathy. The was also an
ill-defined 3 by 3.7 by 3.5 soft tissue mass worrisome for a
neoplastic process. There were several lymph nodes
worrisome for metastatic lesions.
5/15/2016 At 10:00 pm a nurse noted that the patient no longer wanted
to have an IV and IV antibiotics, wanting to see the doctor
saying, "I don't want that IV it's not working." He requested a
new treatment plan.
5/16/2016 A doctor saw the patient. The patient had diarrhea. The
patient wasn't eating solid food. The doctor noted a serum
sodium of 131; potassium 3.9; WBC 4.8; and hemoglobin 14.
The doctor documented that the ER documented that a CT
scan was more consistent with a tumor. The doctor ordered
an ENT consult.
5/18/2016 A doctor told the patient that a CT scan was consistent with
cancer.
5/18/2016 The patient was approved for UIC ENT on this date which was
prior to the referral.
5/19/2016 The patient went to UIC ENT but there was no report in the
record.
5/20/2016 A doctor noted that the patient said a biopsy was
recommended. The doctor documented that the report was
unavailable. The doctor told the patient to wait for the ENT
recommendations.
5/23/2016 The doctor noted that the ENT report was still unavailable.
The doctor discharged the patient from the infirmary with a 12 week follow up pending review of the ENT report.

65

The neck mass was not evaluated appropriately for over
three months.

11

Care was delayed because there was no report from UIC
ENT. It is not clear whether a biopsy was done.

11

Care was delayed because there was no report from UIC
ENT.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 66 of 431 PageID #:12264
Patient #8
6/1/2016 A doctor saw the patient, who now weighed 136 pounds. The
ENT report was still unavailable and the doctor asked for the
ENT report. The doctor said that a biopsy was done and they
were awaiting results.
6/9/2016 A doctor wrote a note stating that he would contact the
scheduler to obtain the biopsy results.
6/16/2016 A nurse saw the patient and documented a weight of 128
pounds. The patient said he couldn't swallow and was losing
weight. The nurse consulted an NP, who ordered boost a
nutritional supplement.
6/21/2016 An approval for a full body PET scan at Rush Copley.

3, 11

6/30/2016 A doctor saw the patient. The weight was 122 pounds. The
doctor noted that the patient was losing weight. The doctor
did not document what the biopsy results were but
documented that the plan was to await a PET scan at Rush.
The diagnosis was still a "neck mass" without diagnosis.

4, 8

66

11
8

11

Care was delayed because there was no report from UIC
ENT. The doctor also took no action to evaluate the
nutritional status of the patient, who was losing weight
quickly.
Care was delayed because there was no report from UIC
ENT.
The NP should have ordered lab tests, albumin, prealbumin, blood count, and metabolic panel to assess the
nutritional status of the patient. Boost may have been
insufficient.
There was no ENT report and it was unclear what the
therapeutic plan was. It had been a month for the
patient to obtain a PET scan and yet a therapeutic plan
for the patient's head and neck cancer wasn't clearly
documented. It was possible that the biopsy showed
cancer but this was unclear. Care failed to follow
generally accepted guidelines or usual practice. This is
so because there was no documented plan and it
appeared that delays in treatment were related to not
having notes from the ENT consultant.
The patient had the neck mass for over four months and
a metastatic cancer was known for six weeks and a
diagnosis was still not made. The patient had lost so
much weight that a nutritional assessment was
indicated, including a survey of what the patient was
eating or able to eat. In this assessment, laboratory
tests should have been ordered. This was not done.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 67 of 431 PageID #:12265
Patient #8
7/11/2016 The patient went for a test on this date but it was unclear
what test the patient was undergoing. It was unclear from
documentation in the record what the diagnosis of the patient
was and what the therapeutic plan was.

11

Reports were not in the record and therefore the
therapeutic plan was not documented.

7/11/2016 The PET scan showed soft tissues in the neck consistent with
malignancy and cervical lymph nodes consistent with
metastatic lesions. The left hip was suggestive of metastasis.
7/27/2016 A doctor saw the patient. The patient weighed 120 pounds.
4, 8, 11
The doctor documented that a PET scan was consistent with
metastatic cancer. The doctor did not have a clear plan except
for follow up with UIC ENT or oncology.

This is an incompetent system of care when a patient
with known cancer since 5/15/16, over two months ago,
still had no diagnosis or therapeutic plan. The patient's
weight loss was even worse, yet the doctor still did not
perform a nutritional assessment or order labs for that
purpose. Care failed to follow generally accepted
guidelines or usual practice.

8/5/2016 A doctor saw the patient. The doctor noted seeing the patient 1, 2, 4,
the day before when he was found on the floor bleeding from
8, 14
the nose. Notably the patient did not have a documented
note from the previous day. The doctor documented that the
patient felt weak and fell. The doctor noted that the patient
had a follow up with ENT the following week and ordered a
wheelchair. The doctor did not take a history except that the
patient said his legs got weak and wobbly when he was
walking and he fell. The history was inadequate, the
examination only included listening to the heart and lungs, and
the only assessment was generalized weakness. The doctor
did not have a diagnosis.

The patient had an apparent syncopal episode the day
before yet the doctor failed to take an appropriate
history, perform an appropriate examination, or make a
diagnosis. Diagnostic lab tests or EKG were not ordered.
There was no effort to make a diagnosis for the patient's
syncope. The only intervention was to give the patient a
wheelchair for long distances, which failed to address
the patient's problem. This was indifferent to the
patient's serious medical need. Care was grossly and
flagrantly unacceptable. The patient should either have
been sent to an ER or had multiple blood tests and EKG.

8/5/2016 An approval for follow up with ENT after the PET scan.

67

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 68 of 431 PageID #:12266
Patient #8
8/11/2016 A brief note on a referral form to ENT documented complete
involvement of the oropharynx with invasion of the larynx and
bilateral nodal disease. The recommendation was for
chemotherapy and radiation therapy.

12

8/18/2016 A doctor saw the patient, who now weighed 117 pounds. The
doctor noted that the patient had a metastatic oropharyngeal
cancer and was cachectic. Yet the doctor took no action to
determine if the patient's nutritional status was adequate. The
doctor documented that chemo and radiation therapy was to
follow at UIC.
8/23/2016 A doctor saw the patient and noted that chemotherapy and
radiation therapy were planed and advised the patient to
"fatten up." The doctor noted that the patient had two
pressure ulcers on the buttock and one on the hip, yet did not
place the patient on the infirmary or order wound care. The
only order for the pressure ulcers was to order an egg-crate
mattress.

4, 8

4

This was indifferent. Advising the patient to "fatten up"
without making an evaluation of what the patient was
able to eat, how much he was eating, and what his
current nutritional status was is indifferent. This patient
had head and neck cancer and in the past said he was
unable to swallow, yet the doctor made no attempt to
determine what the patient was able to eat. The doctor
also failed to competently address three pressure
ulcers. Care was incompetent.

8/30/2016 A doctor saw the patient and discussed upcoming
chemo/radiation therapy but did not indicate when this was to
occur. The doctor did not address the pressure ulcers but did
note that the patient hadn't received his egg crate mattress
yet.

4

The doctor failed to develop a timely or thorough
treatment plan. It wasn't clear whether reports were
available or whether the doctor was simply indifferent
to the patient's serious medical illness. The doctor
failed to pay any attention to the pressure ulcers if they
still existed except to note that the mattress hadn't yet
arrived. Care failed to follow generally accepted
guidelines or usual practice.

8/31/2016 Chemotherapy and radiation therapy was approved.

68

The ENT consult occurred three months after cancer
was diagnosed on CT scan and six months after initial
symptoms. This delay was significant and unacceptable.
Care failed to follow generally accepted guidelines or
usual practice.
The doctor failed to order laboratory tests to assess
nutritional status or to modify therapy so that
nutritional status was adequate despite documenting
that the patient was cachectic. This was indifferent.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 69 of 431 PageID #:12267
Patient #8
9/5/2016 A nurse saw the patient for dizziness. The nurse documented
blood pressure of 94/62 with irregular pulse. Yet, the patient
was not referred to a provider.

16

The patient had a significant symptom and abnormal
vitals with an irregular pulse. Not sending the patient to
a provider placed the patient at risk of harm.

9/8/2016 A nurse saw the patient who had "blanked out." The nurse
1, 2, 14
used a seizure protocol. The blood pressure was 60/40. The
nurse documented that the plan was to call a physician. When
the physician saw the patient, he did not order an EKG, order
blood tests or perform orthostatic blood pressure. The doctor
documented, "When I initially saw pt. I was asking him how he
felt, + he looked at a distant + started losing consciousness
[with] mild body shaking no hx of sz." Notably the doctor
didn't even examine the patient with blood pressure
consistent with shock. The plan was to put the patient on the
infirmary for 23 hour observation and to observe for loss of
consciousness. The doctor's assessment was loss of
consciousness without known etiology, possible seizure, and
possible brain metastasis. Yet the doctor did not refer to a
higher level of care.

The patient had syncope and hypotension at a level
consistent with shock, yet the doctor failed to take
adequate history, ordered no blood tests or EKG, and
failed to thoroughly evaluate the patient who should
have been sent to a hospital as the doctor felt that the
patient might have had brain metastases; a CT of the
brain was indicated. The BP was consistent with shock.
Care was grossly and flagrantly unacceptable and most
likely reflected incompetent or poorly trained
physicians.

9/9/2016 A doctor saw the patient and said that the patient felt fine and 4, 8, 11
wanted to return to his housing unit. The doctor did not check
the blood pressure. The doctor told the patient to use a
wheelchair. The doctor noted that the patient had
experienced possible loss of consciousness and he suspected a
seizure. Because the diagnosis was uncertain a CT brain was
indicated. The doctor discharged the patient back to general
population. Notably the doctor did not check the patient's
pressure ulcers.

Because the patient had prior possible loss of
consciousness and because the doctor did not have a
diagnosis, a CT brain and EKG were indicated. The
doctor sent the patient back to his housing unit without
assessment of the patient's pressure ulcers or without
assessing the patient's nutritional status. This was
indifferent care. The doctor did not document what the
therapeutic plan was and it was not clear exactly what
the plan of the oncologist and radiation therapist was.

69

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 70 of 431 PageID #:12268
Patient #8
9/15/2016 An oncologist wrote a brief note on the referral sheet stating
that inpatient admission for high dose cisplatin chemotherapy
and radiation therapy needed to be scheduled.

11, 12 There were no consultant reports so the status of the
patient was unclear. It had been 4 months since it was
known that the patient had cancer and 7 months since
first symptoms yet he had not yet started therapy. This
was a significant delay that placed the patient at risk.

9/19/2016 Approval for change of the G tube placement.
9/19/2016 Radiation therapy was approved. Apparently the patient went
for a radiation oncology visit.
9/22/2016 A doctor saw the patient and noted that the patient saw UIC 2, 8, 11,
oncology on 9/12 and they recommended admission for
chemotherapy. A dental evaluation and radiation therapy
were also recommended. Consultant reports were not
available. The doctor documented that the patient "saw UIC
(Onc or ENT?)." The doctor did not know the current
therapeutic plan because reports were unavailable. The doctor
noted that the patient had an on-site dental evaluation
scheduled for 9/19/16. The doctor noted that the staff was
checking on the admission dates for chemo and radiation
therapy. The doctor documented that the patient had an
irregular pulse and the doctor ordered an EKG within the next
seven days.

The patient had an irregular pulse which could reflect
atrial fibrillation. An immediate EKG should have been
promptly obtained, yet the doctor ordered an EKG as a
routine. This placed the patient at life threatening risk.
The doctor failed to examine the pressure ulcers or
verify that they had resolved. The lack of reports
significantly contributed to fragmented care, resulting in
lack of knowing what the treatment plan was. Care was
grossly and flagrantly unacceptable.

9/26/2016 An EKG showed multiple premature atrial beats that probably
accounted for the irregular pulse previously noted.
10/17/2016 A doctor noted that the patient had received five radiation
treatments so far.

12

10/26/2016 A nurse documented that the patient remained at UIC after a
scheduled visit and would be admitted.

70

The patient started receiving treatment for his cancer
after five months, which placed the patient at risk. Care
failed to follow generally accepted guidelines or usual
practice.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 71 of 431 PageID #:12269
Patient #8
10/24/2016 A radiation oncologist recommended six cans of Boost daily,
increased pain medication, and evaluation of the patient's
premature atrial contractions.
11/11/2016 During the hospitalization it was noted that the patient had an
unresectable tumor and that the patient had significant weight
loss and cachexia and that a PEG tube was placed 10/27/16.
The patient had multiple laboratory abnormalities which on
return to Dixon were not noted.

11/12/2016 The patient was discharged from the hospital.
11/14/2016 The patient was admitted to the infirmary after return from
UIC where he was admitted for chemotherapy and a PEG tube.
This was not discussed in physician notes previously. The
doctor noted that the hospitalization was complicated by a
tube leak, free air leak, electrolyte abnormalities, and
pneumonia. The patient required transfusion. Remarkably,
the doctor did not document what the laboratory
abnormalities were and did not order any lab tests. The
patient also had mucositis for which an antiviral agent was
prescribed. The doctor noted 2+ edema without assessing
why the patient had edema. The only assessment was
oropharyngeal cancer and dysphagia. The patient had
multiple problems that the doctor did not assess. From this
note, the extent of the patient's problems were not known.
This placed the patient at risk.

11/15/2016 The patient left for radiation therapy.

71

12

It is not clear whether the five month delay in treating
the patient resulted in a possibly treatable cancer
becoming untreatable. Doctors at Dixon failed to
evaluate the patient's nutritional status. Ultimately the
patient needed a feeding tube. Whether this was
avoidable is uncertain, yet doctors at Dixon were
indifferent to this with respect to appropriate
evaluation and treatment. Care failed to follow
generally accepted guidelines or usual practice.

4

An appropriate treatment plan was not documented.
The hospital report was available but the doctor didn't
document all of the patient's problems or document the
plan for the patient's problems. The extent of the
patient's problems and therapeutic plans were unknown
to the prison doctor. This placed the patient at risk.
Care failed to follow generally accepted guidelines or
usual practice.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 72 of 431 PageID #:12270
Patient #8
11/15/2016 At 8:00 pm a nurse noted that the patient was not responding
verbally and was found on the floor. The patient was
lethargic. A doctor was called but instead of sending the
patient to a hospital ordered neuro checks and to call him if
the patient became unresponsive.

14

The patient was unresponsive yet the doctor failed to
evaluate the patient and did not refer to a higher level
of care. Care was grossly and flagrantly unacceptable.
The patient had a serious condition and the doctor
should have referred the patient to a hospital.

11/16/2016 At 8:00 am a nurse documented that the patient had a left
dilated pupil and was scheduled for a writ. The patient had
bilateral leg swelling. The nurse called a doctor, who ordered
morphine for an unclear reason. The patient was apparently
scheduled for a medical appointment but there was no
evidence in the record that this appointment took place.

14

A unilateral dilated pupil and bilateral leg swelling were
not evaluated. The doctor should have evaluated the
patient, as a dilated pupil indicates a serious lifethreatening problem. Care was grossly and flagrantly
unacceptable.

11/16/2016 A doctor saw the patient and noted that the patient had
requested pain medication and increased the morphine
sulphate, but the history of pain was not taken and the extent
of pain was not clear. The doctor noted that the patient had a
fall the night before. The doctor documented that there was
no serious injury. There was no evidence on his examination
that the pupil was examined. Neurologic examination was not
done, an EKG wasn't done, the doctor didn't evaluate the
pressure ulcers, the doctor didn't document what the
treatment plan was.
11/16/2016 At 7:00 pm a nurse performing neuro checks identified a
dilated right pupil. The nurse did not document calling the
doctor.

1, 2, 4 The patient had a fall yet the doctor didn't determine
why the patient fell or if this was due to complications
of his illness or other condition such as cardiac
abnormality. Failure to address this placed the patient
at risk of harm. The doctor failed to address the
abnormal pupil, and failed to inquire as to why the
patient fell. Care was indifferent.

16

72

The nurse should have notified the doctor.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 73 of 431 PageID #:12271
Patient #8
11/17/2016 A nurse found the patient unresponsive. The patient was sent
to a hospital. The hospital performed an EKG that
documented that the patient was in atrial fibrillation. A CT
scan of the brain showed mild atrophy but no masses or acute
intracranial abnormality.

73

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 74 of 431 PageID #:12272

12/24/2013 A doctor wrote a note stating "no specific complaint, no
change [assessment] dementia [plan] continue same care."

1, 2, 4 This doctor wrote identical notes multiple times without
documenting a history, physical examination, or
appropriate assessment. This is indifferent. The doctor
was a surgeon and did not appear to know how to
manage primary care problems.

12/30/2013 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

1/3/2014 The patient fell after taking a shower. A doctor saw the
patient and noted no problems.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

1/16/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

74

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 75 of 431 PageID #:12273

1/20/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

1/22/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

2/5/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

2/11/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

75

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 76 of 431 PageID #:12274

2/19/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

2/24/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

3/4/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

3/12/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

76

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 77 of 431 PageID #:12275

3/19/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

3/27/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

4/15/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

4/23/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

77

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 78 of 431 PageID #:12276

5/7/2014 Calcium 7.9; sodium 136; potassium 4.6. No LFTs done.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

5/21/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

6/9/2014 A doctor wrote an identical note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status.

6/28/2014 A nurse documented finding the patient in bed with his left
face swollen, weakness of the right arm, and confusion with
oxygen saturation of 89%. The patient was sent to a hospital.
6/28/2014 The patient was admitted to the hospital. On 7/14/14, the
patient had an echocardiogram showing moderate LV
enlargement, severe LV dysfunction with EF 30%, mitral and
tricuspid regurgitation, and moderate to severe pulmonary
hypertension. This hospital record was incomplete and only
included the echo.
7/16/2014 The patient returned from the hospital. The patient was on
oxygen therapy. He was admitted to the infirmary.

The repeated failure to monitor this patient was grossly
and flagrantly unacceptable care.

11

78

The hospital discharge summary was not available and
placed the patient at risk of harm.

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 79 of 431 PageID #:12277

7/17/2014 A doctor wrote an infirmary admission note documenting that 1, 2, 4
the patient had a stroke with subsequent respiratory failure.
The therapeutic plan was brief, stating to continue all
discharge medications. The doctor did not discuss oxygen
therapy or the need for it. Activity of daily living monitoring
was not mentioned. The doctor did not document a
neurological examination except "confused alert," which was a
very confusing statement. The patient's neurological status
had not been clarified with respect to activity of daily living
monitoring. A blendarized diet was prescribed but nutritional
status not identified.

The doctor failed in his history to document what the
therapeutic plan upon discharge from the hospital was.
The examination was inadequate and the plan was
incompetently performed.

7/18/2014 The inmate was found on the floor by his bed. The nurse
found no injury but it was not witnessed how the inmate came
to be on the floor. Blood pressure was 96/54. A doctor didn't
see the patient but co-signed the form on 7/21/14.

The patient was hypotensive and appeared to have had
a syncopal episode shortly after hospitalization for
stroke. The nurse should have consulted a doctor.

7/21/2014 A doctor noted that a cardiology consult at UIC was approved
at collegial.
7/22/2014 A doctor saw the patient and noted that the patient had no
specific complaint. The only documented examination
documented was "alert confused." The doctor ordered
oxygen saturation daily for two weeks.
7/22/2014 A Wexford approval for cardiology post hospitalization.
7/24/2014 The patient was found by a nurse on the floor in front of his
chair. The nurse noted no injuries. A doctor co-signed the
injury report on 7/24/14. The nurse documented that the
inmate was not able to explain how the fall happened and
wrote ("as normal for I/M").

16

1, 2, 3 The history and physical examination were inadequate
particularly since the patient experienced an apparent
syncopal episode four days previous.

1, 2, 3 The patient experienced a fall. A doctor signed an
incident report but did not examine the patient. The
nurse documentation presumed that falling was a
normal event for the inmate. Care was indifferent.

79

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 80 of 431 PageID #:12278

8/5/2014 A doctor's note included "S. No specific complaint, takes diet
well, [objective] no acute finding [assessment] post CVA [plan]
continue same care".

8/13/2014 A doctor noted no specific complaints. There was no history.
The only physical examination was to state the lungs were
clear. The only assessment was dementia. The doctor
ordered to give oxygen PRN when the oxygen saturation was
below 91%. The doctor did not order pulse oximeter checks.

8/21/2014 A nurse completed an injury report that the inmate was found
on the floor. The nurse noted that the inmate was confused
and was wrapped in a cover. The patient was evaluated by a
CN 2. A doctor co-signed this injury report on 8/26/14.

1, 2, 4 The doctor failed to document an adequate history,
physical examination, or plan. This was especially
problematic because the patient had two falls since his
stroke and the doctor did not evaluate why the patient
fell.
1, 2, 4 The history and physical examination were inadequate.
The plan was incompetent. To give oxygen "as needed"
when the saturation was below 91% gave unclear
direction to the nurse. What conditions would qualify
as "as needed?" This order was confusing and not
competently written.
16

8/21/2014 BUN 35; creatinine 1.59; albumin 2.7; cholesterol 195; TG 129;
HDL 31; LDL 138; hemoglobin 11.3; MCV 77.
8/21/2014 A nurse found the patient on the floor at 2:30 pm wrapped in
a cover and confused.
8/21/2014 A doctor saw the patient at 4:00 pm. The entire note was "S: 1, 2, 4, 6
no complaint alert [objective] no change [assessment]
dementia [plan] continue same regimen." The doctor didn't
evaluate whether there were injuries in the recent fall.
8/27/2014 A different doctor saw the patient and noted that the patient
was doing well without use of CPAP. To date, it wasn't clear
that the patient was on CPAP. The only assessment was postCVA, dementia, and COPD. This was the first mention of
COPD. The doctor ordered CPAP as needed. This is an
inappropriate plan, as how would a patient know he needed
CPAP during sleep.

80

4

The nurse should have referred a confused patient who
just fell to a physician for immediate examination.

The patient just had a fall. Yet the doctor did not
evaluate the patient. This appeared indifferent or
incompetent. The doctor also failed to assess recent
abnormal laboratory test results.
This was an incompetent plan. CPAP is used during
sleep for sleep apnea which is not a condition that
requires as needed use. The doctor appeared to not
know how to treat sleep apnea.

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 81 of 431 PageID #:12279

9/4/2014 A doctor wrote a note identical to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

9/17/2014 A nurse completed an injury report. During rounds a nurse
found the inmate on the floor. The treatment plan was to
encourage the patient to call staff for help.
10/9/2014 A doctor wrote that the patient had no complaint and that the
patient was not using oxygen and was breathing "normal"
without BiPAP. This patient had dementia and it was unclear
how it was determined that the patient was consciously not
using the oxygen or whether the patient was just demented
and didn't know he was supposed to use it. The plan was to
continue the same care. This patient was confused and
apparently unable to care for himself. The patient was
incapable apparently of intentionally deciding to use or not
use oxygen. The doctor made no attempt to objectively
discover whether the patient needed oxygen therapy. The
doctor did not document oxygen saturation, did not stress the
patient and check oxygen saturation, and the doctor did not
even document why the patient was initially placed on oxygen
so it wasn't clear why the oxygen should be stopped.

10/23/2014 The inmate fell to the floor while eating breakfast on his bed.
A doctor co-signed the injury report on 10/29/14.

16

1, 2, 4 The doctors history, examination, and plan were not
competent and failed to determine whether use of
oxygen was still necessary.

16

81

The nurse should have referred the patient to a doctor.

The nurse should have referred the patient to a doctor.

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 82 of 431 PageID #:12280

10/29/2014 A doctor wrote a note identical to the 12/24/13 note, except
the doctor added that the lungs were clear.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status.

11/10/2014 A doctor wrote a note identical to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status.

12/29/2014 BUN 24; creatinine 1.52 (0.5-1.5); albumin 3; cholesterol 174;
TG 127; HDL 30; LDL 119.
12/31/2014 A doctor wrote an identical note to the 12/24/13 note except
to add that the patient "takes diet well."

1,2, 4

The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status.

1/24/2015 An identical doctor note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status. This doctor
was a surgeon and did not appear to have knowledge on
appropriate evaluation of patients.

1/31/2015 An identical doctor note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status.

3/19/2015 An identical doctor note to the 12/24/13 note.

1, 2, 4 The doctor didn't document an adequate history,
physical examination, or plan. The doctor wrote the
identical brief note 24 times without any specificity
regarding changes in the patient's status.

82

Patient #9

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4/6/2015 An injury report documented the patient fell and asked, "help 11, 19 The patient had a potential serious medical condition
me please, it hurts." The doctor was called and ordered an xafter a fall. The doctor neglected to evaluate the
ray but did not examine the patient. An ADA van was
patient and the x-ray was delayed four days. This is
unavailable and the patient didn't go for the x-rays until
indifferent treatment.
4/10/15, four days later.
5/5/2015 The patient developed diarrhea noted by a nurse but not
19
The doctor neglected the patient's condition.
addressed by a provider.
5/15/2015 The patient had been progressively more confused. On this
1, 2, 3, While the confusion may have been due to the patient's
day the patient stated he needed to get out the back door
11, dementia, an evaluation was indicated. The doctor
performed no history, performed no examination, and
which made no sense. The nurse documented that the patient
the treatment plan of Ativan actually placed the inmate
was very confused and called the doctor. Instead of an
at risk of harm. The manufacturer recommends
evaluation, the patient was medicated by phone order with
extreme caution when using in persons at risk of falls.
Ativan, which was ordered every 12 hours for seven days
This patient had multiple falls. To prescribe this drug
without a physical examination. Later that day the doctor
over the phone without fall precautions is dangerous
ordered a CMP and CBC. These tests were not done.
and placed the patient at risk of harm. The lack of an
ADA van placed the patient at risk of delayed diagnosis.
The ordered labs were never done. Care was grossly and
flagrantly unacceptable.
5/15/2015 A nurse follow up note documented that the patient was
sitting in the chair unresponsive except to sternal rubs. He
was described as slightly lethargic. The nurse did not call a
doctor. There was no nursing note the following day.
5/23/2015 At 10:00 am the patient was agitated and confused. The nurse
called a doctor who ordered Ativan IM every eight hours for
agitation for 30 days without evaluation of the patient.

83

16

The prescription of Ativan may have adversely affected
the patient. A patient who is unresponsive needs to be
evaluated. The nurse should have called the doctor.

8, 19

The patient was a fall risk and this drug needs to be
given with extreme caution for those with fall risk. Also,
the doctor had not made a diagnosis of the patient's
confusion and agitation and diagnostic (labs, CT scan
brain) evaluation was indicated, but the doctor did not
even evaluate the patient. This was indifferent care and
grossly and flagrantly unacceptable.

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 84 of 431 PageID #:12282

5/23/2015 A nurse documented that the patient was ambulating
unsteadily and appeared agitated and confused. When the
nurse approached the patient he fell. The pulse was 120. The
nurse noted no injuries. The nurse called the doctor, whose
only order was to monitor the patient.

8, 19

The patient likely had a change in status (confusion and
agitation). Additional testing was indicated including
labs and CT scan. Instead, nothing was done. The
doctor failed to recognize that his prescription of Ativan
may have worsened the patient's condition.

5/24/2015 A nurse documented that the patient appeared more
confused than usual. There was no referral or physician
examination.
5/26/2015 A doctor saw the patient and wrote that the patient had no
specific complaint despite the patient being unable to give a
history. The doctor noted that the patient was agitated and
confused and that mental health was to evaluate the patient.
The only examination was to document, "no acute findings."
A diagnosis of Alzheimer's disease was made without any
objective assessment of the patient. The plan was to
"continue same care."

16

The nurse should have referred the patient to a doctor.

1, 2, 4 The doctor attempted no history. The doctor
performed no neurologic examination or mental status
examination. The doctor ordered no laboratory tests to
determine if the patient had a reason for the confusion.
CT scan should have been considered. The doctor did
not evaluate the potential for falls given his prescription
of Ativan. Care was indifferent and incompetent.

5/26/2015 The patient complained that his stomach didn't feel well. The
nurse informed the doctor, who gave a phone order for a CMP
and CBC. There was no documented follow up of these tests
and it appeared that they were not done.

11, 19 Ordered tests were not done. The patient needed
evaluation but no examination was done.

6/23/2015 A doctor hadn't documented a note for a month. The doctor
wrote an identical note to the 12/24/13 note.

1, 2, 4 The history, physical examination and assessments were
inadequate.

84

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 85 of 431 PageID #:12283

7/8/2015 A nurse saw the patient at 6:30 am and wrote that the patient
couldn't get up to eat. The nurse noted that the patient was
totally dependent for activities of daily living including feeding
and that his condition "is declining." He was missing his
dentures and needed a dental referral. A doctor saw the
patient at 9:35 am and wrote that there was no change in
status and that the patient needed help in ambulation. The
only examination documented "no change." The plan was to
"continue same care."
7/11/2015 A nurse documented that the patient appeared "very weak"
and that his condition was "declining." It wasn't clear what
the nurse perceived as wrong but no referral was made.

1, 2, 4, If there were no change in status, how was it that the
19
patient needed help in ambulation unless his need had
previously been ignored. Since the doctor determined
that the patient needed help with ambulation, a change
in therapy was indicated but the doctor documented
"no change." He did not initiate how to help the patient
with ambulation. Care was indifferent.

16

The nurse should have referred to a physician.

7/12/2015 A nurse documented that the patient was very weak and
needed to be held up to be fed and ate only a few spoonfuls of
breakfast. The nurse documented notifying the doctor.
7/12/2015 At 1:35 pm the patient was incontinent of bladder and bowel.
The nurse notified a doctor, who ordered CBC, CMP, UA with
culture in the morning. The blood was actually documented as
drawn that day and at 6:35 pm a nurse documented that the
hospital called that the hemoglobin was 6.1. The doctor was
called and the doctor ordered the patient to be sent to the
hospital.
7/12/2015 WBC 20.4; hemoglobin 6.1.

7/13/2015 Patient admitted to UIC for anemia.
7/16/2015 Surgical path report indicating terminal ileum indicating
infiltrating poorly differentiated adenocarcinoma. The size of
the specimen was 15 by 8 by 5.6 cm.

85

These tests were significant and indicate possible
infection and significant blood loss and required
immediate action.

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 86 of 431 PageID #:12284

7/24/2015 A final report documented that the patient was transferred
from OSH to UIC after a hemoglobin of 6 was found. At UIC
the hemoglobin was 5.5. After transfusion a RLQ mass was
palpated. A CT scan found a RLQ mass concerning for
malignancy. The patient developed fever. A laparoscopic
study found abscess with necrosis and biopsy found poorly
differentiated adenocarcinoma. A partial colectomy with
ileostomy were performed. The patient had poorly
differentiating adenocarcinoma arising from a tubular
adenoma infiltrating through the ileum and muscularis
adenocarcinoma.

UIC physicians were able to palpate an abdominal mass
which was unidentified at Stateville likely because either
the doctor did not examine the patient or because the
doctor could not appreciate the mass. It appeared
based on notes that the doctor did not examine the
patient.

7/24/2015 An oncology consultation in the hospital documented that the
patient had a history of chronic kidney disease, HTN and was
admitted for a hemoglobin of 6 and a RLQ mass. The
oncologist noted that a biopsy was positive for cancer and that
the patient had 12/14 lymph nodes positive for metastases.
The oncologist stated that the patient did not have the
capacity for decision making regarding treatment options.
Chemotherapy was not planned due to the patient's condition.
Nutritional support was recommended.
7/27/2015 The patient was discharged from the hospital. In the hospital
the patient developed fever and was treated for an
intraabdominal abscess. The patient had exploratory
laparotomy with ileocecotomy and ileostomy. Pathology on
the specimen yielded poorly differentiated adenocarcinoma
arising in a tubular adenoma. Due to the advanced stage of
the malignancy no chemotherapy was planned.
7/27/2015 A nurse documented that the patient had staples on his 14
inch abdominal wound and that the patient had liquid stool
covering the wound and under the patient's nails. The patient
was described as confused.

86

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 87 of 431 PageID #:12285

7/27/2015 When discharged from the hospital, the hospital
recommended to perform calorie counts and follow up with
nutrition recommendations for diet.
7/28/2015 A doctor ordered a pureed diet for six months.

4

7/29/2015 A doctor admitted the patient to the infirmary post colon
resection. The patient was on aspirin, and Norvasc. The
doctor took no history of what had occurred in the hospital
including the recommended therapeutic plan. The patient's
current condition was documented as "healing wound
abdomen good condition." The doctor ordered a general diet
and activity "as tolerated" despite repeated past falls and
inability to care for himself. The doctor's physical examination
was that the patient was alert and oriented x 4. The doctor
documented that the patient was functioning well.

The hospital had recommended a calorie count and
nutritional follow up. Instead the doctor ordered a
pureed diet without consideration of its nutritional
content.
1, 2, 4 The doctor performed an incompetent history and
physical examination and appeared unaware of the
patient's existing status. This was indifferent to the
patient's serious medical condition. The doctor did not
assess the patient's nutritional status or ensure that the
patient was safe and protected despite his grim
prognosis.

8/1/2015 A nurse documented that the patient was very combative and
"need more staff to help change." The colostomy bag had
come off and the nurse described the inmate "in a total mess."

11

This patient needed a skilled nursing unit or hospice
care but it was clear that there were insufficient staff to
care for the patient.

8/2/2015 The nurses were changing the colostomy bag and the patient
swung at two nurses with two correctional officers present.
The nurse called a doctor who ordered an increase of the
Ativan to 1 mg IM every six hours for 60 days!

4

The patient was at risk of falls. The Ativan was
dangerous. The doctor made no attempt to discover
what was causing the agitation. Care was grossly and
flagrantly unacceptable.

87

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 88 of 431 PageID #:12286

8/3/2015 A doctor wrote a brief note stating "confused returned from
med writ. Had skin staples removed. Recommendation
consult oncology." The only examination was "no change
healing abdominal wound." The plan was to "continue same
care." Despite the patient being confused, the doctor
continued the Ativan order.

1, 2, 4 The doctor failed to take any history by way of review of
nursing notes or other documents, documented
minimal examination, and continued the same care
which included Ativan for agitation even though the
patient continued to experience falls.

8/3/2015 Later that day a nurse found the patient on the floor. The
patient's cell mate said that the patient attempted to get out
of bed and fell.
8/3/2015 On a referral form to the surgeon at UIC seen for follow up,
the surgeon noted that the staples were removed and
recommended to review the pathology and oncology
recommendations. A CEA baseline was recommended which
was not done. The doctor appeared to ignore or not review
the oncology recommendations.
8/4/2015
8/4/2015
8/4/2015
8/6/2015

Collegial review approved an oncology visit.
Wexford approved an air mattress.
Wexford approved an oncology appointment.
The doctor wrote "spells of agitation and restlessness. Violent
behavior toward nurses." The only documented examination
was "confused restless." The assessment was Alzheimer
dementia and the doctor prescribed Ativan for 30 days.

88

16

The nurse did not refer to a doctor.

19

Doctors at UIC made recommendations which were
ignored.

4

The doctor made no attempt to identify risk factors for
the delirium including hydration, medication side
effects, and supportive care measures. The use of a
benzodiazepine for Alzheimer's delirium has a limited
role. The risk of falls in this patient should have led the
doctor to choose a neuroleptic drug and to check for
metabolic problems and supportive care measures. This
treatment was harmful to the patient, as it placed him
at continued risk for falls and may have been
responsible for worsening of the agitation.

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 89 of 431 PageID #:12287

8/10/2015 The doctor note was virtually the same documenting "no
1, 2, 4 The doctor's continued failure to document a
specific complaint. Confused. [objective] no change
reasonable history, physical examination, and
assessment appeared indifferent.
[assessment] dementia Alzheimer, post colectomy [plan] same
care."
8/19/2015 At 4:00 am a nurse documented that the patient was in acute
distress and was agitated and refused ileostomy care and
diaper change. The nurse documented that additional help
was needed to change the patient, who remained
"uncooperative" during care. The patient was wearing mittens
apparently to prevent disrupting the ileostomy.
8/19/2015 The doctor noted that the patient had no specific complaint
and that there was a good response to Ativan. The doctor's
plan was to continue same care. There was no examination
except a statement that the ileostomy was functioning.
8/25/2015 An injury report documented that the patient fell to the floor
getting up out of bed. The nurse noted no injuries and stated,
"no medical treatment necessary." A provider did not
examine the patient.
8/26/2015 An injury report documented that the patient fell to the floor
attempting to get up out of chair. The nurse said there were
no injuries and declared that no treatment was needed. A
doctor did not examine the patient. The nurse documented
that a doctor would follow up as needed.
8/26/2015 A doctor documented the same note except adding that the
patient had metastases. There was no other comment. The
plan was to continue same care. The doctor failed to note
that the patient had two recent falls.

1, 2, 4 The doctor failed to note prior nursing notes that the
patient at 4:00 am was agitated and uncooperative. The
doctor was not incorporating nursing information into
his assessments despite the patient's inability to give a
history.
16
A doctor should evaluate the patient after a fall. There
was no assessment given the use of Ativan.

16

A doctor should evaluate the patient after a fall. There
was no assessment given the use of Ativan.

1, 2, 4 The doctor did not document new findings in the
history, or document a reasonable examination or
assessment, and failed to note that the patient had
recent falls. Care was indifferent.

89

Patient #9

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8/31/2015 A different doctor saw the patient and wrote a very brief note
stating that the patient had an erythematous coccyx without
skin breakdown, which is an early decubitus. The doctor made
no changes to prevent a decubitus ulcer.

3

The doctor should have ensured that preventive
measures were taken to prevent pressure ulcers.

9/1/2015 At 3:30 am a nurse documented that when they removed the
ileostomy bag the patient's clothes and bed linens were full of
feces. The patient had been scratching around his ileostomy.
9/1/2015 At 7:35 am a doctor saw the patient. The entire note was "no
specific complaint [objective] no change [assessment]
dementia post colectomy for metastatic ca [plan] continue
same care." The doctor failed to note the patient's pruritis
and interference with the ileostomy causing contamination
with feces. The doctor failed to review the nursing notes.

1, 2, 4 The doctor failed to note significant patient
management problems apparently due to indifference
to nursing management problems complicating patient
care.

9/6/2015 A nurse found the patient with feces all over his bed linen.
The patient had pulled off the ileostomy bag. The patient had
mittens placed on his hands but he had removed these as well.
9/9/2015 The doctor wrote an identical note to the 9/1/15 note.

1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.

9/14/2015 The doctor wrote an identical note to the 9/1/15 note.

1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.

9/22/2015 The doctor wrote an identical note to the 9/1/15 note.

1,2, 4

9/25/2015 The patient fell off the toilet. A nurse documented that the
patient fell while trying to transfer off the toilet. The nurse
documented that the patient was confused.

16

90

The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
The nurse should have referred to a physician.

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 91 of 431 PageID #:12289

10/5/2015 A different doctor wrote documenting that the patient was
confused. The doctor did not update the patient's status,
perform any examination except to note confusion and a
colostomy, and did not update the status of the patient.

1, 2, 4 The patient was having repeated falls. There was no
evaluation of medications, attempts to protect the
patient, or evaluate the patient's metabolic status.

10/26/2015 A doctor wrote an identical note to the 9/1/15 note.

1,2,4

The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.

10/29/2015 A doctor wrote an identical note to the 9/1/15 note.

1,2,4

The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.

11/2/2015 A doctor wrote an identical note to the 9/1/15 note.

1,2,4

The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.

11/9/2015 A doctor wrote an identical note to the 9/1/15 note.

1,2,4

The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.

11/16/2015 A doctor wrote an identical note to the 9/1/15 note.

1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.

11/23/2015 A different doctor saw the patient for pus coming from the
ear. The doctor noted a perforated TM with pus and
diagnosed otitis media and started Bactrim for seven days.
11/23/2015 Remarkably, a couple hours later the usual doctor (Medical
Director) saw the patient and wrote an identical note to
9/1/15 not noting the otitis media.
11/24/2015 The patient was sent out on a writ.

1, 2, 4 This was clearly indifferent.

91

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 92 of 431 PageID #:12290

11/24/2015 This oncology appointment was approved 8/4/15 and didn't
take place for more than three months. The oncologist write a
brief note on the referral form. There was no report. The
note said that given the advanced dementia and extensive
malignancies, no treatment was recommended.
Hospice/palliative care was recommended. No follow up was
recommended.
11/26/2015 A doctor ordered a clear liquid diet for 24 hours based on a
nurse call that the patient had liquid stool draining from the
ostomy site.
11/27/2015 A nurse noted that the patient was lethargic and had diarrhea.
The patient was sent to a hospital.
11/29/2015 The patient returned to the infirmary from the hospital. There
was a nurse admission note to the infirmary but no physician
note. The first physician evaluation was on 12/3/15 when the
doctor wrote an identical note to the 9/1/15 note.
11/29/2015 The patient was discharged from UIC on 11/29/15 after an
11/27/15 admission. The patient was admitted for altered
mental status. The patient was treated with antibiotics and
improved. A urinary infection was diagnosed. C difficile was
negative. Chest x-ray was negative. Patient was transitioned
to Bactrim. The patient's initial BUN was 56 and improved
with hydration. So the patient was significantly dehydrated on
arrival. X-rays of the abdomen and chest showed no acute
problems.
12/3/2015 This was the first note after hospitalization and the doctor
wrote an identical note to the 9/1/15 note.

1, 2, 4 Care was indifferent, as the doctor failed to even review
hospital notes, note the status of the patient, or assess
whether the patient had improved or not after
hospitalization. Care was grossly and flagrantly
unacceptable.

92

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 93 of 431 PageID #:12291

12/7/2015 A doctor's note was identical to the 9/1/15 note.

1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.

12/14/2015 A doctor's note was identical to the 9/1/15 note.

1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.

12/23/2015 A doctor wrote that the patient had no specific complaints.
1,2, 4 The doctor was indifferent to the status of the patient
The examination was "no change" and the assessment was
and unaware of what was happening to the patient.
"dementia post metastatic ca colon resection." The plan was
"continue same care."
12/29/2015 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
1/5/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
1/11/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
1/18/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
1/25/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
2/2/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
2/8/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
2/15/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.

93

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 94 of 431 PageID #:12292

2/16/2016 At 6:00 am a nurse found the inmate on the floor who asked,
"help me." The nurse identified no injuries.
2/23/2016 A nurse found the inmate on the floor yelling "help me." A
doctor saw the patient and wrote, "IM fell again today." The
doctor assessed no injuries.

16

The nurse should have referred to a physician.

4

The doctor wrote that fall precautions should be used
but didn't specify what these were. The doctor wrote to
continue the present management. It appeared that
the patient was still on Ativan.

2/29/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
3/7/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
3/14/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
3/21/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
3/28/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
4/5/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
4/11/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.
4/18/2016 A doctor wrote a note that was identical to the 12/23/15 note. 1, 2, 4 The doctor was indifferent to the status of the patient
and unaware of what was happening to the patient.

94

Patient #9

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 95 of 431 PageID #:12293

4/19/2016 At 1:30 am a nurse noted that the patient was listless and
notified a doctor. The patient was pale, diaphoretic, and
listless. He was lying in bed without any sheets or covers and
appeared to be in pain and was not responding as usual.
4/19/2016 At 3:00 am a nurse documented that the patient was in bed
and condition was unchanged since 1:40 am. The doctor was
notified and ordered the patient sent to the hospital.
4/19/2016 At 6:25 am a nurse noted that the patient was sent to a
hospital and had acute encephalopathy, hyperkalemia, and
elevated troponin.
4/21/2016 An autopsy was done. Fingernails were medium length and
dirty, the patient had multiple scars on the extremities and
back. The toenails were dirty. The cause of death was sepsis.

95

It was clear that the patient's status had not been
monitored at the facility.
Based on the autopsy, it appeared that the patient had
been neglected at the facility.

Patient #10

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 96 of 431 PageID #:12294

1/7/2013 Patient was seen at HTN chronic clinic. The presence of risk
factors line was blank even though the patient had multiple
risk factors.
7/1/2013 The patient complained to a CMT that he was "throwing up
black stuff and also defecating black stool all day. I haven't
eaten anything all day cause of my vomiting." The CMT
documented referring the patient to a doctor the following
day. This referral did not occur. There was no evidence of
evaluation of this potential GI bleed.

7, 16

7/16/2013 A doctor saw the patient in diabetes chronic clinic. The doctor
did not address the patient's very recent complaint of possible
GI bleeding. The doctor took no history. The doctor also saw
the patient for hypertension clinic and noted no chest pain.
The blood pressure was 106/84. Lipids were not addressed.

10/9/2013 A provider saw the patient for HTN chronic care clinic. Blood
pressure was 120/68; pulse was 92. The patient was
lightheaded. The patient was on Vasotec 20 BID, HCTZ 25,
120, ASA. The provider decreased the verapamil from 120 to
80 mg daily despite the blood pressure being in good control.
This was done because the patient was lightheaded. The
patient was not listed as having high blood lipids despite very
high risk and contemporary recommendations for high dose of
statin.

96

The patient had symptoms of gastrointestinal bleeding
and was on a NSAID and aspirin and should have had
endoscopy. Instead, the patient wasn't even referred to
a provider. Subsequent providers failed to identify
these symptoms. Care failed to follow generally
accepted guidelines or usual practice.

1, 2, 8 The doctor failed to take history of the very recent
possible GI bleed. The patient should have been
referred for endoscopy. The doctor also did not assess
lipid therapy in a 68-year-old male with multiple
cardiovascular risk factors. Care failed to follow
generally accepted guidelines or usual practice.
2, 4

The provider failed to assess lipids. The patient had
multiple cardiovascular risks and should have been
assessed for lipid disorder. Because of age and multiple
risk factors, the patient likely needed to be on a statin
medication, but this was not done. Care failed to follow
generally accepted guidelines or usual practice.

Patient #10

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 97 of 431 PageID #:12295

1/15/2014 The patient was seen in HTN chronic clinic. The blood
pressure was 139/82 which is considered elevated for a
diabetic. The doctor assessed good control but didn't increase
the medication. Lipids were not addressed.

2, 3

1/28/2014 A doctor wrote a chart note documenting review of labs. The
doctor documented "control of hyperlipidemia fair" but did
not institute treatment.

2

97

The provider assessed good BP control when control
was questionable. A reasonable goal is 130/80 or less
especially with cardiovascular risk factors. Although the
goal is 140/90, consideration of the patient's
cardiovascular risks should have been made. The doctor
did not assess whether the patient had lipid disorder in
a patient at high risk of cardiovascular disease. Blood
pressure medication should have been considered to be
adjusted and a statin drug should have been started.

The doctor diagnosed fair lipid control but it is unclear
what this meant. The patient probably needed
treatment with a statin drug but this was not done.
Care failed to follow generally accepted guidelines or
usual practice.

Patient #10

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 98 of 431 PageID #:12296

5/6/2014 A PA saw the patient in diabetes chronic clinic. The blood
pressure was 140/80. The PA documented that the patient
was on Motrin without addressing why. The blood pressure
was listed as in good control when it was elevated for a person
with diabetes. The PA listed the total cholesterol of 161 and
HDL of 41. According to the American Heart Association 10
year risk calculator the patient had a 53% 10 year risk of heart
disease or stroke and should have been recommended a high
intensity statin drug. The PA did not address lipid treatment
apparently not understanding the risk factors of the patient.

2, 17

The PA failed to appreciate the cardiovascular risk to the
patient. Ibuprofen (Motrin) carries a FDA black box
warning for serious cardiovascular thrombotic events.
The warning states, "Nonsteroidal anti-inflammatory
drugs (NSAIDS) cause an increased risk of serious
cardiovascular thrombotic events, including myocardial
infarction, and stroke, which can be fatal. This risk may
occur early in treatment and may increase with duration
of use. Ibuprofen is contraindicated in the setting of
coronary artery bypass graft (CABG) surgery." A second
black box warning is that Ibuprofen can increase risk of
serious gastrointestinal (GI) adverse events including
bleeding, ulceration, and perforation of the stomach or
intestines, which can be fatal. These events can occur at
any time during use and without warning symptoms.
Elderly patients and patients with a prior history of
peptic ulcer disease and/or GI bleeding are at greater
risk for serious GI events." Motrin can also exacerbate
hypertension and can cause renal disease and carries a
warning to use with caution in persons with
hypertension.

12/17/2014 A doctor renewed Motrin for six months at 800 mg a day
without an evaluation. The doctor did not note the Black box
warnings or HTN. This was an error.
1/26/2015 A1c 7.1; cholesterol 190; TG 79; HDL 44; LDL 130; HGB 14.9.

17

Care failed to follow generally accepted guidelines or
usual practices.

2/7/2015 The patient had an annual physical examination. Colorectal
screening was not offered but a digital rectal examination was
done, which was guaiac negative.

7

The patient should have had colorectal cancer screening
consistent with contemporary guidelines. This was
especially true since the patient had prior episode of GI
bleeding.

98

Patient #10

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 99 of 431 PageID #:12297

4/17/2015 Diabetes chronic clinic BP 163/89, weight 203; A1c
documented as 7.3. The doctor did not address the elevated
blood pressure. The patient was on NPH 20 units and
metformin 850 BID. On a different HTN chronic clinic form the
HTN was addressed. The doctor documented good
hypertension control even though it was not, and fair high
blood lipid control even though the patient was no on antilipid therapy. The doctor did increase the verapamil from 80
to 120 mg. The patient was also on lisinopril, metformin, NPH
insulin, HCTZ, verapamil, aspirin, and 800 mg Motrin once
daily. The use of Motrin should not be continuous as it was
because of the risk for kidney disease and risk for thrombotic
events. The doctor documented the LDL cholesterol as 133
which is high.
4/30/2015 Sodium 134; A1c 7.3; cholesterol 191; TG 71; HDL 44; LDL 133;
HGB 16.3
7/22/2015 A1c 7.1.
8/13/2015 A provider saw the patient for HTN clinic. The blood pressure
was 158/95. A repeat was 146/85. The blood pressure was
listed as in good control and blood lipids were listed as in good
control. There was no change of medication despite the
elevated blood pressure. The A1c was listed as 7.1. The
doctor ordered an EKG. The doctor noted that the creatinine
was 1.48. The patient was still on Motrin yet the doctor did
not identify why the patient was taking this medication and
that it might be damaging his kidney.

99

2, 4

The doctor failed to make an accurate diagnosis of the
blood pressure control. The doctor assessed good
control when it was poor control; yet medication was
increased. This patient had an American Cardiology 10year risk of heart disease or stroke of 65%. There
should have been aggressive treatment of
cardiovascular risk factors including addition of a statin
drug and the Motrin should have been discontinued.
Care failed to follow generally accepted guidelines or
usual practice.

2, 4, 6 The doctor failed to make an accurate diagnosis of the
blood pressure control. The doctor assessed good
control when it was poor control; medication should
have been increased. This patient had an American
Cardiology 10-year risk of heart disease or stroke of
65%. There should have been aggressive treatment of
cardiovascular risk factors including addition of a statin
drug and the Motrin should have been discontinued.
Also, the doctor noted an elevated creatinine but did
not review use of the Motrin. Care failed to follow
generally accepted guidelines or usual practice.

Patient #10

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 100 of 431 PageID #:12298

8/23/2015 An EKG shows non-specific STT wave changes that could be
consistent with ischemia.
11/22/2015 A1c 6.7.
12/21/2015 A provider saw the patient for a periodic semi-annual diabetic
evaluation. The blood pressure was 151/87. The doctor did
not address the elevated blood pressure. The doctor renewed
Motrin for three months, restricting the patient to 10 tablets a
month.
2/24/2016 Total cholesterol 172; TG 82; HDL 42; LDL 114.
3/17/2016 Diabetes chronic clinic BP 163/89, weight 203; A1c
documented as 7.3. The doctor did not address the elevated
blood pressure. The patient was on NPH 20 units and
metformin 850 BID. On a different HTN chronic clinic form the
HTN was addressed. The doctor documented good
hypertension control even though it was not, and fair high
blood lipid control even though the patient was no on antilipid therapy. The doctor did increase the verapamil from 80
to 120 mg. The patient was also on lisinopril, metformin, NPH
insulin, HCTZ, verapamil, aspirin, and 800 mg Motrin once
daily. The use of Motrin should not be continuous as it was
because of the risk for kidney disease. The doctor
documented the LDL cholesterol as 133 which is high.
3/23/2016 Microalbumin/creatinine ration 37 (0-30); A1c 8; cholesterol
175; TG 88; HDL 47; LDL 110.

100

6

This EKG could have been consistent with ischemia yet
was not documented as reviewed with respect to the
patient's clinical picture.

17

Blood pressure medication should have been adjusted.
Same comments as above related to treatment with a
statin and use of Motrin. However, the doctor did
decrease the amount of Motrin the patient was given.

4

The blood pressure was adjusted but was done with
verapamil. Since the patient had prior angina, a beta
blocker should have been considered. The doctor did
not address lipid risk. The patient had a 45% 10-year
risk of heart disease or stroke based on recent labs. He
should have been on a high intensity statin. The doctor
ordered Motrin when it placed the patient at significant
risk of thrombotic events. Care failed to follow
generally accepted guidelines or usual practice.

Patient #10

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 101 of 431 PageID #:12299

4/14/2016 A doctor saw the patient for annual diabetic clinic. The doctor
noted that the A1c was 8 but said the lipids were "OK" which
they were not. The blood pressure was 139/88. The doctor
wrote that he discussed statin coverage with the patient who
wanted to defer starting. The doctor wrote that he referred
the patient to Dr. Obaisi. The doctor increased NPH insulin to
26 units HS but did not address the elevated blood pressure.
4/15/2016 An EKG shows non-specific STT wave changes that could be
consistent with ischemia. The changes are different from the
previous EKG of 8/23/15.

101

4

The blood pressure was not considered elevated but
because the patient had high cardiovascular risk,
medication increase should have been considered. The
doctor did not address lipid risk and treatment, and
ordered Motrin when it placed the patient at significant
risk. Care failed to follow generally accepted guidelines
or usual practice.

Patient #10

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 102 of 431 PageID #:12300

4/15/2016 A doctor saw the patient who complained of waking up
feeling nauseous and became cold and clammy and vomited.
The doctor noted that an EKG showed sinus tachycardia. [The
EKG showed also non-specific STT wave changes that could be
consistent with ischemia]. The blood pressure was 112/74,
which is low for this patient and the heart rate 92. The doctor
took no other history. The doctor's assessment was diabetes
R/O coronary event or NSAID gastritis and dehydration. These
assessments appeared to be accurate. However, the plan and
follow up was below standard of care. The doctor ordered
CBC, CMP, troponin, CK-MB, stopped Motrin, and started
omeprazole for a week and gave a liter of fluid and gave the
patient a dose of NTG. The doctor did not take a history usual
for angina. The CBC was drawn and showed hemoglobin of
10.3, which is very low but was never followed up. This was
consistent with a GI bleed, as the patient had a prior normal
hemoglobin. The patient had a prior normal hemoglobin of
13.7. The CMP, CK-MB, and troponin were not done or were
unavailable in the medical record. The doctor also only
prescribed a single nitroglycerin tablet but did not order longterm anti-anginal medication. The omeprazole was only
ordered for seven days. The doctor did not follow up. Given
the high risk of this patient, a possible anginal event should
have prompted a stress test or cardiac catheterization.

4/18/2016 An EKG shows resolution of STT wave changes from 4/15/16.
This is significant because it supports a suggestion of ischemia.
Given the patient's history a stress test or cardiac
catheterization were indicated.

102

14

On this day, especially given the drop in blood pressure,
the 10-year risk of heart disease or stroke was 38%. If
the blood pressure of 4/14/16 (139/88) was used, the
patient had a 10-year risk of heart disease or stroke of
52%. This was a very high risk patient. The doctor failed
to take an adequate history for acute coronary
syndrome but did acknowledge the possibility. Also, the
patient was on long-term Motrin which carries a black
box warning for cardiac thrombotic events. Since the
EKG was abnormal and suggested ischemia, the patient
should either have been referred to a hospital to rule
out MI or been placed on regular anti-anginal
medication and referred for urgent stress test or
angiography. Ordering tropinin levels in a prison is not a
good idea because if positive, the prison could not
reasonably treat the patient appropriately and the
patient's access to hospital care would be delayed. After
this lack of referral, subsequent physicians did not order
routine cardiology referral, increase anti-anginal drugs,
or order stress testing or cardiac catheterization. This
patient had multiple risk factors for a cardiac event
(smoker, HTN, diabetes, high blood lipids, male sex,
age). Care failed to follow generally accepted guidelines
or usual practice. This place the patient at risk of cardiac
thrombotic event.

Patient #10

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 103 of 431 PageID #:12301

4/18/2016 Hemoglobin 10.3. There was no evidence in the progress
notes of follow up of this significantly abnormal test.

4/18/2016 A doctor saw the patient for follow up of the dehydration. The
blood pressure was 101/61. The patient was able to eat. The
doctor took no history typically used for angina. The doctor
repeated the EKG but did not comment on it. The EKG was
now normal when on the 15th it showed STT changes
consistent with ischemia. This reversal of ischemic changes is
significant and demonstrates that the patient had ongoing
angina.

6

This significant laboratory finding was not acted on,
placing the patient at significant risk. The patient should
have been referred for upper endoscopy. Care failed to
follow generally accepted guidelines or usual practice.

1, 7

The doctor should have obtained a history given the
recent event on 4/15/16. The doctor failed to
document review of the EKGs in sequence and assess in
light of the patient's cardiovascular risks. Because of
the reversal of EKG changes, the patient should have
been referred for stress testing. Care failed to follow
generally accepted guidelines or usual practice.

5/5/2016 The Medical Director saw the patient. The blood pressure was 1, 2, 3,
149/83 and the pulse 98. The doctor did not discuss the
7, 17
recent possible anginal episode. The doctor addressed back
pain but took no history, diagnosed chronic back pain, and
prescribed 600 mg Motrin twice a day for 60 days despite the
elevated blood pressure. The doctor did not discuss the blood
pressure or evaluate the recent lab showing a significant drop
in hemoglobin.

7/20/2016 A1c 6.7
8/1/2016 A doctor saw the patient for diabetic clinic. The blood
pressure was 135/82 which is not elevated blood pressure for
persons with diabetes but is considered possibly elevated for
persons with diabetes and cardiovascular disease. The A1c was
6.7. The doctor made no changes to therapy and did not
address the blood pressure.

103

2, 3

The doctor failed to review the abnormal hemoglobin of
10.3. The doctor failed to adjust medication for
elevated blood pressure. The doctor failed to assess the
patient's recent possible anginal episode in light of the
patient's risk factors. The doctor prescribed Motrin
despite a possible recent anginal episode and despite
the black box warning for risk of thrombotic cardiac
events. The patient should have been referred for
stress testing. Care failed to follow generally accepted
guidelines or usual practice.

The doctor should have considered adjustment of blood
pressure medication but did not. The doctor should
have initiated lipid therapy or discussed with the patient
but did not. Same comments as above for statins and
Motrin. The abnormal hemoglobin was unnoticed. Care
failed to follow generally accepted guidelines or usual
practice.

Patient #10

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 104 of 431 PageID #:12302

8/3/2016 Cholesterol 157; TG 99; HDL 42; LDL 95; hemoglobin 12; MCV
71 (80-99);
8/12/2016 A doctor wrote a very brief illegible note. A nurse took blood
pressure of 142/95 but it was not addressed.

9/5/2016 A doctor saw the patient for HTN chronic clinic. The blood
pressure was 150/87 and a retake was 133/83. The doctor
assessed "good" HTN control but the control was
questionable. The doctor made no changes.

11/30/2016 A1c 7.
12/6/2016 A doctor saw the patient for diabetic clinic. The blood
pressure was 145/91. The A1c was 7. The doctor made not
changes and did not adjust the blood pressure medication.

1/6/2017 Sodium 134; cholesterol 167; TG 77; HDL 39; LDL 113;
hemoglobin 13.7 MCV 72.7 (80-99).

104

2, 3

The blood pressure was elevated but medications were
not adjusted. The doctor did not address lipid risk
despite a 36% 10-year risk of heart disease and ordered
Motrin when it placed the patient at significant risk.
Same comments as about these issues. Care failed to
follow generally accepted guidelines or usual practice.

2, 3

The blood pressure was initially elevated but
medications were not adjusted. The doctor did not
address lipid risk and treatment and ordered Motrin
when it placed the patient at significant risk. Same
comments as about these issues. Care failed to follow
generally accepted guidelines or usual practice.

2, 3

The blood pressure was elevated but medications were
not adjusted. The doctor did not address lipid risk and
treatment and ordered Motrin when it placed the
patient at significant risk. Same comments as about
these issues. Care failed to follow generally accepted
guidelines or usual practice.

Patient #10

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 105 of 431 PageID #:12303

1/6/2017 A nurse saw the patient for back pain. The blood pressure was
151/97. The nurse referred to a doctor who saw the patient
the same day. The doctor addressed the back pain and
increased the Motrin at 800 BID without addressing the
elevated blood pressure and without recognizing the prior
episode of decrease in hemoglobin. This needed to be
considered because both Motrin and aspirin can cause GI
bleeding which the patient appeared to have sustained. The
Motrin was prescribed at a high dose 800 mg BID but
apparently for two weeks.

4, 17

The doctor failed to treat elevated blood pressure. The
doctor failed to note the prior abnormal hemoglobin
and failed to appreciate black box warnings for Motrin
which placed this patient at significant risk. Care failed
to follow generally accepted guidelines or usual
practice.

1/10/2017 A doctor discontinued the Motrin and started Naprosyn
another NSAID at a dose of 500 mg BID. The patient had
received 28 Motrin tablets as a KOP medication on 1/9/17 and
received the Naprosyn on 1/23/17 which was when the
Motrin would have been completely used up if taken as
prescribed. Nevertheless, giving the patient another NSAID
when the patient was on aspirin and had a recent presumed GI
bleed was problematic. The doctor apparently failed to
appreciate the Black Box warnings for this drug as well as its
effect on hypertension.

17

The doctor failed to appreciate black box warnings for a
NSAID in light of this patient's risk factors. Care failed
to follow generally accepted guidelines or usual
practice.

1/13/2017 A doctor wrote an illegible note. A nurse obtained blood
pressure was 102/70 and the pulse was 101.
1/16/2017 The inmate was not seen in eye clinic due to lock down.
1/18/2017 The patient was not seen by a nurse because of lock down.
1/19/2017 The patient was not seen by a doctor due to lock down.
1/26/2017 The patient was not seen by a doctor due to lock down.

105

Patient #10

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 106 of 431 PageID #:12304

1/31/2017 An annual physical examination was done. A digital rectal
examination included a negative guaiac test. It appears that
this constitutes colorectal cancer screening, which is
inadequate screening.

7, 8

2/5/2017 A nurse was asked to emergently assess an inmate but on
arrival the inmate was lying face down on the floor. The
patient was unconscious and not breathing. CPR was started
and the patient was sent to a hospital, where he died. An EKG
on this date showed acute ischemia.
2/5/2017 A death certificate documented that an autopsy was done but
it wasn't in the record. The death certificate listed the cause
of death as coronary atherosclerosis with gastrointestinal
hemorrhage as a secondary cause of death.
2/6/2017 A Death Summary by the Medical Director at Stateville
documented that the patient had 90% occlusion of a coronary
artery and "limited patchy gastrointestinal hemorrhage." In a
Wexford Mortality Review Worksheet the doctor documented
that earlier intervention was not possible and that there was
no way to improve care.

106

The patient should have had colorectal cancer screening
consistent with contemporary guidelines. This was
especially true since the patient had prior episode of GI
bleeding. The patient should have had screening for
lipid disorder but doctors did not appear to appreciate
the patient's risk for heart disease.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 107 of 431 PageID #:12305
Patient #11
3/11/2014 Total cholesterol 176; TG 71; HDL 42; LDL 120; hemoglobin
14.1; MCV 101.1.
4/5/2014 The patient was evaluated in HTN chronic clinic. The weight
was 180. The blood pressure was 106/69.
7/3/2014 Total cholesterol 178; TG 136; HDL 35; LDL 116; hemoglobin
14.5; MCV 101.7; platelets 148.
7/10/2014 The patient was evaluated in HTN chronic clinic. Blood
pressure was 120/73. The weight was 173, a seven pound
weight loss over seven months. This was not addressed.
11/11/2014 Total cholesterol 189; TG 117; HDL 38; LDL 128. CBC was
normal.
11/25/2014 The patient was evaluated in HTN chronic clinic. The weight
was 178. Blood pressure was 120/75.
2/12/2015 Potassium 3.4; cholesterol 166; TG 107; HDL 36; LDL 109.
5/16/2015 A doctor saw the patient the weight was 171 pounds.
6/3/2015 A doctor saw the patient for a cold. The weight was 160
pounds. The pulse was 117. Neither the 20 pound weight loss
nor the tachycardia was addressed.

6/12/2015 Potassium 3.4; cholesterol 155; TG 123; HDL 36; LDL 94.
8/24/2015 BMP was normal.

107

3

The patient had a 10-year risk of heart disease or stroke
of 16.6% and should have been on a moderate to high
intensity statin.

3

The patient had a 10-year risk of heart disease or stroke
of 22% and should have been on a moderate to high
intensity statin.

3

The patient had a 10-year risk of heart disease or stroke
of 22% and should have been on a moderate to high
intensity statin.

1, 2, 3 The doctor failed to take adequate history regarding
weight loss and did not evaluate adequately for the
tachycardia. The treatment plan should have contained
evaluations to determine why the patient had
tachycardia and weight loss.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 108 of 431 PageID #:12306
Patient #11
10/6/2015 A doctor saw the patient for dysphagia for solid food. The
doctor took no history. The weight was 163 and the patient
had lost 17 pounds since 4/5/14. The doctor noted that the
patient had a right neck mass. The doctor ordered an
antibiotic and follow up in 10 days.

7, 8

10/16/2015 The doctor saw the patient in follow up. The neck mass was
still there and was described as the size of a golf ball. The
dysphagia was worse. The doctor noted a 17 pound weight
loss over seven months. The doctor ordered an ultrasound
with a follow up with the Medical Director in 4-6 weeks.

Neck mass and dysphagia is consistent with carcinoma
which needs to be ruled out before more benign
conditions are considered. It wasn't clear what infection
the doctor was considering but a simultaneous EGD
and/or neck CT were indicated.
Ultrasound is not a preferred test for evaluation of neck
mass but was an option. A 4-6 week follow up was too
long.

10/20/2015 An ultrasound showed nodular densities on the right side of
neck question of adenopathy or neoplasm.
10/27/2015 A collegial review approved an ultrasound. This was a low
value test for this condition. The patient needed a biopsy. A
CT scan would have been reasonable.
10/28/2015 The Medical Director saw the patient. The only note was "U/S
[presumably ultrasound] neck masses R neck, CXR this week."
This patient needed a prompt biopsy of the mass.
10/28/2015 A US of neck was approved for right neck mass with dysphagia.
The patient had already had the test.
10/30/2015 A chest x-ray showed diffuse emphysema, COPD, tortuous
aorta.
11/10/2015 A collegial review approved a UIC oncology visit.
11/18/2015 The Medical Director saw the patient. The doctor noted that
the patient had a fixed neck mass and assessed throat
neoplasm and appeared to order a local ENT consultant.

108

2

These abnormalities were not incorporated into the
assessment of the patient and were not managed.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 109 of 431 PageID #:12307
Patient #11
11/30/2015 A Joliet ENT doctor saw the patient and noted a neck mass and
recommended a PET scan, laryngoscopy with biopsy,
bronchoscopy, and esophagoscopy.
12/3/2015 The Medical Director saw the patient and noted that the
patient returned from a writ. The Medical Director noted that
the patient has a tumor on the posterior tongue and was to
have endoscopy, laryngoscopy, bronchoscopy, and biopsy.
12/8/2015 A collegial review approved a PET scan and laryngoscopy with
biopsy.
12/18/2015 The patient returned from a PET scan. His weight was 154
pounds. The pulse was 128 but not addressed.
12/18/2015 A PET scan was consistent with malignancy on the right side of
the tongue with nodal metastases.
12/22/2015 A doctor saw the patient, who now weighed 151 pounds. The
doctor noted that the PET scan showed metastatic tongue
cancer and that the inmate was scheduled for chemotherapy
and radiation therapy.
12/30/2015 The patient complained to a nurse that he was coughing up
blood. The pulse was 113. The nurse referred to a doctor.
The Medical Director saw the patient. The doctor
documented that there was no change in the neck mass, the
lungs were clear. The doctor assessed cough with bloody
sputum "once". The doctor ordered a chest x-ray and
prescribed Claritin an antihistamine.
1/4/2016 A chest x-ray was reported as "negative study."
1/8/2016 The patient had a laryngoscopy and biopsy. The heart rate
was 107.
1/8/2016 A tongue biopsy showed invasive squamous cell cancer
moderately differentiated.

109

3

The doctor did not mention a PET scan which had been
recommended.

2, 3

Cough with bloody sputum in a patient with head and
neck malignancy should prompt concern that there was
an open wound in the area of the cancer, but this was
not a concern apparently.

7

It was three months since the patient first had
symptoms of a neck mass and dysphagia until the time
of diagnosis. The diagnosis was not timely.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 110 of 431 PageID #:12308
Patient #11
1/13/2016 The Medical Director saw the patient and noted that the
patient had laryngoscopy, bronchoscopy, and EGD. The
patient needed follow up with ENT in a week.
1/21/2016 ENT consultant on a referral form wrote that the biopsy
showed squamous cell carcinoma and needed chemotherapy
and radiation therapy with follow up in two months after
completion of radiation therapy.
1/26/2016 The Medical Director stated that ENT at UIC was approved.
The Medical Director had stated on 1/13/16 that the ENT
follow up was to occur in a week.

11

If the patient had bronchoscopy and EGD, the results
were not found.

10

The patient had already seen the ENT doctor but the
Medical Director didn't note the therapeutic plan. It
was unclear if he understood what the ENT had
recommended.

10

The doctor failed to understand the radiation oncology
note which asked for the PET scan images since they
only had a report. The doctor instead ordered another
PET scan.

2/1/2016 A doctor wrote a note but it was illegible.
2/4/2016 The patient went to radiation oncology. They recommended
chemoradiation. The PET scan images were requested.
Medical oncology was to see the patient on 2/11/16. A 1-2
week follow up was recommended for a simulation.
2/8/2016 The Medical Director saw the patient post write at UIC
radiation oncology who wanted a PET scan. The patient
already had a PET scan on 12/18/15 but apparently it was
ordered again. The doctor didn't order follow up.
2/9/2016 The PET scan, medical oncology, dental, and radiation
oncology appointments were approved at collegial review.
2/11/2016 The patient went to radiation oncology and radiation therapy
was to start in two weeks at UIC. The doctor ordered a CBC
and CMP.

110

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 111 of 431 PageID #:12309
Patient #11
2/16/2016 The Medical Director saw the patient after a writ but didn't
say what the writ was for or what occurred. It wasn't clear
what the treatment plan was.

10, 11 The therapeutic plan and ongoing treatment of the
patient were unclear based on progress notes. It was
not possible to determine from the medical record what
therapy the patient was receiving and when he received
it.

2/16/2016 A CT scan of the neck was approved in collegial.
2/17/2016 Potassium 3.4; cholesterol 130; TG 50; HDL 38; LDL 82;
hemoglobin 12 (13.2-18); platelets 160.
2/22/2016 A nurse wrote that the patient just returned from UIC
10, 11 There was no report. The plan was unclear and follow
radiation oncology. The nurse noted that the patient needed
up didn't occur.
a CT scan which did not appear accurate. Since there was no
report it wasn't clear what happened.
2/22/2016 There was no report but radiation oncology noted that a CT
11
There was no report.
planning scan was done.
2/25/2016 The patient went to head and neck oncology clinic. The
patient had a T2N3M0 stage IVb tongue cancer. Laryngoscopy
was done. The plan was radiation and chemotherapy with
cisplatin. A port was placed. An echocardiogram was
scheduled for 2/29/16. The note documented that radiation
oncology wanted a CT scan to assess a lung lesion. The patient
was to follow up in 2-3 weeks in head and neck oncology and
was to start cisplatin with medical oncology and also receive
radiation therapy.
2/29/2016 The patient went to UIC for an echocardiogram. It wasn't clear
from Stateville doctor's documentation that an
echocardiogram was to be done. The report of the
echocardiogram showed normal LV function and normal EF.

111

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Patient #11
2/29/2016 The Medical Director wrote that the patient needed cardiology 10, 11 The doctor was not reviewing consultation reports and
clearance for chemotherapy and radiation therapy. An as
the therapeutic plan was not described. Since there
needed follow up was ordered. It wasn't clear what was
were no formal reports it wasn't clear exactly what the
occurring, as the doctor did not document what occurred at
plan was.
recent UIC visits.
3/1/2016 A radiation oncologist wrote a brief note stating that Chest CT 10, 11 It was three months since the patient first had
and pulmonary consult were indicated because there were
symptoms of a neck mass and dysphagia until the time
suspicious LN on CT simulation performed for radiation
of diagnosis. The diagnosis was not timely. The
treatment purposes only. Bronchoscopy was indicated to
recommendation for pulmonary and bronchoscopy
evaluate these LNs to exclude malignancy, infection,
were not done. There was no evidence of a report.
granulomatous disease.
3/2/2016 A staff physician saw the patient and noted that the patient
10, 11
had a Port-a-Cath in his right chest and was getting
chemotherapy. This was the first mention that the patient had
actually received chemotherapy. It wasn't clear what the
therapeutic plan was for the patient.

Hospital records were unavailable and the doctor didn't
know what occurred at the hospital. Follow up of
oncology was not being done. They had recommended
return if the patient decompensated, which had
occurred.

3/7/2016 There was no report but the oncology clinic referral form had
comments written on the bottom and noted that the patient
received cisplatin and would need daily RT M-F for six and a
half weeks. They noted that the patient had received
radiation the day before. The patient was to return daily for
radiation M-F and weekly for chemotherapy. The actual note
was not present.

There was no report.

3/8/2016 A nurse documented that the patient went for radiation
therapy and was to return the following day for the next dose
of radiation.
3/9/2016 The patient went for radiation therapy.

112

11

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 113 of 431 PageID #:12311
Patient #11
3/10/2016 The patient received another PET scan. The lesion was mildly
increased since the last PET scan. Cervical lymph nodes were
also mildly increased but there were otherwise no changes
from the prior study.

10, 11 This was an unnecessary PET scan. The oncologist
wanted the PET scan film not a repeat PET scan but the
report was not present and the doctor did not correctly
review the recommendations on the referral comments.

3/14/2016 A medical oncologist saw the patient for cisplatin. The
recommendation was to encourage fluids and administer an
antiemetic for nausea and to return in a week.
3/21/2016 The patient was given radiation therapy. The medical
oncologist noted that the patient had mucositis. The
radiation oncologist recommended to increase Boost to six
times a day with a teaspoon of salt as the patient had lost
eight pounds over the past week due to dysphagia. A PEG
feeding tube was recommended. The also recommended
morphine 10 mg every three hours. They mentioned
something illegible about blood pressure medication noting
that the BP was normal.

11

We couldn't find the prescription as the record was so
disorganized.

3/21/2016 The Medical Director documented that the patient had pain
and UIC oncology recommended morphine and to keep on the
infirmary. The doctor admitted to the infirmary and started
morphine. The doctor had not been monitoring the patient's
pain or status other that when told by UIC what to do.

10

The doctor was not documenting a careful review of
consultants or documenting their complete therapeutic
plan but was only documenting certain items.

3/21/2016 The patient was admitted to the infirmary. He weighed 149
pounds. The patient was on a soft diet and the doctor ordered
two additional cans of Boost three times a day. The nurse
documented that the patient was having increasing dysphagia
and losing weight and was admitted to the infirmary to
monitor this. The patient was still on Cardura and dyazide for
hypertension.

113

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Patient #11
3/26/2016 The Medical Director wrote a note. The entirety of the note
was "S: no specific complaint O: no changes A: oral ca on
radiation P: continue same care." This gave no information as
to the status or progress of the patient.

1, 2, 3, The doctor was taking no history, not performing
adequate examination, or documenting a plan
consistent with one recommended by the consultants.
It isn't clear from documentation that the doctor
understood the status of the patient. The doctor did
not update any of the patient's other medical conditions
or monitor for them.

3/28/2016 The doctor wrote a note stating "S: no specific complaint, O:
no changes, A: oral cancer on radiation P: continue same
care." This note failed to identify the therapeutic plan or
recent consultant recommendations and did not address
whether the patient was still in pain. The doctor did not
address the mucositis or pain or evaluate the weight or
whether the patient could eat.

1, 2, 3 The doctor was taking no history, not performing
adequate examination, or documenting a plan
consistent with one recommended by the consultants.
It isn't clear from documentation that the doctor
understood the status of the patient.

3/30/2016 The patient asked a nurse for more Boost. The nurse did not
refer the patient.
3/31/2016 The patient went to radiation. They noted that the patient
had difficulty swallowing due to thrush. The patient had lost
six pounds. Continued treatment for oral thrush was
recommended. Boost was recommended eight times a day
and salt water and baking soda mouth wash. Liquid Pepcid or
famotidine were recommended for reflux. These
recommendations were unnoticed at the prison.
3/31/2016 UIC recommended in a letter to Stateville that an x-ray of his
knee should be taken as the patient complained of knee pain.
4/4/2016 The patient wasn't able to get chemotherapy due to low
platelets of 67. He did receive normal saline presumably due
to dehydration. There was no report but this information was
on the referral form.

114

The doctor appeared to be treating ITP. Prednisone is
not indicated in thrombocytopenia from cirrhosis. This
was incompetence and demonstrated lack of knowledge
of primary care by this surgeon. The diagnosis and
treatment were therefore inappropriate and placed the
patient at risk.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 115 of 431 PageID #:12313
Patient #11
4/5/2016 The doctor wrote that the patient was at UIC hospital under
oncology care but it wasn't clear what was happening to the
patient. The doctor did not review UIC notes or document
understanding what the status of the patient was. The doctor
hadn't seen the patient since 3/28/16.

1, 10

4/8/2016 The patient returned from the hospital and a nurse
documented that the patient received a G-tube. On admission
to the infirmary the nurse noted that the patient had failure to
thrive. The patient was still on six cartons of Boost a day
instead of the eight recommended. The hospital note was not
located.
4/8/2016 A nurse documented that the patient insisted on feeding
himself through his G-tube. He was angry and accused the
Medical Director of "putting him in the condition he is in now.
He stated the MD ignored him 6 years ago."

11

4/11/2016 The patient was seen in oncology clinic. The patient was
dehydrated and hypotensive with WBC 1.2 and ANC of 0.7.
The recommendation was to watch for petechial rash and take
neutropenic precautions by separation from general
population. The patient was to shower daily and give
saltwater and baking soda mouth wash for mouth soreness.

115

The patient failed to review prior UIC recommendations
or note the updated status of the patient. The UIC
recommendation for a knee x-ray wasn't noted. The
doctor didn't appear to prescribe additional Boost and
MARs did not show that the patient received additional
nutritional supplement.
The report was not available and it wasn't clear what
occurred at the hospital.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 116 of 431 PageID #:12314
Patient #11
4/11/2016 The Medical Director documented seeing the patient at 4:00
pm, although based on hospital notes it appeared that the
patient was at the hospital from 4/11/16 to 4/12/16. The
doctor documented that the patient had difficulty swallowing
and was on a liquid diet by the oncologist. The doctor didn't
obtain the weight or document understanding of the
nutritional status or caloric intake of the patient. The only
examination was documented as "no change." The plan was
"continue same care." It appeared that the doctor
documented the wrong date.

The doctor appeared to document a note when the
patient was hospitalized.

4/12/2016 The patient returned from the hospital for hypotension. It was
noted that the patient's blood pressure was 78/50. The
patient was found to have gout of the right toe and was
started on a tapering prednisone dose. Fluconazole was
started for the thrush.
4/18/2016 The Medical Director noted that the patient left for radiation
therapy. The examination was documented as "no changes."
The plan was "continue same care." The doctor failed to see
the patient since his hospitalization for hypotension and gout
and did not acknowledge the mucositis.

10

The doctor failed to review the recent hospitalization
failing to note that the patient was treated for gout,
hypotension and had thrush. The doctor was ignorant
of the patient's status.

10

The doctor failed to review the consultation notes and
failed to note the current status of the patient. He also
failed to update the patient's ongoing medical
conditions.

4/21/2016 The oncologist wrote on a referral form that the patient
received IV hydration with magnesium and that a CT/PET scan
needed repeating in three months. A month follow up was
requested. A report of this visit was present in the record.
4/25/2016 The Medical Director note stated "S:no complaint O: no
change A: Ca throat on chemo P: continue same care." He
did not note the recent oncology note or document the plan.

116

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Patient #11
4/29/2016 A staff physician saw the patient for chest pain and feels acid
reflux in his throat. The doctor continued Pepcid, added
metoclopramide and advised the patient to take smaller
portions of liquid when feeding. It wasn't clear if the patient
continued to feed himself.
5/2/2016 The Medical Director note stated "S:no complaint O: no
change A: Ca throat on chemo P: continue same care."

1,2,3

5/9/2016 The MD note stated "S: no specific complaint O: no change A:
1,2,3
throat ca P: continue same care."
5/16/2016 The doctor wrote a note stating "S: requests medical shower O 1,2,3
no change A: throat ca P: medical shower 3x a week x 3
months."
5/19/2016 A radiation oncologist wrote comments on a referral form
stating that Boost needed to continue and the patient needed
a restaging CT PET scan in two months and should follow up
with medical oncology. Massage of the neck was
recommended post radiation.
5/23/2016 The doctor documented that the patient had no specific
complaint but then wrote "discomfort neck post radiation UIC massage." The examination stated "no acute findings" and the
doctor ordered PT to massage the neck once a week.

The Medical Director documented no knowledge or
recognition of the patient's status and did not document
evaluation of the patient.
The Medical Director documented no knowledge or
recognition of the patient's status.
The Medical Director documented no knowledge or
recognition of the patient's status.

6/1/2016 A staff doctor noted that the patient was waiting for restaging. The patient had less dysphonia and dysarthria.
6/6/2016 The Medical Director wrote "S:no specific complaint O: no
change A: throat ca on radiation chemo P: continue same
care." There was no monitoring of weight or ability to eat, the
gout, or any of the patient's other problems.

117

1, 2, 3 The doctor failed to address any of the patient's chronic
conditions, took no history, failed to document
examination, and failed to establish a plan of care.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 118 of 431 PageID #:12316
Patient #11
6/13/2016 The Medical Director wrote that the patient still had dysphagia
and had burning in the chest. The examination was
documented as "no change." The doctor ordered Carafate
suspension.
6/20/2016 The doctor documented that the patient was feeling better
but that the swelling in the anterior upper neck was less and
the patient was able to swallow better. There was no
examination except to state "no change" and the plan was
"continue same care."
6/27/2016 The doctor noted that the patient was swallowing better but
needed more viscous lidocaine. The examination was
documented as "no change." The doctor ordered viscous
lidocaine.
7/5/2016 The doctor noted that the patient's feeding tube was partly
clogged. The examination was "no acute findings" and the
plan was to irrigate the feeding tube as needed.

1,2,3

The doctor failed to update any of the patient's other
problems.

1,2,3

The doctor failed to update any of the patient's other
problems.

1,2,3

The doctor failed to update any of the patient's other
problems.

1,2,6

The doctor failed to address any of the patient's chronic
conditions, took no history, failed to document
examination, and failed to establish a plan of care.
Abnormal labs were not addressed. The doctor even
failed to address the patient's difficulty breathing that
occurred two days previous. The doctor failed to
mention that the patient was on prednisone and
albuterol.

7/5/2016 Albumin 2.8 BUN 15 creatinine 0.8.
7/6/2016 WBC 3.2; HGB 9.2; MCV 104.
7/10/2016 A nurse wrote that the patient couldn't breathe and was
audibly wheezing. The nurse called a doctor who ordered
prednisone and albuterol without evaluation. The respiratory
rate was 20; P 88; BP 146/87 and oxygen saturation 97%.
7/12/2016 The doctor wrote "S: no specific complaints O: no change A:
post radiation tongue ca P: continue same care."

118

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 119 of 431 PageID #:12317
Patient #11
7/25/2016 The doctor wrote the patient had "same cough + SOB-" The
1,2,3,8 The doctor took no history, performed no examination,
only examination was the statement "lung breath sounds
and the plan of a nebulizer was based on no clear
diminished." The doctor ordered a nebulizer and albuterol
diagnosis. The doctor ordered no labs or x-rays but
BID.
should have.
7/27/2016 At 4:30 pm the patient complained to a nurse that he was
2, 3 The doctor was treating the patient based on no specific
having trouble breathing and was coughing and having trouble
diagnosis. The assessment was therefore uncertain and
getting sputum up. The doctor was notified who ordered a
the treatment plan was apparently a guess.
DuoNeb.
7/27/2016 At 8:00 pm the patient complained that he couldn't breathe.
1, 2, 3 There was no history, the doctor did not examine the
The oxygen saturation was 99%, BP 133/88, P 113, and
patient and the plan was made without a diagnosis.
respirations 26. The Medical Director was notified and
ordered DuoNeb therapy. Stat labs were ordered but it wasn't
clear what labs were done.
7/27/2016 At 10:50 pm a nurse documented labs as glucose 108; BUN 17;
HGB 10.9.
7/27/2016 Lab results from St Joseph Medical Center showed WBC 4.3;
HGB 10.9; MCV 100; platelets 123; but there was no hospital
report.
7/28/2016 The Medical Director documented that the patient returned
10, 11 There was no evidence of an ENT consultation. There
from ENT and a PET scan was recommended for three months.
were labs from the St Joseph Medical Center but we
could not locate an ENT consultation. Reports were not
available.
7/31/2016 At 1:30 am the patient complained that he couldn't breathe.
1,2,3 The doctor was ordering parenteral antibiotics without
The BP was 126/94; P 120 R 22 and O2 sat 98%. The nurse
taking a history, performing an examination, making a
received a phone order for Rocephin.
diagnosis. This was an inappropriate way to make a
therapeutic plan.
7/31/2016 At 3:10 am the patient was short of breath. The temperature
3
Vistaril is not a medication for shortness of breath.
was 99.3; P 125; R 22; BP 121/66 and oxygen saturation 98%.
The doctor ordered Vistaril.

119

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Patient #11
7/31/2016 At 5:30 am a nurse documented vitals of temperature 99; P
113; BP 143/90; oxygen saturation 94%. Based on these vitals
the doctor ordered the patient to be sent to a hospital.
8/5/2016 The patient returned from the hospital. It wasn't clear what
occurred.
8/5/2016 A doctor wrote an infirmary admission note. The doctor noted
that the patient was treated for pneumonia but didn't
document any other detail of what occurred in the hospital.
8/8/2016 A doctor noted that the patient was requesting to stop
morphine as it didn't agree with him. The examination was
"no change." The doctor started Vicodin. The doctor didn't
take history or assess the patient's pain or ask why he didn't
want the morphine.
8/15/2016 A doctor wrote that the patient wanted renewal of Tums. The
examination was "no change" and the plan was to order Tums
two tabs three times a day as needed for six months. There
was no other history, physical examination, assessment, or
documentation of a therapeutic plan for his problems
8/16/2016 Sodium 134; albumin 3.
8/22/2016 A doctor noted that the throat pain was worse and that Norco
was not relieving the pain. The patient was requesting
morphine. The doctor ordered morphine. The only
examination was "no change."
8/29/2016 The doctors note was identical to the 6/6/16 note.

120

11

There was no report from the hospital and it wasn't
clear what happened.
1
The history was so poor it wasn't clear that the
treatment plan was appropriate. The doctor as usual
did not address any of the other problems of the
patient.
1, 2, 3 The history was inadequate. The doctor didn't evaluate
any of the patient's other problems and the therapeutic
plan only addressed the morphine.

1, 2, 3 The history, physical examination, assessment, and plan
were inadequate as the doctor did not address any of
the patient's main problems.

1, 2, 3 The history, physical examination, assessment and plan
were inadequate as the doctor did not address any of
the patient's main problems.
1, 2, 3 The doctor again failed to take history, perform
examinations, or make assessments based on the
patient's problems.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 121 of 431 PageID #:12319
Patient #11
9/6/2016 The doctor wrote that the patient had no specific complaint
except dandruff. The doctor noted that the PET scan showed
no sign of recurrence. The only examination was "no acute
finding." The plan was to order tar shampoo.
9/13/2016 The doctor's note was identical to the 6/6/16 note.

9/19/2016 The doctor's note was identical to the 6/6/16 note.

9/25/2016 The doctor's note was identical to the 6/6/16 note.

9/27/2016 The doctor wrote that the patient had a leak around the
feeding tube. The examination was "small amount of leak."
The assessment was that the doctor was to address the Gtube leak after the PET scan on 9/29/16. What was unusual is
that the doctor wrote on 9/6/16. only 23 days earlier, that the
PET scan showed no recurrence. This wasn't clear and there
were no reports in the record.
9/28/2016 The patient was found non-responsive on the toilet. He was
unresponsive and CPR was started and he was transferred to a
hospital taken by local paramedics. The patient expired at the
hospital.

121

1, 2, 3, The PET scan report wasn't found in the medical record.
11
The doctor failed to take history, perform examinations,
or document the therapeutic plan of the patient.

1, 2, 3 The doctor again failed to take history, perform
examinations, or make assessments based on the
patient's problems.
1, 2, 3 The doctor again failed to take history, perform
examinations, or make assessments based on the
patient's problems.
1, 2, 3 The doctor again failed to take history, perform
examinations, or make assessments based on the
patient's problems.
1, 2, 3 Aside from assessing the G-tube, the doctor took no
history and performed no other examination. The
doctor made no assessments of the patient's main
problems. The doctor did not assess the nutritional
status of the patient.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 122 of 431 PageID #:12320
Patient #11
9/28/2016 The coroner's certificate of death on 9/28/16 listing the cause
of death as hypertensive cardiovascular disease.

122

While the patient had hypertension, an echocardiogram
was normal less than a year before the patient's death.
It seems extremely unlikely to have a normal
echocardiogram and yet die of hypertensive
cardiovascular disease. Notably, the coroner made no
mention of the head and neck cancer.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 123 of 431 PageID #:12321
Patient #12
8/11/2015 The patient was incarcerated at Graham CC. The reception
history documented Huntington's disease and hepatitis C. The
weight was 203 pounds. The physical examination did not
explain the Huntington's disease or hepatitis C. The rectal
exam was refused. All exam boxes were checked normal. The
plan was illegible.
8/18/2015 An intake physical examination was done. The PA
documented hepatitis C, but did not document a history of
Huntington's disease as documented on the history. Some of
the assessment was illegible.
6/13/2016 The patient was at WCC.
7/22/2016 AST 90 (10-40); alt 77 (10-50); calcium 9.2; sodium 138.
7/28/2016 The patient was at Western and there was a note
documenting that the patient was scheduled with medical
oncology at UIC and the patient would transfer to Stateville
NRC for appointments.
7/28/2016 There was a note at WCC that the patient was being
transferred to NRC for a UIC oncology appointment.
8/2/2016 The patient transferred from WCC to NRC on writ status.
8/4/2016 Comments from oncology on the referral form stated that the
patient had hyperkalemia, HCC, and HCV. The patient was
given kayexalate with directions to NRC to manage the
hyperkalemia. It was recommended to get a triple phase CT
scan, with a follow up in two weeks. The potassium was 5.5.
The oncologist prescribed 15 gram of kayexalate rectal
suppository for two days with recommendation to repeat the
BMP in two days.

123

11

There was a gap of a year in the medical record.

11

There was no consult report.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 124 of 431 PageID #:12322
Patient #12
8/5/2016 A doctor at NRC documented that the patient was there for a
writ to go to UIC oncology. The problems listed included
hepatitis C, hyperkalemia, and dry eyes. The doctor noted
that he would check with manager to clarify recommendation
with Barbara at UIC. The doctor asked the unit manager to
follow up with UIC to clarify the next steps of management.

10, 11 There was no consultation report. This led to not
knowing the therapeutic plan.

8/23/2016 Wexford UM wrote an approval that a surgical appointment
on 8/4/16 and oncology FU on 8/11/16 were rescheduled to
8/30/16. A requested referral was not yet received. This
means that Wexford obtains the referral after the
appointment is scheduled.
8/29/2016 Wexford approved a CT scan and follow up oncology visit.
The referral was still not received by Wexford UM. This was
very late, as the oncologist requested a two week follow up
and the CT scan had yet to be done.
8/30/2016 The CT chest and pelvis were done, showing hepatocellular
carcinoma.
9/1/2016 A doctor saw the patient post-UIC writ. The doctor
documented that the patient had a CT scan. The doctor noted
that the report was to follow. The doctor noted no follow up
date on the consult with oncology.
9/8/2016 EKG normal sinus rhythm.
9/12/2016 The patient was admitted to the hospital for two days and
discharged on 9/13/16. hepatic angiogram was done and
lipidol and chemotherapy was administered in the hepatic
artery for hepatocellular carcinoma. They recommended CMP
drawn on 9/15/16 and faxed to coordinator at clinic and to
start calcium carbonate. A PA wrote an order for waist chains
and leg irons during movement.

124

12

The recommended CT scan was not timely performed.

10, 11 There was no report and the doctor didn't know the
follow up date. Follow up after the consultation was
not informed.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 125 of 431 PageID #:12323
Patient #12
9/14/2016 A doctor noted that the patient returned from the hospital
post embolization. The patient told the doctor he would need
blood tests but the doctor didn't know what these were. The
doctor didn't have prior IDOC medical records or the report
from the recent UIC hospitalization and asked the unit
manager for these.

10 ,11 Records were unavailable from UIC. This resulted in not
knowing the therapeutic plan and failing to follow up on
recommendations from UIC.

9/19/2016 Calcium 7.9; sodium 136; potassium 4.6. No LFTs done.
9/21/2016 Wexford approved a request for interventional radiology for
FU of TACE.
9/21/2016 Wexford approved a CT abdomen.
9/22/2016 The patient returned from UIC post chemoembolization.
9/22/2016 The patient went to radiology. A note on the referral form
recommended comfort measures with a two month follow up.
There was no report. A one year prognosis was given. The
diagnosis was hepatocellular carcinoma.
9/23/2016 A doctor noted that the patient returned from UIC. The
patient told the doctor he had six months to live. The doctor
did not document what had occurred to the patient at UIC.
The doctor noted a repeat CT scan was needed in two months.
9/26/2016 Calcium 8.5 (8.6-10.6); PTH 14 (12-88); Vit D 17 (20-80).
9/30/2016 A doctor noted that the patient had recent
chemoembolization at UIC and was seen for an abnormal laba low vitamin D level. The doctor noted that the patient had a
liver tumor and had recent chemoembolization. The doctor
started calcium carbonate, vitamin D, and repeated a PTH,
BMP, and vitamin D in three weeks.

125

11

Records from UIC were unavailable. The doctor did not
know the status of the patient.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 126 of 431 PageID #:12324
Patient #12
10/5/2016 The patient went to liver clinic. There were a few brief lines
on the referral form. Further treatment was pending a
discussion with oncology. The report documented that the
patient had compensated cirrhosis. They recommended
continuing with embolization and if the disease worsened to
consider hospice. They recommended return to clinic if
hepatic decompensation occurred. Waist chains and leg irons
were ordered for movement.

11

The report was not available only comments on the
referral form. It is not clear anyone was aware of these
recommendations.

10/7/2016 A doctor noted that the patient was seen by GI at UIC and has
FU pending with oncology. The doctor noted that the patient
had advanced HCC/ cirrhosis. The doctor did not assess any
labs or note what the plan was at UIC.

11

The doctor did not document review of the report.

10/11/2016 The patient went to radiology. There were a few brief lines on
the referral form. A two month follow up was recommended.
A procedure was recommended in 45 days. They
recommended a CMP. There was a oncology note in the
record that summarized the patient care. It said that HCC was
found January 11, 2016 found on ultrasound screening. A CT
scan was done on 2/26/16 noting cirrhosis and 3 cm
hypodense lesion in the lateral lobe; an MRI 3/23/16 showing
a large infiltrative mass of the L lobe ; in April 2016 the AFP
was elevated; and a CT guided biopsy was done not until
5/24/16 and a PET scan was done 5/26/16. The patient wasn't
seen at UIC until 8/4/16 and the patient didn't have treatment
of the HCC until 9/12/16. The note documented that the CT
guided biopsy results from 5/24/16 were requested multiple
times but not received.

12

The oncology note documents that HCC was identified
in January of 2016 but treatment wasn't given until
September of 2016, a nine month delay. Repeated
requests for biopsy results were not heeded. This was a
significant delay in access to necessary care. Also, It is
not clear what occurred at the Western facility and
whether there was delay there as well.

126

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Patient #12
10/21/2016 Glucose 115; Calcium 8.5; albumin 2.5; alk phosphatase 186
(40-125); AST 126 (10-40); ALT 58 (10-50); platelets 112
11/12/2016 WBC nl platelets 181; glucose 102; creatinine 0.6; sodium 133;
potassium 4.4.; albumin 2.8; AST 89; ALT 40; alk phos 214;
bilirubin 1.6; calcium 8.2.
11/13/2016 A CMT wrote a note that Provena St Joseph's Lab called with
stat lab results. When the call was returned no personnel in
the labs were present to take the call.
11/14/2016 CT abdomen done. Liver tumor invasion of vein was
worsened. Leg irons and waist chains were ordered for
movement. The CT scan showed cirrhosis with infiltrative
tumor on the left lobe with tumor thrombosis, hepatic and
retroperitoneal adenopathy. This was consistent with
hepatocellular carcinoma.
11/15/2016 A PA wrote the patient went to UIC on 11/14/16. The PA
10, 11,
noted a fluid wave and noted labs including albumin 2.8; alk
17
phos 214; bilirubin 1.6; sodium 133 and potassium 4.4. The PA
ordered 40 mg of Lasix for 30 days and Aldactone 50 mg daily
for a month. The patient had an MRI but results were
pending. The PA wrote she would try to get an earlier GI
appointment than the 12/10/16 appointment. Lasix 40 and
spironolactone 50 were ordered for 30 days. The PA failed to
know that consultants at UIC had noted that on 8/4/16 the
patient needed kayexalate for hyperkalemia. Spironolactone
exacerbates hyperkalemia and when used the manufacturer
recommends monitoring potassium, which was not done.

127

The patient apparently had a CT scan not an MRI. The
PA did not have the CT results and didn't know that the
patient went for a CT not an MRI. The lack of reports
caused confusion and created an unsafe condition of
practice. The PA started spironolactone in a patient
with prior recent hyperkalemia without establishing
monitoring parameters.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 128 of 431 PageID #:12326
Patient #12
11/21/2016 A PA followed up with the patient. The MRI results were still
pending. The patient had lost five pounds. The PA
documented that the patient had abdominal ascites and
peripheral edema. The PA said that patient had end-stage
hepatic coma but the PA didn't perform a mental status exam
and didn't note that the patient had encephalopathy. The PA
requested the MRI result and noted that GI FU was pending.

2, 11

The PA diagnosed hepatic coma but the patient did not
have evidence for encephalopathy or coma. The failure
to receive reports continued. The PA believed that the
patient had an MRI when the patient had a CT scan.

11/30/2016 A MAR for November documents that the patient received a
two week supply of KOP meds on November 30, 2016. A
nurse documented that a new order was needed for these
meds.
1/8/2017 A nurse wrote an infirmary admission note documented that
the patient complained that he couldn't breathe and for that
reason was apparently admitted to the infirmary. There was
no provider notes. There was a telephone order for Lasix 40
and spironolactone 50 daily.

17

The medication renewal process didn't work and the
patient's medication stopped in mid December and
wasn't started again until 1/8/17, about 3-4 weeks later.

1/9/2017 BUN 36; sodium 130; potassium 5.4; albumin 2.5; bilirubin 3.7;
alk phos 696; AST 305; ALT 173; WBC 13.7 platelets 202.

The patient couldn't breathe and should have been seen
by a provider. The patient had significant ascites on
11/21/16 but hadn't been seen in over six weeks. Care
was grossly and flagrantly unacceptable.

6

These labs did not appear to be reviewed based on
progress notes.

1/9/2017 A doctor admission to the infirmary noted that the patient had 11, 19 Reports were not present. The patient had been lost to
increased abdominal girth and shortness of breath and was on
follow up for six weeks and missed critical medication
Lasix and spironolactone but that this medication expired
for 3-4 weeks resulting in exacerbation of ascites.
about four weeks ago. The doctor ordered a CBC, CMP, chest
x-ray, and asked for the oncology notes from the last visit
which were still not present. The doctor increased the
spironolactone to 100 mg daily.
1/10/2017 A nurse documented the doctor as saying that he would
arrange to pull the fluid out [presumably ascites].

128

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Patient #12
1/11/2017 A nurse documented that the patient had "gross" edema of
both legs. The nurse called a PA who saw the patient,
diagnosed decompensated liver disease and liver coma and
sent the patient to St. Joseph Hospital. Although the patient
said he couldn't breathe the vital signs were normal. The
patient did have ascites. There is a St. Joseph hospital
prescription on a patient information form indicating that the
patient was in the hospital on 1/11/17.
1/11/2017 A PA evaluated the patient but did not review labs from
1/9/17. The PA sent the patient to the hospital for
paracentesis.
1/14/2017 The patient was discharged from the hospital. The discharge
summary was not available but the discharge instructions
noted that the patient had ascites, hyponatremia, and liver
cancer with instructions to follow up at UIC ASAP for
paracentesis.
1/14/2017 A nurse admitted the patient to the infirmary post
hospitalization.
1/15/2017 A nurse called Boswell pharmacy twice for Aldactone which
was apparently unavailable.
1/16/2017 The doctor noted that the patient had paracentesis at the
hospital. The doctor referred the patient for repeat
paracentesis. The oncology records were still not present.
The recent hospital records were also unavailable. The doctor
ordered spironolactone to 50 mg daily and titrate as needed.
Aside from getting a paracentesis the doctor did not know
what had occurred at the hospital. The doctor ordered a CMP
on 1/18/17. The doctor documented that the patient would
probably need repeat paracentesis. The status of the HCC was
unknown.

129

11

A hospital report was not available.

11

UIC records were still not present and providers did not
know recommendations for care. The hospital records
were also unavailable so the status of the patient wasn't
known.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 130 of 431 PageID #:12328
Patient #12
1/17/2017 A chest x-ray showed an elevated diaphragm consistent with
ascites.
1/17/2017 An incident report documented transferring the patient to the
hospital.
1/18/2017 BUN 32; sodium 130; calcium 8.2; albumin 2.3; bilirubin 3.3;
alk phos 472; AST 165; ALT 119.
1/19/2017 A doctor noted that the abdominal girth was 44 inches. The
10, 11
patient had 2+ edema. The doctor documented that the
records were still pending and that the patient had a history of
HCC but the plan wasn't apparently known. The doctor didn't
know what had occurred at the hospital.

Hospital records were unavailable and the doctor didn't
know what occurred at the hospital. Follow up of
oncology was not being done. They had recommended
return if the patient decompensated, which had
occurred.

1/20/2017 There is a gap in progress notes from 1/20/17 until 2/15/17.
Labs, MARs, prescriptions were present but there were no
progress notes.

11

The absence of a record was significant. It is unclear
what happened to this patient and it appeared that he
was ignored for a month although this is unverifiable. It
wasn't clear if the patient was evaluated by providers
over this time period.

2/1/2017 Lactulose was started but it wasn't clear who ordered it or
why. To date the patient did not have evidence, documented
in the record of hepatic encephalopathy. Ciprofloxacin,
lactulose, Levaquin and 60 mg of Lasix were ordered by phone
order but there was no note.
2/2/2017 A referral form was present signed 2/2/17 for UIC emergency
room for paracentesis.
2/10/2017 BUN 149; potassium 6.9; sodium 127; creatinine 3.88; CO2 17;
anion gap 12; albumin 12; bilirubin 8.1; alk phos 397; AST 173;
ALT 158; WBC 15.9; hemoglobin 12.2; platelets 133; INR 1.9.

19

It appeared that the patient was treated for infection by
phone without physician evaluation. The lack of
medical records was significant.

2/11/2017 Glucose 33; creatinine 4; sodium 125; potassium 6.6.
2/12/2017 Glucose 44; BUN 138; creatinine 3.9; sodium 124; potassium
6.8.

130

6, 17

6

The patient was in hepatorenal syndrome and the
diuretic should have been adjusted. The potassium was
critical and should have been addressed.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 131 of 431 PageID #:12329
Patient #12
2/14/2017 Glucose 47; BUN 157; potassium 6; sodium 130; creatinine
4.18.

6

2/15/2017 The patient signed an agreement to participate in the Hospice
Program.
2/17/2017 Glucose 95; BUN 164; potassium 3.9; sodium 128; creatinine
6
3.8; calcium 8.2; albumin 2.2; bilirubin 6.5; alk phos 304; AST
199; ALT 145.
2/20/2017 Hemoglobin 11.4; glucose 64; creatinine 3.2; sodium 123;
6
potassium 2.8; calcium 7.8; WBC 12.6; hemoglobin 11.4;
platelets 22.
2/20/2017 A doctor saw the patient. This was the first visit since
1, 2, 3
1/19/17, a month ago despite the patient having a life
threatening condition. The doctor failed to take any history or
give an update of the status. The only history was "no specific
complaint." The only examination was to note that the
patient had greater abdominal girth and petechiae on the skin.
The assessment was hepatic cancer with metastases. The only
plan was "continue same care" without specifying what the
care was. The patient's plan was unknown.
2/20/2017 A nurse documented receiving a call from St Joseph hospital
for a lab result. Platelets were 22,000 and WBC 12.6. The
nurse notified Dr. Obaisi who ordered depomedrol 80 mg IM
stat and prednisone 60 mg daily for three days by phone
order.
2/25/2017 A doctor ordered to measure the sacral wound weekly and to
clean the sacral wound with saline and apply wet to dry
dressings.
2/26/2017 A doctor ordered a stat dose of Lasix by phone.

131

2, 17

The patient was in hepatorenal syndrome and the
diuretic should have been adjusted. The potassium was
critical and should have been addressed.

The labs were significantly abnormal but there was no
evidence of review.

The doctor failed to take adequate history, failed to
adequately evaluate or diagnose the patient's condition
and failed to develop a proper therapeutic plan. The
patient was in hospice but the doctor did not address
any comfort issues with the patient. Care was
indifferent.

The doctor appeared to be treating ITP. Prednisone is
not indicated in thrombocytopenia from cirrhosis. This
was incompetence and demonstrated lack of knowledge
of primary care by this surgeon. The diagnosis and
treatment were therefore inappropriate and placed the
patient at risk.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 132 of 431 PageID #:12330
Patient #12
2/27/2017 A death certificate documented the cause of death as liver
cancer. An autopsy was performed. The secondary cause of
death was cirrhosis.
2/28/2017 A Wexford Mortality Review worksheet documented
cholangiocarcinoma as the cause of death but it appears to
have been hepatocellular carcinoma from his hepatitis C. The
form documented that earlier intervention was not possible.

132

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 133 of 431 PageID #:12331
Patient #13

7/9/2010 The problem list included alcohol and tobacco abuse, stage II
hypertension, and stage IV chronic renal disease.

This patient had chronic kidney disease at a very young
age. It wasn't clear why he had kidney disease.

5/8/2014 PTH 576 (12-88)
6/6/2014 BUN 55 Creatinine 14.58; ferritin 355; phosphorous 8;
hemoglobin 11.4; PTH 648

Treatment goal for phosphate is 3.5-5.5; calcium < 9.5;
and PTH less that 2-9 times the upper limit of the lab.
However, PTH levels >400 have a higher risk of bone
turnover disorders (osteitis fibrosa and mixed uremic
osteodystrophy), African Americans may be more
vulnerable to bone disease at lower PTH levels. For the
UIC lab the normal limits are 12-88, so the goal would
be < 792. Dialysis patients with a phosphate > 5.2 have
a 1.34 greater mortality risk.

7/3/2014 PTH 500.
7/3/2014 BUN 55; creatinine 13.5; ferritin 359; cholesterol 116; TG 65;
HDL 42; LDL 61; phosphorous 5.3; hemoglobin 10.2; MCV
105.9, hepatitis BsAg negative.
7/4/2014 Hepatitis C negative, hep B Ab +
7/21/2014 HTN clinic; BP 159/98. The doctor documented fair control
but did not adjust medication.

7/31/2014 A nephrologist wrote a few brief lines on a referral form and
recommended increasing labetalol to 400 mg BID. The blood
pressure was not documented.
8/7/2014 PTH 949; BUN 61; creatinine 14.87; ferritin 311; hemoglobin
11.8.

133

3

The patients blood pressure was elevated but not
treated. Given that the patient had end-stage renal
disease this was not competent care. Care failed to
follow generally accepted guidelines or usual practice.

3

The PTH and BUN were both high, indicating possibly
insufficient dialysis time. This apparently was not
checked.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 134 of 431 PageID #:12332
Patient #13
8/20/2014 A nephrologist wrote a few brief lines on a referral form and
recommended changing sessipor to 60 mg daily and obtaining
a fistulogram.
9/4/2014 BUN 61; creatinine 14.79; ferritin 343; phosphorous 6.7;
hemoglobin 11.8; MCV 106.3; PTH 963 (12-88)
9/8/2014 Wexford approval of fistulogram.
9/18/2014 A nurse documented the patient going out on writ. The blood
pressure was 168/100. Later the same day a nurse
documented blood pressure of 171/109. No referral was
made.
9/19/2014 The patient obtained a fistulogram.
9/22/2014 A doctor saw the 38 year old patient in follow up of the
fistulogram. The blood pressure was 175/108. The doctor
noted that the fistulogram was working. The doctor did not
address the elevated blood pressure.
9/24/2014 The patient transferred from Graham to Stateville. The
patient had hypertension and was on dialysis.
9/24/2014 A nurse took a phone order for kayexalate 15 gm Wednesday
and Sunday for three months.
9/25/2014 A prescription for kayexalate and four other medications was
not signed or noted as a phone order.
10/8/2014 Apparently a nephrologist wrote a brief note stating will adjust
BP meds if not improved by next visit.
10/29/2014 BUN 52; potassium 5.4; creatinine 13.07; calcium 11;
hemoglobin 10.6; MCV 101.6
11/4/2014 A doctor noted that the patient returned from UIC. The
patient told the doctor he had six months to live. The doctor
did not document what had occurred to the patient at UIC.
The doctor noted a repeat CT scan was needed in two months.

134

3

The phosphorous and PTH were high indicating possibly
insufficient dialysis time. This apparently was not
checked.

16

The nurse should have consulted a physician.

3

The doctor failed to address the elevated blood
pressure.

2

The assessment of good control of blood lipids without
evaluation of the lipids is inappropriate and not based
on objective findings.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 135 of 431 PageID #:12333
Patient #13
11/9/2014 Apparently a nephrologist wrote he would recheck the patient
next visit. The documented blood pressure appeared to be
152/88.
11/19/2014 B12 577 (180-914); folate 11.9 (>5.8); potassium 5.5
12/4/2014 Apparently a nephrologist documented that the patient had
hyperkalemia. The nephrologist recommended kayexalate as
needed but did not adjust blood pressure medication.
1/15/2015 BUN 19; creatinine 5.2.
3/18/2015 BUN 46; potassium 7.1; creatinine 13.04; hemoglobin 11.3;
MCV 106.8;

3

6, 19

135

The BP medication was not adjusted.

The BUN should have prompted concern for inadequate
dialysis time. The elevated potassium was at a critical
level as levels above 7 can cause cardiac conduction
abnormalities, cardiac arrhythmias, including sinus
arrest, idioventricular arrhythmias, ventricular
fibrillation and asystole all of which can cause death.
There was no evidence in the record that someone
evaluated the patient for this. Typically, an EKG is done
and prompt treatment initiated. Care was grossly and
flagrantly unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 136 of 431 PageID #:12334
Patient #13
3/26/2015 HTN clinic; the BP was 135/88; the patient had a 2/6 diastolic
murmur. The doctor assessed good control for both blood
pressure and lipids and continued the same medications. The
provider did not discuss in the history whether the patient was
receiving medication. It appeared that the patient was only
receiving 64% of his medication.

1, 7

The patient had a murmur and should have had an
echocardiogram ordered. For persons on dialysis, it is
recommended by UpToDate consultants that blood
pressure be maintained to a goal of 130/80. The
pressure was not at a good goal for a dialysis patient
and medication should have been adjusted. Also,
examination of the MAR showed that the patient was
not receiving his medication timely and had only
received approximately 64% of his medication from
December through April of the current time period. Yet
the doctor was not obtaining this history from the
patient. Care failed to follow generally accepted
guidelines or usual practice.

17

The patient had not been receiving his medication and
the nephrologist should have brought this up with
prison nurses and doctors to address.

6, 19

The potassium was a critical level but no one addressed
it. This is systemic failure and care was grossly and
flagrantly unacceptable, as the program should have a
system to respond to hyperkalemia given the dialysis
population.

4/2/2015 Apparently a nephrologist wrote that the blood pressure was
157/104. The doctor increased lisinopril to 40 mg and
increased clonidine to 0.3 mg and recommended referral to
UIC vascular surgeon to evaluate a pseudoaneurysm.
4/22/2015 Wexford approved a vascular surgery evaluation at UIC.
5/22/2015 Apparently a nephrologist saw the patient. The BP was
183/103. The consultant noted that the patient was out of
blood pressure medication and therefore did not change
dosages.
6/3/2015 A RN received a call from UIC lab about a critical potassium of
6.7. This lab was not in the medical record.

136

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Patient #13
7/8/2015 A RN received a call from UIC lab about a critical potassium of
7.2. The nurse informed the Medical Director. There were no
orders. This lab was not in the medical record.

7/17/2015 Apparently a nephrologist saw the patient. The blood
pressure was not noted. Kayexalate was recommended once
a week.
8/19/2015 The patient returned from a writ. The blood pressure was
169/96. The nurse noted that the patient had a medical
director appointment on 8/24/16. Nothing was done to
address the increased blood pressure.
8/19/2015 Vascular surgery saw the patient at UIC over four months after
referral. The blood pressure was 164/94. The surgeon said
that no intervention was indicated. The vascular surgeon
noted that there was a 4/6 murmur radiating to the neck that
warranted further work up.

6, 19

The potassium was a critical level but no one addressed
it. This is systemic failure and care was grossly and
flagrantly unacceptable as the program should have a
system to respond to hyperkalemia given the dialysis
population.
The nephrologist was the first doctor to address the
high potassium that occurred repeatedly recently.

16

The nurse should have consulted a physician.

3

This is indifferent care to have elevated blood pressure
but not address it. Care failed to follow generally
accepted guidelines or usual practice.

8/22/2015 A dialysis nurse took a phone order from a nephrologist for
kayexalate 15 gm Wednesday and Sunday for six months.
8/24/2015 The Medical Director saw the patient for a post-writ visit. The
doctor noted that the patient went to UIC access clinic which
indicated no need for revision of the shunt. There was no
other history. The examination was "no change" the
assessment was "post med writ" and the plan was "FU prn."
The doctor did not address the elevated blood pressure of
168/103. The doctor also failed to note the surgeon's
recommendation to evaluate the murmur.
9/1/2015 Collegial review approved an echocardiogram.
9/2/2015 Wexford approved an echocardiogram.

137

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 138 of 431 PageID #:12336
Patient #13
9/2/2015 Wexford denied a cardiology visit to evaluate the murmur but
approved an echocardiogram. This presumed that there was
someone at Stateville who could evaluate a murmur. When
the echocardiogram was completed no one at Stateville
documented reviewing its results.
9/4/2015 UIC lab reported BUN 62; potassium 6.6 creatinine 13.09,
albumin 3.8; alk phos 139; Ferritin 923; transferrin 186 (200400); cholesterol 111; TG 114; HDL 39; LDL 49, hemoglobin
10.6.

6, 19

The BUN should have prompted concern for inadequate
dialysis time. The elevated potassium was also high
and should have been promptly evaluated. It appears
that no one did anything about these lab results.
Prompt provider evaluation should have occurred.

9/10/2015 Apparently a nephrologist saw the patient. Blood pressure
was 155/97 and potassium 6.6. The doctor did not address
the elevated BP documenting that the patient just took
clonidine. The nephrologist stopped kayexalate and started a
different medication.

3

The blood pressure had been elevated for over a year
and the potassium was high, there was no apparent
consideration or documentation of dialysis time or
adjustment of blood pressure medication. The dialysis
record was not available so it is difficult to determine
the nephrologist's thinking.

10/10/2015 A doctor saw the patient who complained of not feeling good.
The blood pressure was 148/88 and oxygen saturation was
88%. A recheck of BP was 150/96. The only history pertinent
to his complaint was that the patient was in no acute distress
and that the patient had difficulty breathing. The lungs were
clear. The assessment was "dyspnea [with] HTN + dialysis".
The patient was sent to the health care unit but there were no
further notes indicating that the patient was examined in the
health unit.

2, 14

The patient had significant findings with hypoxemia,
shortness of breath. The patient needed to have a
diagnosis made, should have had an x-ray, and should
have had further evaluation including with laboratory
testing. Yet there is no evidence in the record that the
patient was evaluated. The patient should probably
have been sent to a hospital. Care failed to follow
generally accepted guidelines or usual practice.

138

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 139 of 431 PageID #:12337
Patient #13
10/28/2015 At 4:00 am a nurse noted that UIC lab called about a critical
8.5 potassium level. The nurse took no action except that the
am nurses would follow up with the doctor. At 1:30 pm the
same day a nurse documented that a doctor was notified
about the critical lab. The nurse documented that the patient
would follow up in following morning. This lab was not in the
medical record.

6, 19

10/28/2015 Apparently a nephrologist saw the patient. The BP was
168/95. The doctor did not address the elevated blood
pressure.
11/6/2015 At 3:00 am a nurse noted that UIC lab called about a critical
potassium of 7.6. The dialysis nurse notified the am nurse to
follow up.

3

The doctor did not adjust blood pressure medication or
apparently ordered increased dialysis time.

6, 19

The potassium was a critical level but no one addressed
it. This is systemic failure and care was grossly and
flagrantly unacceptable as the program should have a
system to respond to hyperkalemia given the dialysis
population.
The doctor did not adjust blood pressure medication or
apparently ordered increased dialysis time.

11/27/2015 Apparently a nephrologist saw the patient. The BP was
150/84. The potassium was 5.9 and the doctor increased
kayexalate. The doctor did not address the elevated blood
pressure.

3

139

A potassium of 8.5 is life threatening and required
immediate attention yet it was treated as a routine.
There was no evidence that this test was evaluated.
Care was grossly and flagrantly unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 140 of 431 PageID #:12338
Patient #13
12/1/2015 A nurse evaluated the patient for non-specific discomfort. The
blood pressure was 143/89. The nurse called a doctor who
ordered a stat only dose of atenolol. The patient had
shortness of breath, lightheadedness, tachycardia (126),
weakness and diaphoresis. An EKG was done but there was no
documentation of the results. Notably the EKG is not an
automated machine so it has no interpretation and the nurse,
being unable to evaluate the EKG could not inform the doctor
of the results. One EKG showed a rate of about 145 with non
specific STT wave changes. T waves appeared peaked. The
patient should have been sent to a hospital to evaluate for
acute coronary syndrome.

14

Ordering a stat dose of atenolol under these
circumstances is incompetent. The patient should have
been admitted to a hospital for evaluation. A stat
potassium should have been obtained. The T wave did
appear peaked which may have been consistent with
hyperkalemia. The patient had Care was grossly and
flagrantly unacceptable.

1/3/2016 Apparently a nephrologist saw the patient. The BP was
170/107 and potassium 5.8. The doctor increased labetalol to
400 mg BID. And gave a stat dose of clonidine.
1/9/2016 A medical staff [unclear if this was a nurse or doctor]
documented an evaluation. The patient was brought to the
clinic at 1:50 am by the dialysis nurse with nausea, vomiting
profuse sweating and abnormal vital signs including P 96;
oxygen saturation 90; BP 178/105. The temperature was 94.6,
which is hypothermia. The BP increased to 189/113. The
patient was monitored for several hours, given Tums, and
eventually the BP came down to 161/98 and the patient was
sent to his housing unit. If this was a nurse evaluation a doctor
was not called. The nurse gave the patient his am medication
apparently about 1:30 am.

140

14,16 It seems inappropriate to conduct dialysis at 1:30 am
when breakfast is only a couple hours later. It wasn't
clear if this note was from a doctor or a nurse. In either
case, the patient had vomiting, diaphoresis,
hypothermia and significantly elevated blood pressure.
These signs are consistent with sepsis or possibly acute
coronary syndrome which should have been ruled out.
The patient should have had stat laboratory tests and an
EKG but instead nothing was done except to give him
TUMS. The patient should have been sent to a hospital.
It appears that dialysis is being done in the early
morning. Care was grossly and flagrantly unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 141 of 431 PageID #:12339
Patient #13
1/14/2016 The patient received the echocardiogram requested more
than four months previously. The echocardiogram showed
mild to moderate increased left ventricle, elevated left atrial
and ventricular end diastolic pressures, EF of 60-65%, diastolic
dysfunction, severely dilated left atrium, moderately dilated
right atrium, elevated pulmonary artery pressure,
1/18/2016 The Medical Director saw the patient. This note was brief
stating "post echocardiogram at UIC, report pending, no
complaint O no acute findings A post med writ P FU prn."
The blood pressure was 178/113 but not addressed by the
doctor. The doctor did not evaluate the results of the
echocardiogram and, based on notes, no one ever reviewed
these results.
2/4/2016 Apparently the nephrologist saw the patient. The BP was
178/82. The nephrologist recommended a vascular surgery
visit. Blood pressure was not addressed.
2/9/2016 The Medical Director noted that Wexford approved an
appointment with the UIC fistula clinic.
2/21/2016 At 10:15 am nurse saw the patient for a cold. The
temperature was 101.9 and the BP 160/102. The nurse
documented "to UC for eval" but it wasn't clear what this
meant.

141

This echocardiogram was not timely. This is not a
difficult test to obtain. The echocardiogram showed
significant hypertensive heart disease.

3, 10

The doctor failed to review the echocardiogram results
which were abnormal and showed significant
hypertensive heart disease. The doctor also failed to
modify blood pressure medication despite significantly
elevated blood pressure. Care failed to follow generally
accepted guidelines or usual practice.

3

The doctor failed to modify medication for elevated
blood pressure. The dialysis sessions may have needed
to be longer.

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Patient #13
2/21/2016 At 10:30 pm a nurse noted that the patient felt nauseous and 1, 2, 3,
he had chills. The temperature was 101.4 and BP 170/95. The
19
patient said he was sent up from sick call for increased
temperature and blood pressure. The nurse notified a doctor
and received orders for Tylenol, Compazine and to monitor
the temperature for two days. There was no evidence of
monitoring. There was no follow up.

The patient had fever, elevated blood pressure, and
nausea. There was inadequate history. At a minimum,
the patient should have been placed on the infirmary
for an ASAP chest x-ray and blood work. Instead, the
doctor only gave the patient something to reduce
nausea. The patient should have been examined in
person but was not. Care failed to follow generally
accepted guidelines or usual practice.

3/8/2016 Apparently a nephrologist saw the patient. The potassium was
6.2; BP 198/102. The doctor made no change to BP
medication.
3/22/2016 A RN saw the patient in his cell and the inmate complained of
shortness of breath. The BP was 160/86 and pulse 114 with
respiratory rate 28-32. A CMT escorted the inmate to the
health unit in a wheelchair.
3/22/2016 A nurse saw the patient at 10:35 am. The inmate was
wheezing with pulse 116; R 32 and BP 160/80. Within two
minutes the patient collapsed and CPR was initiated. Within
15 minutes paramedics arrived and the patient was intubated
and transferred to a hospital.

The doctor failed to modify medication for elevated
blood pressure. The dialysis sessions may have needed
to be longer.

3/22/2016 The Wexford Mortality Review Worksheet documented that
earlier intervention was not possible, there was no way to
improve medical care, and the medical response could not be
improved.
3/23/2016 A death certificate lists the cause of death as hypertensive
heart disease. An autopsy was done. The anatomic diagnoses
were concentric LV hypertrophy, cystic granular kidneys,
pulmonary edema, and cerebral edema. The cause of death
was hypertensive heart disease.

142

3

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Patient #13
3/22/2018 A review of the MARs for five months from December 2014
through April 2015 for hypertension medication only revealed
that the patient received only 3/5 monthly packets of
Labetalol; 5/5 packets of lisinopril; 3/5 packets of nifedipine;
2/5 packets of Furosemide and 3/5 packets of hydralazine.
The total % received was 16/25 packets or 64% of his
medication.

143

17

The patient was not receiving medication as ordered.
No one was monitoring this.

Patient #14

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1/11/2013 The Medical Director documented that the patient had a gran
mal seizure and hadn't had one in several months. The doctor
sent the patient back to his cell house and ordered serum
dilantin and Tegretol levels next week. No follow up was
ordered.
3/2/2013 The patient had a seizure. The BP was 162/98. The nurse sent
the patient to the ER but there was no evidence that the
patient was seen in the ER.
4/2/2013 A PA noted that the patient had a seizure. The PA ordered
dilantin and Tegretol levels and referral to the doctor's clinic.

10

The doctor should have ordered follow up after a
seizure.

4/11/2013 Annual seizure clinic. The patient said he had seizures once a
month. The patient also described repetitive stereotypical
behavior. The patient was on Dilantin 200 BID and Tegretol
600 BID watch take. The doctor documented that the patient
had absence seizures and complex partial seizures. The doctor
documented that the anticonvulsant levels were therapeutic.
The doctor documented poor seizure control but the doctor
made no changes. This patient should have been referred to a
neurologist. The doctor also saw the patient for HTN clinic.
The patient wanted to go off statin medication. The blood
pressure was 136/97 with a repeat blood pressure of 130/100
but the doctor made no change of blood pressure medication
and stopped the statin. The doctor documented that the
patient didn't want to change his blood pressure medication at
this time.

12

Drug levels were not in the medical record. The patient
had three seizures over the past three months. There
was no evidence that the patient had ever had brain
imaging or an EEG. There was also no evidence that the
patient was ever evaluated by a neurologist. The
patient had poor seizure control but was not referred.
Care failed to follow generally accepted guidelines as
the patient should have been referred to a neurologist .

8

Therapeutic drug levels should have been ordered.

8

Therapeutic drug levels should have been ordered.

4/11/2013 Cholesterol 152; HDL 40; LDL 95.
4/17/2013 The patient had an unwitnessed seizure. The doctor was
notified and the patient sent to his cell house.
5/29/2013 The patient had a seizure. The LPN took no action; did not
notify a doctor and sent the patient back to his housing unit.

144

Patient #14

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6/6/2013 The patient had a seizure and was evaluated by a CMT. The
CMT referred the patient to a doctor since the patient had
three seizures since 4/11/13. No provider evaluated the
patient.
6/7/2013 A doctor ordered a dilantin and Tegretol level but did not see
the patient.
6/29/2013 A doctor saw the patient for follow up of seizures. The doctor
noted that the patient had uncontrolled seizures. The doctor
noted that the patient had therapeutic blood levels. The
doctor added Keppra 500 BID. The blood pressure was
162/101 but the doctor noted that the patient hadn't taken his
medication yet so he made no changes.

16

The CMT should have consulted a doctor.

1

The history failed to contain mention of medication
monitoring. Notably, drug levels were not in the
medical record. The patient was not monitored for side
effects of his medications.

8/6/2013 A doctor saw the patient for seizure clinic and noted that the
patient didn't have a seizure for two months and kept the
patient on the same medication.
9/26/2013 A nurse saw a patient after a seizure. The BP was 151/100.
The nurse called a doctor who ordered a next day follow up.
The next day instead of seeing a doctor an LPN saw the patient
and documented that the patient would follow up with a
provider on 10/3/13 and therapeutic drug levels would be
drawn.
10/3/2013 The Medical Director saw the patient but didn't address the
1, 3, 15 The history was inadequate and failed to address the
seizures. He addressed a leg discrepancy and ordered a shoe
seizure and therefore there was no follow up of this.
lift.
The patient's recent seizures were not addressed by the
physician; therapeutic drug levels should have been
drawn. The recent elevation of blood pressure wasn't
addressed.
11/20/2013 The inmate had a seizure and was seen by a CMT who
16
The referral to a provider never occurred.
encouraged the patient to increase his fluid intake and would
schedule the patient for a 11/25/13 visit.
11/27/2013 A PA saw the patient for shoulder pain but did not address the
seizure disorder.

145

Patient #14

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12/3/2013 The patient had a seizure. The blood pressure was 166/95 and
8
pulse 103. A doctor was notified but the patient was sent
back to his housing unit.
12/5/2013 The patient had a seizure. The note was extremely brief. It
2, 6, 8
stated, "Presents to HCU for follow up s/p seizure. Has been
on Keppra, Tegretol + Dilantin. Hadn't had a seizure in a few
months but he had a couple since then." That was the extent
of the evaluation. There was no review of therapeutic drug
levels, no examination, and no order of drug levels.
12/11/2013 A doctor wrote a note without seeing the patient reminding a
nurse apparently to check drug levels for follow up in seizure
clinic.
12/26/2013 The patient had a seizure. A CMT referred the patient to the
HCU where a nurse saw the patient. The nurse did not consult
a physician.
12/31/2013 A nurse completed a seizure clinic database. The blood
pressure was 140/100. The nurse noted that the patient was
on Dilantin 200 BID, Tegretol 600 BID, and Keppra 500 BID.
The nurse apparently ordered a repeat dilantin level and
ordered follow up in 2-3 weeks. There did not appear to be
consultation with a physician. A doctor apparently signed the
note but a nurse appeared to write the note. The nurse or
doctor did not document seizure frequency or compliance
with medication or describe a history of when the seizures
occurred or what may have precipitated the seizures. There
was another note on the same day for HTN clinic. The BP was
elevated but the doctor took no action to adjust medication or
to note compliance except to state that medication
compliance was reviewed. The doctor did note that the
dilantin was subtherapeutic but took no action. A repeat
Dilantin level was ordered with follow up in 2-3 weeks.

146

The doctor should have ordered a therapeutic drug level

The doctor failed to make an adequate assessment after
a seizure. There was no evaluation of prior drug levels
and the doctor didn't order drug levels after a seizure.

16

The nurse should have consulted a physician.

11

It appeared that the nurse was completing a seizure
clinic note instead of a doctor. This constituted
performing out of the scope of one's license.

Patient #14

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2/14/2014 A doctor wrote that the patient said he hadn't had a seizure
for "a good while." The blood pressure was 140/98. The
doctor increased the lisinopril to 30 mg daily.
4/24/2014 The patient was seen in HTN clinic. The blood pressure was
129/91 and 103/79. The doctor made no changes. The doctor
noted that the last seizure was four months ago. The patient
was on Dilantin, Keppra and Tegretol. No change was made.
The doctor didn't document drug levels.
5/18/2014 A nurse documented that the patient was brought to the
health unit after a seizure. The blood pressure was 226/109
and the pulse 121. The patient was confused. The nurse
notified a doctor but no actions were taken. A half hour later
the blood pressure had decreased to 132/84 with pulse 105.
The patient was discharged to his housing clinic.
5/19/2014 A nurse saw the patient. The blood pressure was 150/86. No
action was taken.
6/18/2014 The patient had a seizure and was seen by an LPN. The nurse
took no action.
7/4/2014 The patient apparently had a seizure. A nurse saw the patient
and documented BP of 151/90 and 148/87. The Medical
Director was notified and sent back to his housing unit.
8/7/2014 A doctor saw the patient in HTN clinic. The blood pressure
was 126/76. The doctor noted that the Dilantin level was 7.7
on 7/10 and 8.2 on 7/28. The Tegretol was 5.2. The doctor
noted that the last seizure was between 3-12 months ago
even though the patient had at least two seizures since
6/18/14. The doctor increased Dilantin to 300 mg BID.

147

8

Drug levels should have been obtained. Old levels
should have been reviewed.

16

The nurse should have consulted a physician.

8

Drug levels should have been obtained. Old levels
should have been reviewed.

Patient #14

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9/22/2014 A doctor saw the patient and noted that the patient said
Dilantin 300 mg was too much as he was groggy and
uncoordinated, so the patient decreased the dosage to 200
BID. The doctor did not examine for nystagmus or ataxia and
decrease the Dilantin to 100 BID then 100 daily and then
discontinue. The doctor noted that the Dilantin had been
subtherapeutic since 7/4/14.
11/21/2014 A nurse saw the patient for post seizure. The blood pressure
was 158/90. The patient refused to go to the HCU. The
Medical Director was notified.
11/29/2014 A doctor saw the patient and noted that the patient had a
seizure two weeks ago. The doctor documented "coindental
discontinuation dilantin." The doctor continued the Keppra
and Tegretol but did not obtain drug levels and wrote "no
need to adjust meds."
1/15/2015 The Medical Director saw the patient. The blood pressure was
158/85. The doctor saw the patient for a leg discrepancy and
ordered an x-ray of the pelvis, lumbar spine, and left knee but
did not address the elevated blood pressure or epilepsy.
1/22/2015 Wexford approved an orthopedic appointment.
2/2/2015 A CMT saw the patient post seizure. The CMT was told by the
patient had a seizure a month ago. The CMT noted that the
last Dilantin level was 8.2 but the patient was no longer on
Dilantin. The CMT did not consult a physician but noted that
the patient was scheduled to see the Medical Director on
2/3/15 and ordered a Dilantin level for 2/2/15.

148

8

Drug levels should have been obtained. Old levels
should have been reviewed.

16

The nurse should have consulted a physician.

Patient #14

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2/3/2015 The Medical Director saw the patient and noted that the
patient had his hip x-ray which showed severe degenerative
arthritis of the left hip and an old subcapital fracture. The
entire examination was documented as "no change." The
doctor told the patient that he was scheduled for orthopedic
clinic. The doctor did not address the seizure disorder.

2,

The x-ray showed severe arthritis with an old fracture
yet the doctor failed to properly examine the patient

2/3/2015 A doctor saw the patient in seizure clinic. The patient was
noted to have a seizure the day before. The doctor took no
other history. The drug levels were not checked. The doctor
did order a Tegretol level and noted that the patient was on
Keppra 500 am and 1000 hs. The patient was also evaluated
for HTN. The BP was 121/78. The doctor made no changes.

1,6

The doctor failed to take an adequate history including
review of prior therapeutic drug levels.

2/21/2015 The patient experienced a seizure. The BP was 194/92. The
patient has several superficial lacerations to the neck, R cheek
and chin. The Medical Director was called and he prescribed
50 mg of atenolol stat and sent the patient back to his housing
unit.

2, 3

The patient had elevated blood pressure after a seizure
which typically occurs. The doctor treated this with a
single dose of atenolol which was inappropriate. If the
doctor had waited until the post-ictal state resolved no
treatment probably would be indicated. If the blood
pressure remained elevated, long term medication
adjustment would be indicated not a stat dose of
medication. This doctor was a surgeon who did not
appear to know how to treat this problem.

3/17/2015 A nurse saw the patient for dizziness and lightheadedness.
The blood pressure was 160/92. No action was taken.

16

The nurse should have consulted a physician.

4/26/2015 The patient was seen post seizure. The blood pressure was
210/99. The Medical Director was called and prescribed
clonidine0.2 mg with his hs medication. It was 8:25 pm. The
nurse documented that the patient would be seen by the
Medical Director on 5/4/15 but this visit never occurred.

2, 3, 10 Stat medication for post-ictal high blood pressure is not
indicated. The patient should have been re-evaluated
after the post-icatal state resolved. There was also
failure to follow up.

149

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5/21/2015 A doctor wrote an extremely brief note. The blood pressure
was 150/83. The doctor increased the Procardia to 60 mg a
day with follow up in HTN clinic. There was no history, no
history of medication compliance, and no examination other
than vital signs.
7/28/2015 Wexford approved a CT of the hip.
8/5/2015 The Medical Director saw the patient post writ and noted that
a CT scan of the L hip was recommended. The doctor took no
history, there was no examination and no documented plan.
8/6/2015 Cholesterol 217; HDL 35; LDL 154.
8/20/2015 A doctor saw the patient in HTN clinic. The patient was on
Procardia 60, aspirin, Zocor 20, HCTZ, and lisinopril. The BP
was 141/91 but no changes were taken. With respect to
seizures, the history was that the last seizure was 2 months
ago. Tegretol level was noted to be 9.3. The doctor ordered
tapering Tegretol to discontinue. The doctor noted that the
patient was responding to Keppra.
8/23/2015 A nurse saw the patient post seizure. The BP was 199/101 and
pulse 109. The nurse called a doctor who ordered a single
dose of Keppra.
9/3/2015 A doctor saw the patient and noted that the patient had a
seizure three days after his Tegretol was decreased. The
patient was on a Tegretol taper and was currently on 100 mg
of Tegretol BID. Despite the recent seizure, the plan was to
continue the planned taper of Tegretol with a physician follow
up the following week. That visit didn't occur.

150

10

Consultant recommendations were not followed up.

3

The patient's 10-year risk of heart disease or stroke was
26%. He should have been on a moderate to high dose
statin. He should have been on 40 mg of Zocor. His
blood pressure medication should probably have been
adjusted.

3

A single dose of Keppra after a seizure is incompetent
care.

3, 10

The plan of tapering Tegretol appeared to have resulted
in a seizure. Scheduled follow up did not occur.

Patient #14

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9/15/2015 A doctor noted that the inmate had "erratic mental status
change" attributed to seizures. He was found on the floor
unconscious. The doctor noted that the patient developed
seizures five years ago. The doctor noted that there had been
no formal diagnosis by a neurologist. The doctor noted that
most seizures were unwitnessed and no one had reported
generalized tonic clonic movements. The patient was
disoriented and had an expressive aphasia but no repetitive
motor movements. The doctor had a differential diagnosis of
R/O organic causes, dementia, or schizophrenia. The doctor
ordered blood cultures x 3, CBC, CMP, folate, RPR, TSH, ESR,
ANA, Tegretol level, urine drug screen, and mental health
referral and then discharged the patient with a month follow
up. There was no follow up of these labs and these lab results
were not found in the medical record. It did not appear that
the patient received the blood tests.

9/22/2015 BUN 32; sodium 130; calcium 8.2; albumin 2.3; bilirubin 3.3;
alk phos 472; AST 165; ALT 119.
9/22/2015 A CT of the hip was done. There was chronic deformity of the
femoral head and neck with superimposed severe
osteoarthritis which was thought to be due to a
developmental etiology (slipped capital femoral epiphysis) vs
acquired trauma.
9/28/2015 A doctor noted that the CT scan results were not in the
medical record. The doctor took no action.

9/30/2015 A CMT saw the patient post seizure. The blood pressure was
180/120 with pulse of 122. A nurse documented receiving
orders but it wasn't clear what these orders were.

151

8, 10

A different doctor saw the patient and wanted to reevaluate the patient's apparent seizures. Ordered
laboratory tests were not done and ordered follow up
did not occur.

10, 11 A report was unavailable. The result was not followed
up. Based on the x-ray report the patient probably
needed evaluation for hip replacement but this did not
appear to occur.

Patient #14

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10/10/2015 A nurse saw the patient post seizure. The nurse noted that
the inmate had an appointment with the Medical Director on
10/12/15. No consultation was made and no further action
occurred.
10/11/2015 The patient had another seizure. The nurse noted that the
patient had an appointment the next day with the Medical
Director.
10/12/2015 The Medical Director saw the patient. The patient had BP of
104/69. The doctor noted that the patient was having
repeated epileptic seizures ever since Tegretol was stopped.
The only documented examination was "no change." The
patient agreed to an increase of Keppra, which was increased
to 1500 mg BID for six months with a one month clinic follow
up.
10/15/2015 A doctor saw the patient and noted that the patient had no
new seizure events. The doctor continued Keppra.

16

The nurse should have consulted a physician.

16

The nurse should have consulted a physician.

2

The doctor failed to examine the patient. We view a
comment "no change" as no examination.

16

The nurse should have consulted a physician.

2, 8

The doctor performed no examination and did not
obtain therapeutic drug levels despite raising the
medication. Therapeutic levels should have been
reviewed.
Therapeutic drug levels should have been ordered.

11/12/2015 The Medical Director noted that the Keppra was controlling
the seizures. The patient signed a release of information to
obtain the CT scan result. The doctor took no action.
11/17/2015 The Medical Director noted that ortho clinic was approved by
collegial review.
11/18/2015 The patient had another seizure. The Medical Director was
notified and a next day FU with the Medical Director was
scheduled.
11/18/2015 Wexford approved an orthopedic appointment.
11/19/2015 The Medical Director saw the patient and documented
"sustained epileptic seizure yesterday." The doctor performed
no examination, drew no therapeutic drug level, and increased
the Keppra to 2000 pm 1500 am.
11/20/2015 The patient had another seizure. The pulse was 115 and BP
154/81. The nurse notified a doctor, who took no action.

152

8

Patient #14

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11/25/2015 The Medical Director saw the patient post medical writ. The
blood pressure was 98/61. The patient had gone to
orthopedic clinic but the doctor did not document what
occurred at the ortho clinic. The doctor did not address the
seizure disorder.
12/16/2015 An orthopedic surgeon saw the patient. The consultant
wanted medical clearance before surgery could be done to
replace his hip.
12/24/2015 Wexford approved surgery for L hip joint replacement.
1/4/2016 LFTs normal CBC normal; carbamazepine <2
1/8/2016 The patient presented to the health care unit after a seizure.
A doctor ordered Ativan stat. The blood pressure was 170/98
but not addressed. A doctor saw the patient, who was
described by the doctor as delirious, incoherent, and
disoriented. The blood pressure was retaken and was 150/90
with pulse of 120. The doctor ordered that the patient remain
in the ER until the heart rate and blood pressure normalized.
A doctor saw the patient later. The BP was 114/70 and the
pulse 130. The inmate was oriented and coherent. The doctor
released the patient with a follow up with the Medical
Director on Monday.
1/29/2016 An x-ray showed very advanced degenerative arthritis with
marked loss of joint space.
1/30/2016 A LPN went to the cell house for a report of the inmate having
a seizure. The patient was alert and oriented. An RN didn't
evaluate the patient and the LPN took no history. The LPN
noted that the patient was oriented and asked staff to contact
the HCU if the patient had any issues.

153

16

The nurse should have consulted a physician.

Patient #14

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2/2/2016 Seizure annual clinic. The patient was on Keppra 1500 mg am
and 2000 mg pm. The doctor noted that the patient had been
on 3.5 gram of Keppra per day since Nov 2015 with occasional
breakthrough seizures. The doctor documented 2-3 urgent
care episodes since the last visit, presumably for seizures. The
only examination was to state that the patient walked with a
crutch and "neuro intact," whatever that meant. The doctor
noted that the patient had monthly seizures "but so far not
compromising ADL." The doctor noted that the Keppra was
"supramaximal dose-will adjust and monitor." The idea is to
not compromise. At this point, referral to a neurologist would
be appropriate as the patient had continued seizures, did not
have a clear seizure type documented, and was unable to be
controlled. Despite monthly seizures, the doctor reduced the
Keppra to 3 grams a day and return in two weeks.

12

The doctor should have referred to a consultant, as the
doctors were unable to control his seizures.

8

Therapeutic drug levels should have been ordered.

2/11/2016 A doctor saw the patient after the patient had a seizure after
Keppra was reduced. The BP was 128/89. The patient was
noted to be stable after medication changed. The patient
needed clearance for upcoming hip surgery and the doctor
said he would talk to the medical director about this.
2/11/2016 The Medical Director noted the patient was approved for hip
joint replacement.
3/5/2016 The patient was brought to the health unit post seizure. The
BP was 154/85 and pulse 121. Ativan 2 mg IM and Dilantin
300 mg was given stat by phone order. The patient was
initially confused but after 30 minutes the patient was
oriented and sent back to his housing unit.

154

Patient #14

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3/10/2016 The Medical Director saw the patient for shoulder pain. The
only examination was "abduction 90 degrees only;" the
assessment was "seizure DJD L shoulder." The plan was to
schedule the patient for a steroid injection next week.
3/28/2016 A PA wrote a note that the patient was scheduled for a
shoulder injection on 3/16/16, but that appointment didn't
happen due to time constraints and was rescheduled for 3/21,
which didn't happen and was rescheduled for 3/20/16.
3/29/2016 CMP normal; total cholesterol 178; TG 182; HDL 31; LDL 111.
3/30/2016 A doctor performed a shoulder injection.
4/4/2016 At 4:30 am a nurse saw the patient for left chest pain "like my
muscle down there is sore." The blood pressure was 170/102.
An EKG was done and the Medical Director was notified. The
Medical Director ordered clonidine 0.2 mg stat, NTG SL, and
Tylenol with an order to monitor the patient for an hour. If
the pain persisted the nurse was to call him back. If the pain
resolved the patient was to be released with a morning follow
up. The nurse didn't ask again about the chest pain but the
vitals were better with BP 142/88 and pulse 74 and the patient
was sent back to his housing unit.
4/4/2016 At 9:30 am a doctor saw the patient. The doctor noted that
there were no EKG changes and the pain was not responsive
to NTG. The patient had point tenderness over the back and
left shoulder. The doctor assessed gastritis secondary to
NSAID and ordered Zintec 150 hs.
4/4/2016 An EKG automated reading read atrial flutter, but a doctor
overrode this and wrote normal sinus rhythm. There were five
EKGs, none of which appeared to show atrial flutter. Four of
the five EKGs did not include automated readings.

155

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4/25/2016 The doctor saw the patient for annual chronic clinic for
hypertension. The patient was on Zocor 20 mg, lisinopril 30
and aspirin. The blood pressure was 130/85. The doctor
documented that the patient's labs were all "WNL." The labs
weren't documented in the doctor's note.

3

The patient had a 10% 10-year risk of heart disease and
stroke but was only on a low intensity statin.

4/26/2016 A LPN saw the patient on the housing unit after a reported
seizure. The inmate was on the floor "playing with his T shirt.
No seizure activity noted." The LPN sent the patient to the
health care unit. The patient was observed in the health unit
for 40 minutes and then sent back to his housing unit.

16

The nurse should have consulted a physician.

4/30/2016 A nurse saw the patient for a suspected seizure. The BP was
181/105 and pulse 121. The patient was drooling and
confused. The inmate was sent to the health care unit. There
were no notes from the health care unit.

16

The nurse should have consulted a physician.

10

Sooner follow up was indicated.

5/10/2016 The Medical Director noted an orthopedic appointment at UIC
was approved.
5/11/2016 Wexford approved a UIC ortho appointment for DJD of the hip
for a slipped femoral epiphysis.
5/26/2016 The patient apparently had a seizure. The pulse was 106 and
BP 146/88. The patient was confused and had garbled speech
post-ictal. The Medical Director was called who ordered a one
week follow up.
6/2/2016 The Medical Director documented that the inmate was
inquiring about his hip surgery. The doctor appeared to tell
the patient that the surgery would be soon. There was no
examination.
6/21/2016 The patient went to UIC ortho but pre-operative laboratory
tests didn't accompany the patient so the appointment was
rescheduled.

156

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6/21/2016 A brief comment by UIC ortho on the referral form stated that
the patient had hip osteoarthritis and needed pre-op labs and
paperwork before surgery could take place. They
recommended return to clinic when these had been done.
The report by the orthopedic service stated that the patient
needed the prison doctor to medically clear the patient and
that pre-op labs had to be done.
6/23/2016 The Medical Director saw the patient post writ and noted that
the patient needed lab work and paperwork. The doctor did
not evaluate the patient for his seizures despite recent
seizures.
6/28/2016 CMP normal except CO2 21 and anion gap 13. CBC normal.
7/16/2016 The patient had an unwitnessed seizure. BP was 152/91. The
nurse took no action.
8/2/2016 Phenytoin 3.3 (10-20); CBC normal.
8/9/2016 A doctor saw the patient in semi-annual seizure clinic. Much
of the note was illegible. The patient had no urgent care
episodes, presumably seizures. The Dilantin level was 3.3 and
the Keppra level was pending. It isn't clear how the patient
got on Dilantin and the history didn't explain the change in
therapy. The doctor noted that the patient was on Dilantin
300 mg and Keppra 1000 mg BID. A follow up in two weeks
with serum drug levels was ordered.

16

The nurse should have consulted a physician.

16

The nurse should have consulted a physician.

8/16/2016 An EKG without a legible date was signed as reviewed on this
date. Was NSR with septal infarct age indeterminate.
8/24/2016 A nurse saw the patient for an apparent seizure. The pulse
was 114 and BP 132/81. The patient was given his seizure
medication and sent back to his housing unit.
10/2/2016 EKG sinus bradycardia with voltage criteria for LVH.

157

Patient #14

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10/6/2016 Metabolic panel normal except C02 23; cholesterol 133; TG
83; HDL 33; LDL 83.
10/17/2016 A doctor saw the patient in semi-annual HTN clinic. The
patient was on HCTZ, Procardia, aspirin, lisinopril and Zocor
20. The BP was 111/76. An EKG was ordered with follow up in
six months.
10/18/2016 Glucose 118; Cholesterol 158; TG 115; HDL 27; LDL 108. CBC
normal.

3

These lipid values with the 10/17/16 BP values yield a
13.6% 10-year risk of heart disease or stroke A
moderate to high intensity statin was indicated.

8

Drug levels should have been obtained. Old levels
should have been reviewed.

12/14/2016 The Medical Director documented that orthopedic follow up
was approved. This was based on the June UIC ortho preoperative surgery appointment that was cancelled because
the patient didn't come with pre-operative laboratory tests.
12/14/2016 Wexford just received the request for orthopedic follow up
and approved an orthopedic appointment. This was six
months after the prior ortho visit.
1/10/2017 A nurse saw the patient for a seizure. The pulse was 128 and
BP 190/97. The pulse came down to 112 and BP 155/91.
After the confusion improved the Medical Director was
notified. No orders were given and the patient was sent back
to his housing unit.
1/10/2017 The orthopedic clinic documented that the patient needed to
get medical clearance from APEC. Apparently this is a UIC
unit.
1/11/2017 The Medical Director saw the patient post UIC ortho write.
The patient needed medical clearance. The doctor had no
plan.
1/13/2017 A doctor saw the patient for seizures. The doctor noted that
the patient was taking Dilantin and Keppra. The only
examination was to note that the patient was alert and "PE
[physical examination] unremarkable." The doctor ordered a
Dilantin and Keppra level and a follow up.

158

Patient #14

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1/26/2017 A doctor saw the patient to follow up on lab work. However,
the tests were not done and the doctor ordered follow up
when the lab tests were done.
1/26/2017 Phenytoin 5.3 (10-20).
1/28/2017 At 11:56 am a nurse noted that the patient was brought to the
ER after a seizure. The BP was 184/96 and pulse 96. The
patient was unable to follow directions and had a laceration
on his chin. A few minutes later the patient was alert and
responding. A doctor placed three sutures in the chin and
wrote a note. The doctor noted that the patient was alert with
confusion initially but became alert. The only neurologic
examination was to note the pupils were equal and reactive.
The doctor placed sutures, dressed the wound, and ordered a
Dilantin and Keppra level but did not order any medication.
The doctor ordered follow up in two days.
1/28/2017 At 5:30 pm a LPN was called to a cell house for the patient
having a seizure. The patient was unresponsive and sustained
a cardiac arrest. CPR was started and apparently continued
until paramedics arrived. The patient was pronounced dead at
the hospital at 6:16 pm.
1/29/2017 The death certificate listed coronary atherosclerosis as the
cause of death. The death certificate indicated that an
autopsy was done but the autopsy report was not in the
medical record.

159

The patient was on Lisinopril 30; HCTZ 25; Nifedipine 60;
simvastatin 20; ASA, Keppra 1500 BID; Dilantin 300 QD.

Patient #14

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2/1/2017 A death summary was completed by Dr. Obaisi. He stated that
the patient was incarcerated 25 years previously and was on
treatment for hypertension and epilepsy. Medications at the
time of death included lisinopril, HCTZ, Nifedipine, simvastatin
20 mg, ASA, Keppra, Dilantin, alendronate 70 mg weekly, oscal
1000 mg daily and famotidine 20 mg. He noted that the
patient was scheduled for hip replacement. The only
remaining discussion was the day of his death in which the
patient experienced seizures twice.
The goal of epilepsy management is to derive an
accurate diagnosis, measure of seizure frequency,
monitor medication side effects, and evaluate for
disease related psychosocial problems. UpToDate
states it is usually appropriate to refer to a neurologist
to make the diagnosis and formulate a treatment
strategy. Referral to an epilepsy specialist may be
necessary if there is doubt about the diagnosis and/or if
the patient continues to have seizures. Drugs are
typically designed for the seizure type. Keppra is a drug
used for a broad range of seizures; phenytoin and
Tegretol treat a narrow range of seizure types. Keppra
is used for myoclonic, partial onset and tonic-clonic
seizures. For Keppra the patient should be monitored
for ataxia, abnormal gait, psychiatric or behavioral
symptoms with CBC if patients experience fever or
recurrent infection. Tegretol levels should be checked
every two months until levels are constant.

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Patient #15
8/12/2016 The patient was admitted to NRC from Cook County Jail. He weighed 207 pounds and
was identified with mental illness.
1/13/2017 An x-ray of the chest and abdomen showed a metallic density in the right lower pelvis
suggesting a foreign body.
6/2/2017 There was a rectangular foreign body in the left upper quadrant extending to the left
upper mid abdomen measuring up to 19 cm. Recommend continued follow up.
7/12/2017 At 5:30 pm a nurse noted that an officer witnessed the patient swallowing a spork. The
nurse documented that the inmate "denies need for medical @ this time." The nurse
did not consult a doctor. The nurse noted, "Will have no complication from swallowing
a foreign object." There was no referral to a doctor.

16

7/13/2017 At 12:40 pm a nurse documenting notifying a doctor that the inmate said he swallowed
another spork. The nurse called a doctor, who ordered an abdominal x-ray.

7, 19

7/13/2017 No radiopaque foreign body is seen in the abdomen or pelvis.

Care was grossly and flagrantly
unacceptable. Swallowing a foreign
body such as a spork with a sharp
end is potentially life-threatening and
to state that the patient denies a
need for medical care when the
The doctor should have examined the
patient. A plastic item will not show
up on x-ray and the patient should
have been followed, and if the item
was not retrieved in the stool then

7/16/2017 A nurse saw the patient who said, "I went on hunger strike because no one cares about
the spork I swallowed." The nurse did not address the complaint of having swallowed a
spork.

19

The complaint was ignored and a
physician should have evaluated the
patient.

7/23/2017 A nurse evaluated the patient with a laceration noted on his right arm. The patient said
he did it with a spork. The pulse was 148. The nurse described the laceration as 10 by
3 cm, which is large. The nurse placed steristrips but did not refer the patient despite a
large laceration and a significant tachycardia.

16

The nurse should have consulted a
physician.

161

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Patient #15
7/24/2017 At 9:15 pm a nurse saw the patient for abdominal pain. The patient asked to be put on
sick call. The nurse documented the patient saying, "Don't put any pressure on my
stomach." The pulse was 104 and the temperature was 100. The nurse assessment
was "ineffective coping; pain R/T unk etiology ABD C/O abdominal pain." The nurse did
not refer the patient to see a physician. The patient was on a crisis watch.

16

The nurse should have consulted a
physician.

16

The psychiatrist should have
consulted a physician

9/29/2017 The patient was evaluated for suicide potential by a licensed mental health staff. The
patient complained that he was concerned about being refused sick call and wanted to
go to an outside hospital. The patient was angry and wanted to see a doctor. The
licensed staff wrote that the last suicide attempt was on June 12th and June 13th when
the inmate swallowed sporks. However, the more recent episode of swallowing a spork
was not mentioned. There was no referral to medical.

16

It is unclear whether the mental
health staff knew that the patient
had swallowed a spork. If so, the
patient should have been referred to
a physician.

10/2/2017 The patient saw a nurse practitioner and complained that he had swallowed "sporks" a
long time ago and wanted surgery to have these removed. The patient weighed 174
pounds, which was a 33 pound weight loss over the past year. The NP documented a
soft non-tender abdomen with normal bowel sounds. The patient had a history of self
harm. The patient also said he had pain from a piece of a nail clipper embedded in his
forearm. A palpable lump was present on the forearm. The NP ordered an x-ray of the
arm but took no action about the spork. The NP noted in the assessment that the
patient had a foreign body in the GI tract.

7

The NP failed to properly evaluate for
an ingested spork. An ingested item
failing to evacuate should have
resulted in referral for endoscopy.
Care was grossly and flagrantly
unacceptable.

8/7/2017 The patient refused sick call.
9/27/2017 The inmate had a discussion with a psychiatrist that he had swallowed sporks and
wasn't receiving medical attention. The psychiatrist said that the inmate was frustrated
with "what he perceives to be indifferent medical attention." The psychiatrist discussed
"some of the motivations for self-harm." The psychiatrist did not refer the patient to
medical.

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Patient #15
10/12/2017 A licensed clinical professional counselor (LCPC) saw the patient who complained of
stomach pain and wanted to see the nurse practitioner today. He said he was not
satisfied that surgery had been refused and that he was only eating snacks due to
stomach pain. The patient was not referred.
10/12/2017 The patient was scheduled for a foreign body removal on the arm but was
"inappropriate and argumentative" and signed a refusal. The patient was referred to
mental health.
10/18/2017 The LCPC who saw the patient on 10/12/17 saw the patient again. The patient
reported that no one was taking care of his medical needs. The patient reported
vomiting and diarrhea and was weak. The inmate wasn't eating because he was
nauseous. The LCPC spoke to a nurse who "agreed to take vitals." The LCPC spoke with
a nurse who agreed to evaluate the patient for his complaints. The LCPC documented
that he would follow up 10/19/17 regarding a sick call request "given he still had not
submitted one per medical."
10/19/2017 A Mental Health Progress Note stated, "Mr. Page did not attend Co-Occurring group.
He is sick."
10/20/2017 A nurse saw the patient for a complaint of swallowing sporks "months ago." The
patient's weight was 150 pounds, which is a 24 pound weight loss over the past month
and 57 pound weight loss over the past year. The patient complained that about a
week ago he started having abdominal pain that was sharp and burning. The patient
did not notice black or tarry stool and didn't think he had any bleeding. The patient had
nausea, diarrhea, and pain in the center of his abdomen. It hurt when the patient ate.
The nurse noted pain on palpation in the center of the abdomen. The nurse did not
consult a physician and gave the inmate Pepto-Bismol.

163

16

The mental health staff should have
referred the patient to a provider.

16

The patient wasn't referred to a
provider despite legitimate
complaints.

16

The patient had significant weight
loss, abdominal pain, and history of
ingestion of an object. The patient
should have been immediately
referred to a physician. Care was
grossly and flagrantly unacceptable.

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Patient #15
10/21/2017 At sometime around 7:00 am a nurse noted during medication pass that the inmate
was in bed unresponsive. The patient had no respirations or pulse and no signs of life.
The patient was stiff and in apparent rigor mortis. The patient had blood tinged
drainage from his mouth. There was blood in the toilet. CPR was started. Paramedics
arrived. It is not clear a doctor was on the scene but the nurse documented that the
patient was declared dead by 7:40. It isn't clear if this was the paramedics or a doctor.
12/1/2017 An autopsy reported that there were two sporks in the proximal duodenum and the
mucosa was deeply lacerated. The patient had deep lacerations of the proximal
duodenum with 20 ounces of clotted blood present in the stomach with superficial
lacerations of the proximal esophagus. The death was attributed to a GI bleed caused
by ingestion of foreign objects (two sporks).

164

The most common features in history
of foreign body ingestion are
dysphagia, refusal to eat, and
regurgitation of undigested food.
Perforation of the mid or distal
esophagus may result in severe chest
or upper abdominal pain. Endoscopic
evaluation is required even in the
setting of negative radiographs.
Plastic is not readily seen on plain
films so failure to locate an object on
radiographic examination does not
preclude its presence. In patients
with persistent symptoms, an
endoscopic evaluation should be
performed even if the radiographic
examination is negative. A sharp
pointed object in the duodenum or
stomach require urgent endoscopy.

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Patient #15
1/5/2018 An administrative death review was completed. This review found that the inmate had
an autopsy that showed two sporks inside his stomach that had lacerated the small
intestines which was determined to have caused the death. The administrative review
found that the patient had an x-ray on 7/14/17 that showed no foreign body. The
review also noted that the inmate had been seen in nursing sick call on 10/20/17 for
abdominal pain and diarrhea. During the assessment the patient complained of having
swallowed sporks two months ago. The review documented that the nurse assessed a
soft and non-tender abdomen, vital signs were normal, and that a proper protocol had
been chosen and that there was nothing in the nursing assessment that indicated an
emergency. The review noted that he had a number of crisis watch placements for
episodes of self harm including swallowing objects. He was sent to a hospital twice
(5/3/17 and 6/2/17) for swallowing objects. He swallowed a wire on the 6/21/17
admission but there was no hospital report. No problems with medical care were
identified on this review. The review noted that his medication compliance was
sporadic at best. It appeared on quick review that the inmate would refuse as much as
nearly half of his medication. The review noted that his symptom intensity was related
to his medication compliance with more hallucinations, paranoia and delusions when
not taking his medications. The review also noted that the patient was concerned
about not receiving proper medical care and that he also discussed swallowing two
sporks. The review did make a recommendation that psychiatrist should make referrals
for enforced medication if a patient showed inconsistent compliance that resulted in
crisis watches, disciplinary infractions, and increased symptoms and that nurse should
refer patients to a mental health professional when a patient refused medication for
three consecutive days.

165

Patient #16

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11/16/2012 Problem list documented HTN and asthma; no other diseases
were listed.
6/5/2013 An EKG showed a normal sinus rhythm
8/20/2014 A chest x-ray showed clear lungs. The heart was not enlarged.
There was no active pulmonary disease.
12/29/2014 An EKG showed a normal sinus rhythm.
1/24/2015 The patient was seen in asthma clinic at Menard. The PEFRs
was 550 and the patient was described as mild persistent. The
patient was using Xopenex only. There was no history
2/2/2015 Cholesterol 115; HDL 40; LDL 70.
3/17/2015 The patient was seen in HTN clinic at Menard. The blood
pressure was 142/80; weight was 350. There was no history.
Cholesterol was 115; HDL 40; and LDL 70. The patient was on
HCTZ and amlodipine.
7/22/2015 A doctor saw the patient and noted that the patient was being
seen for chest pain amongst other items. The doctor noted
that an EKG was normal. The doctor noted "to be up and
about and walking;" "initially he was not able to walk but later
he walked OK No chest pain No chest pain No SOB." The
doctor prescribed Motrin 200 mg 1-2 tabs TID prn; 18 tabs
were given.
7/23/2015 A nurse saw the patient for chest pain. The patient had the
pain for about an hour. The pain was sharp and felt like
tightness. The patient had dyspnea, dizziness, and had pain in
the arm. An EKG was done. The pulse was 86 with BP 108/70.
The nurse referred the patient to a physician.
7/30/2015 The patient was seen in asthma and HTN clinic at Menard. The
BP was 130/80 and PEFR was 550/550. The patient was listed
as mild persistent. There was no history noted for either
disease. The patient was on Norvasc and HCTZ.

166

17

Because the patient was a smoker, he had a 10-year risk
of heart disease and stroke of 10% and should have
been placed on a moderate to high intensity statin. This
did not occur.
11, 17 We could not locate the EKG in the record. Notably,
Motrin can increase risk of serious cardiovascular
thrombotic events. Use of this drug should have been
considered in a patient with multiple cardiovascular risk.

11, 16 We could not locate the EKG in the record. Referral to a
physician should not be routine for chest pain.

17

The patient had an 8.6% 10-year risk of heart disease or
stroke and should have been prescribed a moderate to
high intensity statin.

Patient #16

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10/21/2015 Patient was seen in HTN clinic at Menard. BP 120/84; pulse
108; the patient had 3+ pitting edema. The patient was on
Norvasc, HCTZ, Lasix; and KCL. The patient was noted in good
control. 3+ edema is of concern but was not addressed. It
may have been due to the Norvasc.
12/2/2015 Cholesterol 134; HDL 40; LDL 84.
1/20/2016 Menard asthma and HTN chronic clinics. Weight 387; BP
138/86; pulse 107; PEFR 560/500; noted as in good control for
HTN on Lasix 40; Norvasc 5; HCTZ 25; KCL 25.
2/26/2016 A nurse saw the patient for chest pain that was stabbing in
nature lasting 3-4 minutes. The blood pressure was 170/68
with pulse 100. The nurse did not appear to consult a
physician but a chest x-ray was ordered along with Tylenol and
CTM. It appeared that a physician signed this note.
3/1/2016 A chest x-ray showed bilateral hilar prominence may be due to
lymphadenopathy. Findings may be due to sarcoidosis. For
more complete evaluation, CT study of the chest with contrast
is suggested.
3/16/2016 A doctor noted that a chest x-ray showed hilar adenopathy. A
referral was made for a CT scan.
4/7/2016 CT of chest was normal without enlarged lymph nodes.
4/14/2016 A doctor noted that the patient had a CT scan but the results
weren't available. The blood pressure was 154/100 and the
doctor noted that the patient had been off his BP meds for
three days. The patient was given reassurance.
6/9/2016 Glucose 118.
6/18/2016 A doctor noted that the CT scan suggestive of sarcoidosisrecommendation was CT with contrast.
7/1/2016 Glucose 93; albumin 3.2 (3.4-5); cholesterol 120; TG 58; HDL
36; LDL 72.

167

2

The doctor did not evaluate why the patient had edema.

19

A physician should have evaluated the patient and an
EKG should have been done. The patient had chest pain
with abnormal pulse and blood pressure.

Patient #16

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7/25/2016 Asthma and HTN clinics; weight 410; BP 132/64; PEFR
540/500; the patient had 3-4+ edema with pitting and listed
in good control. The patient was on Lasix 40; Norvasc 5; HCTZ
25; and KCL with ASA started for a year.

2

The doctor did not evaluate why the patient had edema.

8/11/2016 A doctor saw the patient for chest pain when walking,
increased with deep breathing. Some of the note was illegible
but it appeared that the patient was short of breath. The
doctor diagnosed atypical chest pain and ordered an EKG. The
EKG was not reviewed but showed inferior infarct age
undetermined. The actual tracing was poorly copied and we
were unable to review accurately. The rest of the note was
illegible.

2

The patient had symptoms consistent with angina but
was diagnosed with atypical chest pain. The patient had
multiple risk factors for coronary artery disease
including being a smoker, hypertension, elderly, and
male. His cardiovascular risk was around 10% and he
should have been on a statin. It appeared that the
doctor made an inaccurate assessment based on the
history the patient provided.

8/11/2016 A nurse documented a nurse protocol for chest pain. The
nurse documented shortness of breath with exertion and
experienced chest pain while walking and it felt like tightness.
The nurse referred to a doctor, who saw the patient and
diagnosed atypical chest pain.
8/29/2016 A nurse noted that the patient was dizzy and short of breath.
A doctor saw the patient who was short of breath and
diaphoretic. The doctor sent the patient to a hospital.
8/29/2016 An EKG showed normal sinus rhythm with possible inferior
infarct age indeterminate
8/29/2016 The patient was admitted to Memorial Hospital in Chester IL.
The patient was admitted for shortness of breath and
diagnosed with pulmonary emboli. The patient was also
diagnosed with new onset diabetes with hemoglobin A1c of 7.
The patient was placed on coumadin. The etiology of the
emboli were not determined. The recommendation was
anticoagulation for six months. The patient had a hemoglobin
in the hospital of 11.1

168

Patient #16

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8/29/2016 The patient's annual examination at Menard listed obesity,
GERD, HTN, history of rectal bleed, and questionable hilar
nodes as problems.
8/29/2016 A nurse documented that the patient returned from the
hospital with a diagnosis of pulmonary embolism and was on
anticoagulation.
8/29/2016 A D-dimer test in the hospital was 8.25 (0-0.5) protein C or S or
lupus anticoagulant were not done.
8/30/2016 Chest angiography showed bilateral pulmonary emboli within
segmental and subsegmental RLL, lobar, and RUL and LUL and
LLL segmental branches.
8/30/2016 The patient asked a nurse when he would get his medication
for his blood clots. The nurse documented that the patient
would see a doctor in the morning.
8/30/2016 The patient was admitted to the infirmary and listed as on
coumadin and Lovenox.
9/6/2016 INR 2.56
9/6/2016 INR 2.56
9/7/2016 A doctor noted an INR of 2.56. There had been no history or
10, 17
physical examination since the admission note. The patient
was discharged with a diagnosis of bilateral pulmonary emboli.
Notably, at the hospital there was no evaluation what the
etiology of the bilateral emboli was. There was no
echocardiogram, no lab tests for clotting diseases.
9/13/2016 An EKG showed normal sinus rhythm with possible inferior
infarct age indeterminate
9/14/2016 Gen Medicine clinic at Menard. BP 134/90. The weight was
380. The doctor started or continued coumadin 8 mg for
bilateral pulmonary embolism with "fair control." There was
no history of the pulmonary embolism and it was unclear
when this started. There was no history at all.
9/15/2016 A1c 7.5; INR 2.3

169

The patient wasn't seen for a week after a
hospitalization for pulmonary embolus. Follow up was
inadequate. Based on the recent diagnosis of diabetes
the 10 year risk of heart disease or stroke was 16% and
the patient should have been on high intensity statin.

Patient #16

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9/21/2016 A NP saw the patient and noted that the patient had no
abnormal bleeding and had new diagnosis of diabetes and was
on coumadin. The patient was on coumadin 8 mg and
metformin 500 BID.
10/11/2016 INR 2.5.
10/19/2016 An EKG showed normal sinus rhythm with nonspecific ST
abnormality
10/19/2016 A NP saw the patient for chest pain with shortness of breath.
The NP took virtually no history of the chest pain except that
the patient had no diaphoresis. An EKG was done and the NP
documented that it was normal; it was not. It showed nonspecific STT wave changes. The NP documented that the
patient was laughing and making "joke with staff." The NP
documented normal assessment. The NP ordered a chest xray and follow up with a physician.

10/21/2016 A doctor wrote a note that the patient had chest pain but took
no history, performed no examination and only noted an INR
of 2.6 and ordered a chest x-ray and ordered Tylenol.
11/1/2016 In November the patient missed two doses of coumadin
11/16/2016 INR 2.
12/1/2016 In December the patient missed eight doses of coumadin; he
was at a hospital for several days.
12/16/2016 Glucose 115; calcium 8.5; albumin 3.3; cholesterol 129; HDL
40; LDL 80; INR 2.7.

170

1, 2, 3 The NP failed to take an accurate history. The history
that was taken of chest pain with shortness of breath is
not inconsistent with angina. The EKG was interpreted
as normal by the NP but actually showed nonspecific
STT wave changes which is consistent with ischemia.
The patient also had multiple risk factors for ischemic
heart disease including diabetes, hypertension, smoker,
male and elderly and had a 16% 10 year risk of heart
disease or stroke. The patient also had repeated
episodes of similar pain which appeared to be angina.
The NP should have placed the patient on anti-anginal
drugs and a high intensity statin and referred for
exercise stress testing, stress echo or catheterization.

1, 2, 3 The doctor failed to take a history, did not perform an
examination, and made no assessment of the chest
pain. The only plan was to order Tylenol and refer for a
chest film. Care was indifferent.

Patient #16

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12/20/2016 A chest x-ray showed borderline heart size is seen with
haziness in the perihilar region. This may indicate mild
pulmonary vascular congestion. Please correlate clinically.
12/20/2016 An EKG showed normal sinus rhythm.
12/20/2016 A nurse evaluated the patient using a chest pain protocol. The
blood pressure was 132/84 and pulse 88. The patient had
ronchi noted in the R lung. An EKG was documented as RRR.
The patient had numbness radiating to the arm without
shortness of breath or nausea. The nurse consulted a
physician who made orders but these were not documented in
the note.
12/20/2016 A NP saw the patient for chest pain and shortness of breath
1, 2, 3
since the morning. The chest pain radiated to the left arm.
The patient had cough. The NP documented the EKG as
normal; it was normal. URI was diagnosed. Cough syrup was
prescribed and a chest x-ray was ordered.

12/21/2016 An NP saw the patient in follow up. The patient had no
improvement but diagnosed URI and ordered a follow up as
ordered.
12/21/2016 A nurse saw the patient for shortness of breath since last
night. The patient was on Xopenex. The patient had cough.
PEFR were 380/400/390 and oxygen saturation was 97% and
the patient had ronchi. A physician was not consulted and prn
follow up was ordered.
12/23/2016 Chest x-ray from Memorial Hospital in Chester IL shows
placement of an endotracheal tube.
12/23/2016 A nurse saw the patient for shortness of breath. The patient
had a pulse of 110 and BP of 138/90 with PEFR 250 and
oxygen saturation of 94-97. The nurse consulted a doctor who
ordered the patient sent to a local hospital.

171

The history with respect to the chest pain was
inadequate. The patient had multiple cardiovascular
risk factors and a 13% 10 year cardiovascular risk. The
patient also had multiple episodes of chest pain. He
should have been placed on a statin, antianginal drug
and referred for possible stress test or cardiac
catheterization.

Patient #16

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12/24/2016 A chest x-ray showed an endotracheal tube was removed. The
heart and lungs were normal.
12/25/2016 A CT scan showed discoid atelectasis and ground glass nodular
opacity in the right upper lobe. There was a 12 mm nodule in
the left adrenal gland. A repeat CT scan in 12 months was
recommended. The study was non-diagnostic for pulmonary
embolism.
12/26/2016 A chest x-ray was normal at Memorial Hosp in Chester.
12/26/2016 Duplex scan was negative for DVT in both legs.
12/27/2016 The patient returned from the hospital with diagnoses of
respiratory failure; asthma exacerbation. The patient was on
Ceftin 250 BID and azithromycin 250 daily both for three more
days, a prednisone taper, Lasix 60 mg for 30 days and
continuation of other medications.
12/28/2016 A doctor wrote a very brief note stating, "SOA no Cs denies
SOB chest clear" The plan was to discharge the patient to his
cell with follow up in a week.
1/1/2017 The patient received all doses of coumadin.
1/7/2017 A NP saw the patient for the hospital follow up. The NP noted
that the patient was doing well and noted that the patient was
referred for sleep study. The NP did not document what
occurred at the hospital.
1/17/2017 INR 2.4.
1/18/2017 The patient was approved for a sleep study.
2/1/2017 The MAR showed that the patient refused seven doses of
coumadin. The patient missed six of the first eight doses after
transfer from Menard.
2/4/2017 The patient transferred to Stateville. The patient was
documented as having HTN, asthma, PE, and DM. The patient
was listed as being on Tylenol, Lasix, aspirin, Coumadin, HCTZ,
Glucophage, Norvasc, Pepcid, and Mobic.

172

1,3

1

The doctor's documented history was inadequate. It
wasn't clear he reviewed the hospital note and it wasn't
clear what the therapeutic plan was for this patient at
this time.
The history was inadequate and it wasn't clear what
happened at the hospital.

Patient #16

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2/16/2017 A PA saw the patient and noted that he was a new patient to
Stateville. The PA noted that the patient had HTN and was
due to have a sleep study. The PA noted that the patient was
already referred to chronic clinic. The PA noted morbid
obesity, HTN, type 2 DM,asthma and history of PE in August of
2016. The PA ordered a PT,PTT, CMP, CBC, and Lasix.
2/21/2017 A sleep study showed very severe sleep disordered breathing.
CPAP was recommended. Or referral to ENT for possible
surgery.
2/23/2017 Hemoglobin 9.4; MCV 69.5; MCH 20; MCHC 28.8; INR 1.2 This
was the first CBC in the record at an IDOC facility. The patient
had a hemoglobin of 11.1 at a hospital in Chester IL in August
2016.
3/1/2017 A normal chest x-ray was reported.
3/1/2017 The Medical Director noted that the patient was post sleep
study and was to be presented to collegial for a CPAP device.
The doctor wrote that the patient had a history of pulmonary
emboli and was on coumadin. The doctor ordered an EKG,
chest x-ray, CBC, CMP A1c and follow up in a month. The
blood pressure was 151/84 and pulse 94. The doctor did not
address the elevated BP. The doctor did not check the INR or
note the significant anemia while on coumadin. This was the
first physician visit at Stateville.
3/1/2017 The MAR showed that the patient received coumadin until
3/9/17, when it was discontinued. The patient received no
further doses.
3/3/2017 A doctor saw the patient. The patient had back and neck pain.
The note was partly illegible. The doctor ordered an x-ray of
the neck and back and ordered Robaxin with follow up when
the x-ray was done.
3/5/2017 An EKG showed normal sinus rhythm.
3/7/2017 A1c 7.2; hemoglobin 9.2 with microcytic indices.

173

6

The doctor failed to take note of the recent abnormal
hemoglobin and subtherapeutic INR. This placed the
patient at significant risk.

Patient #16

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3/10/2017 The Medical Director saw the patient and noted that the
hemoglobin was 9.2 and ordered fecal occult blood for a
week. The doctor noted that a rectal examination noted a
mass in the rectum and diagnosed anemia with GI bleeding
and a rectal polyploid lesion. The Medical Director stopped the
coumadin and aspirin and requested ferritin and serum iron
and an INR, folate and B12 with follow up in a week. The
doctor gave no reason for stopping the coumadin. It appeared
that this was done due to the anemia and the apparent
bleeding in the rectum. The pulse was 121. The doctor did
not document the most recent INR. The doctor made no
attempt to evaluate the status of the pulmonary embolism.
The patient had received six months of warfarin, but follow up
on this should have occurred.

3/14/2017 B12 445 (180-914); folate 16 (>5.8); iron 20 (50-180); iron
binding capacity 402 (250-450); transferrin 287 (200-400); INR
1.2.
3/14/2017 A collegial review approved a GI referral.
3/16/2017 A PA saw the patient. The patient asked for a refill of his Lasix.
The PA performed virtually no examination but assessed HTN,
pretibial edema, and sleep apnea. The blood pressure was
135/93. The PA ordered a HTN chronic clinic but did not
adjust BP medication or address the INR result.
3/17/2017 A doctor saw the patient for follow up of neck pain. The BP
was 141/82. The neck was better. The rest of the note was
illegible.

174

Patient #16

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3/28/2017 HTN clinic at Stateville. Patient on Lasix 40; Norvasc 5; HCTZ
25; KCL; BP 138/57 weight illegible; note illegible; HCTZ was
discontinued ASA was continued.

2, 3

3/29/2017 The Medical Director noted that the patient had a collegial
review and had blood testing. The exam was "no change" and
the assessment was only "GI bleeding" without comment on
the pulmonary embolism. The patient was informed he would
soon see GI. There was no other plan or evaluation of the
patient's other patient's problems.
4/3/2017 A doctor referred the patient for colonoscopy and hemorrhoid
banding.
4/3/2017 The Medical Director saw the patient post writ and said that
the patient was to have a colonoscopy and possible
hemorrhoid banding. The GI note was not in the record. The
doctor made no other comment.
4/5/2017 The patient asked the nurse for a breathing treatment. The
patient didn't have wheezing but the nurse took no history but
did note no shortness of breath. The nurse wouldn't give the
patient a treatment and the patient became angry and left.
4/11/2017 The Medical Director noted that colonoscopy was approved.

175

The patient had a 13% 10-year cardiovascular risk with
repeated episodes of angina yet was not started on a
statin drug. Also, unappreciated was that the patient
was on a non-steroidal drug with significant
cardiovascular risk. Yet this was not considered.

Patient #16

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5/10/2017 The patient developed left sided chest pain and was noted by
a nurse to be in mild distress. Though the patient was walking
when the pain started according to the nurse note, the nurse
documented that the pain was not exertional. The Medical
Director saw the patient and noted that the patient developed
pain when walking. The doctor noted that the pain was
pressure like and lasted about a half hour. The doctor noted
that an EKG was normal. This EKG was not in the chart and I
asked the Attorney General's office to locate it but the HCUA
could not locate the EKG. The doctor assessed "chest pain
resolved" and ordered Coreg for six months, a CBC and CMP.

5/16/2017 Glucose 116; hemoglobin 8.7; with microcytic indices;
platelets 487 (150-450).
5/19/2017 An EKG showed sinus tachycardia with ST depression, consider
subendocardial injury or digitalis effect.
5/19/2017 The patient felt chest pain, dizziness, cold and clammy going to
the dining hall and was brought to the health care unit. An
EKG was performed showing acute subendocardial ischemia.
The patient then experienced cardiac arrest and CPR was
started and the patient was transferred to a hospital where he
died.

176

3

The doctor did start a beta blocker. But high intensity
statin was indicated. Also, depending on the EKG
tracing, hospitalization may have been indicated.

Patient #16

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5/25/2017 The Medical Director filed a death summary. The patient's
diagnoses were listed as acute coronary syndrome with fatal
cardiopulmonary arrest; severe asthmatic COPD with acute
pulmonary failure in 2016; severe OSA; pulmonary sarcoidosis;
GI bleeding with low iron and rectal mass; type 2 DM, HTN,
GERD, but the summary failed to document prior pulmonary
embolism. The document stated that the patient transferred
to Stateville on 2/8/17 and at Stateville was found to have
blood in the stool with anemia; a rectal mass was identified in
the rectum and the patient had a guaiac + test and was seen
4/3/17 by GI and was scheduled for colonoscopy. The doctor
noted that the patient had a subendocardial injury on EKG. At
the time of death the patient was on carvedilol, amlodipine,
aspirin, Lasik, HCTZ, Prilosec, and metformin.

5/27/2017 The coroner filed a death certificate. The certificate states that
the cause of death was pulmonary embolism secondary to
deep vein thrombosis. The certificate documents that an
autopsy was done but it was not present in the medical
record.

177

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Patient #17
3/6/2001 The problem list documents an esophageal stricture.
4/12/2001 The problem list documents duodenal ulcer and esophageal
ulcer.
8/12/2002 The problem list documents mitral valve prolapse.
11/12/2002 The problem list documents Barrett's esophagus and PUD
3/14/2011 The problem list documents aortic valve replacement
6/19/2013 An annual physical examination was refused but the doctor
documented the problems as aortic valve replacement,
hepatitis C, Hx of CAD and heart failure, history of esophageal
bleeding, history of atrial flutter, GERD and duodenal ulcer,
history of thoracic aortic aneurysm with aortic root repair at
the same time of his aortic valve replacement, atrial flutter
with ablation at UIC, old compression fx of L4
2/11/2014 A doctor noted review of the EKG showing prolonged PR
interval and L atrial abnormality.
2/19/2014 An LPN wrote that the inmate wanted a heart test that had
been scheduled after surgery for aortic valve replacement.
The patient complained of dizziness when he walked. The
patient stated, "Stateville wouldn't order test." The nurse
referred the patient to the doctor. The patient didn't see a
doctor for this.
3/10/2014 A writ to UIC cardiology was cancelled but there was no
explanation why.
3/13/2014 The patient complained of getting winded walking to chow.
The nurse documented that the inmate was anxious and
breathing "hard and fast" and with "pursed lips." The nurse
took no vital signs and the only comment was "pursed lip
breathing no change."

178

This problem was not being monitored on chronic
disease visits.
These problems were not monitored. There was no
surveillance for the Barrett's esophagus.
2

There was no monitoring of the Barrett's esophagus.
Multiple problems of this patient were not being
followed consistently including aortic valve
replacement, thoracic aortic aneurysm, atrial flutter,
and COPD

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 179 of 431 PageID #:12377
Patient #17
3/14/2014 A nurse saw the patient for shortness of breath. The
respiratory rate was 32. The oxygen saturation was 83% on
room air. The nurse noted shortness of breath when walking.
The nurse noted that the patient's cardiology clinic was
cancelled by UIC. The nurse observed the patient in the
infirmary on oxygen and referred to a doctor but it wasn't
clear when. Later a nurse practitioner saw the patient and
noted increasing SOB over the past few weeks. The NP
ordered 40 mg of Lasix stat and admission to the infirmary and
oxygen to keep the saturation above 90%.
3/14/2014 A NP infirmary admission note documented history of GERD,
Barrett's esophagus, aortic stenosis with prior valve
replacement with heart failure, atrial flutter ablated in 2011,
and aortic aneurysm repair in 2011. The NP did not order a
chest x-ray but did order a CBC but no CMP. An EKG was not
ordered. There was no referral for echocardiogram. The NP
noted that the oxygen saturation was 83%.
3/14/2014 On the 3-11 shift a nurse documented that the patient had
audible expiratory wheezes with dyspnea on exertion and an
oxygen saturation of 88% on 2 liters of oxygen, so the nurse
increased the oxygen to 2.5 liters and the oxygen saturation
increased to 91%.
3/15/2014 A nurse noted that the patient's oxygen saturation was 80%
off oxygen and was 92% on oxygen. No action was taken.
3/18/2014 A nurse noted that after walking short distances the oxygen
saturation dropped to 88% but was above 90% on oxygen.

179

This patient needed a stat blood gas and chest x-ray and
should have been sent to an emergency room for this.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 180 of 431 PageID #:12378
Patient #17
3/20/2014 The patient wanted to go back to his housing. He had oxygen
saturation of 93% on room air. There had not been a
documented physician note since admission on 3/14/14.
3/21/2014 A physician saw the patient for the first time on the unit. The
doctor documented that the patient did not get hemoccult
test as ordered on 3/15/14. The doctor did not document
review of the CBC or even note that it had been done. The
doctor listened to the chest and noted a few rales and a
murmur and discharged the patient with a 3 day follow up
with the NP. A metabolic panel was ordered. The diagnosis
was heart failure. The NP didn't see the patient for 10 days.

3/22/2014 Sodium 137; AST 39; ALT 27; hemoglobin 13.2; platelets 459.
3/31/2014 The NP noted that the patient had been on the infirmary for
respiratory distress. The NP noted clear lungs and assessed
that the shortness of breath resolved without documenting a
presumed diagnosis. No diagnostic tests had been done in the
infirmary to ascertain the reason for the shortness of breath.
The NP continued the higher 40 mg dose of Lasix and started
Ultram 150 BID for four months for unclear reasons. A CMP
was ordered for six weeks with follow up in eight weeks. The
NP did not document review of the CMP; it appeared as if it
was not done. The weight was 181.

180

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Patient #17
4/3/2014 A doctor saw the patient and noted that the patient said he
was to have an echocardiogram and Holter at UIC but it hadn't
been done at Stateville. The doctor reassured the patient that
he had an upcoming appointment at UIC.
5/8/2014 Sodium 133; AST 57; ALT 57.
5/12/2014 A NP saw the patient for increasing shortness of breath in the
evening and at night. The NP noted a few rales in the bases
and 1+ pedal edema. The NP increased the Lasix to 40 am and
20 pm for four months but did not order a chest x-ray or EKG
or CMP.
5/22/2014 The patient went to UIC. But the report was not in the
medical record. A referral form had comments from the
cardiologist, who noted that a stress test was negative and an
echocardiogram showed 55-60% EF with NL function. Since
the EF was normal the findings on exam might be symptoms of
overload vs COPD. The consultant recommended increased
diuresis, lung x-ray to monitor progress and if not better
consider CXR and referral to pulmonary for PFT to rule out
COPD.

181

6

The NP failed to review recent abnormal laboratory
findings.

11

Failure to obtain reports results in not knowing the
status of the patient.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 182 of 431 PageID #:12380
Patient #17
5/29/2014 A doctor documented that the patient had been seen in
cardiology, who recommended increasing the diuretic and if
no improvement get a pulmonary function test and follow up
in six months. The doctor ordered a CMP and started Lasix 60
mg in the morning and 20 in the evening for two months with
follow up with the NP in 3-4 weeks. The weight was 180. The
doctor did not document review of the report and it wasn't
clear what the status of the patient was based on the report.
The weight was 180 pounds. The doctor took no history and
did not perform a physical examination. The only assessment
was heart failure.

1, 2

The doctor took inadequate history and performed no
physical examination post-UIC visit.

6/2/2014 The patient saw a NP. The patient asked to be pushed in a
wheelchair because it was hard to get to chapel. The weight
was 193. The NP documented that the Lasix had been
recently increased and that the patient had a murmur but no
peripheral edema. The problems listed were CAD/CHF/valve
replacement. The patient asked for renewal of Norco but the
NP took no history, no examination, and no assessment of the
status of pain. The NP noted that the patient had a follow up
scheduled for 3-4 months and that he should follow up sooner
if needed. The NP did not note the 13 pound weight gain over
the past several days. The NP prescribed Norco without
evaluation for pain.

17

Prescribing an opioid without clarifying whether the
patient had pain or the degree of the pain is extremely
poor practice and promotes opioid addiction.

6/3/2014 Potassium 5.4; sodium 125; chloride 97; AST 63 ALT 42 (1050).

182

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Patient #17
6/4/2014 A doctor wrote a brief chart review note on reviewing labs.
The doctor noted that the potassium was 5.4 and that sodium
was 125 with chloride of 97. The doctor continued the Lasix of
60 am and 20 pm and decreased the potassium to 20 mcf
"OD" apparently meaning either daily or every other day. The
doctor wrote for fluid restriction"30-40 oz /day" and ordered
repeat electrolytes in two weeks.
6/23/2014 Potassium 4.5; sodium 131.
7/8/2014 A NP saw the patient. The BP was 110/56 and the weight 190.
The inmate reported SOB with walking but no edema of legs.
He had pain in his feet. The patient had no SOB or cough at
night. The NP documented considering COPD and ordered a
chest x-ray as recommended by UIC about two months earlier
in May. The NP ordered a wheelchair for long distance with a
three week follow up.
8/22/2014 A NP saw the patient, whose weight was 197 pounds. The
patient was being seen for review of a chest x-ray. The patient
still had shortness of breath walking long distances. The chest
film was documented as showing "mild changes of CHF +
emphysema." The assessment was CHF with mild emphysema
and bioprosthetic aortic valve. Because of the potential for
having both heart failure and COPD, PFTs should have been
done for diagnostic reasons and to establish the baseline for
this patient.

183

7

Pulmonary function testing should have been ordered.
This was suggested by the cardiologist and we concur.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 184 of 431 PageID #:12382
Patient #17
9/17/2014 A NP saw the patient for renewal of Norco. The NP noted an
open sore on the great toe. The NP changed the Norco to
Tylenol #3 for 30 days. It wasn't clear what pain was being
treated and what the status of the pain was. The NP gave the
patient eight bandages for his ulcer. Weight was 183.

17

It is bad practice to prescribe narcotics without taking a
history of the pain or performing a physical exam to
document the extent and severity of the pain.

10/14/2014 A NP saw the patient. The weight was 186 and BP 110/60.
The patient requested renewal of Tylenol #3. the patient had
a quarter sized lesion on his toe. The NP advised the patient
to tie his shoes [presumably this was thought to have caused
the ulcer].
10/15/2014 Sodium 134.
12/15/2014 Sodium 140 potassium 4.5.
1/4/2015 A partly illegible mental health professional note documented
that the patient was on a religious fast and hadn't eaten for
several days.
1/9/2015 A PsyD saw the patient and noted that the patient was being
seen daily since he began "fasting" on 12/24/15. The patient
appeared delusional but denied hallucinations and there was
no evidence for auditory or visual hallucinations. The insight
and judgment were "poor." The assessment was "appeared
mentally unstable."
1/15/2015 BUN 22; sodium 137; creatinine 1.8; hemoglobin 12.1 (13.218); platelets 211; AST 26; ALT 19

184

These lab tests document kidney disease and mild
anemia. These tests were not documented as reviewed
in the progress notes.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 185 of 431 PageID #:12383
Patient #17
3/2/2015 The patient was admitted to Katherine Shaw Bethea Hospital
for bleeding rectally and vomiting blood and discharged
3/5/15. His heart rate was 130s. The doctor documented that
because the patient was absent from the med line his antiulcer medication was discontinued after 2/12/15. The doctor
told the facility physician and a nurse that a refill check that
failed should end and that the chart should be flagged that he
never go off the PPI due to having had multiple life
threatening GI bleeds. The patient was discharged with acute
upper GI bleed with anemia secondary to blood loss, diastolic
heart dysfunction, hepatitis C, and antral ulcer. The hospital
recommended never to stop the PPI. The patient had
endoscopy showing a deep antral ulcer treated with
electrocautery, hiatal hernia, duodenal erosions, and fibrinous
material in esophagus, probably acid reflux disease. The
patient was transfused four units of blood. The patient had a
diagnosis of Barrett's esophagus, porcine aortic valve
replacement, mitral valve prolapse, CAD, HTN, CHF,
schizophrenia.
3/10/2015 Sodium 141; potassium 4.2; AST 54 (10-40); ALT 60 (10-50).
3/13/2015 Hemoglobin 11.8; platelets 384.
3/15/2015 Hemoglobin 11.4; platelets 306.
3/24/2015 A doctor saw the patient for cardiac chronic clinic for the
aortic valve replacement and Barrett's esophagus. The doctor
noted that the patient was on Prilosec but did not discuss
surveillance of the Barrett's esophagitis. The doctor noted
that the ulcer was not currently bleeding.

185

3

The doctor should have had a plan for surveillance of
Barrett's esophagus.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 186 of 431 PageID #:12384
Patient #17
4/2/2015 A doctor saw the patient for hepatitis C clinic. The doctor
noted that the patient had hepatitis C since 2003 and was
seen by Dr. Paul in the past via telemedicine. This was the
Wexford ID doctor. However, the patient did not see the UIC
hepatitis doctor. The doctor noted that the patient had no
RUQ pain and noted that the ALT was 60 and AST 54 and
platelets 384 with an APRI of 0.35. The doctor ordered a six
month follow up.
5/7/2015 BUN 23; creatinine 1.73; bilirubin 1.8; AST 28; ALT 18;
hemoglobin 11.7; platelets 224
5/28/2015 Total protein 8.1 (6-8); hemoglobin 12.5
6/1/2015 The patient refused omeprazole 13 of 60 doses. Ten of the
refusals were the evening dose.
6/4/2015 BUN 27; creatinine 1.92; cholesterol 114; HDL 31; LDL 65
7/1/2015 The patient's MAR showed that the patient refused
omeprazole 17 of 62 doses.

17

Since omeprazole was so important for this patient, a
physician should have been notified and discussed the
refusal with the patient.

17

Since omeprazole was so important for this patient, a
physician should have been notified and discussed the
refusal with the patient.

16

The nurse should have referred to a physician.

7/8/2015 A1c 4.8.
7/17/2015 Sodium 137; total protein 8.2; AST 43 (10-40); ALT 37 (10-50).
8/9/2015 The weight was 152. A doctor saw the patient. The doctor
noted that the patient had an appointment with GI. The
doctor ordered a CBC and CMP to check the sodium.
8/14/2015 The patient developed a boil on his buttock and a nurse
ordered warm compresses but did not refer the patient.

186

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Patient #17
8/17/2015 An NP saw the patient for a sore on his L great toe and left
buttock. Apparently a doctor gave a phone order for Bactrim
on 8/14/15. The PA continued the antibiotic and offered the
inmate a different pair of shoes which he declined. The
patient had a dime sized lesion on his toe on top of the left
great toe and a 3 cm buttock boil.
8/20/2015 A mental health progress note documented that the patient
was in segregation for having been in possession of razor
blades. The patient questioned why he was in segregation
when he "should be in INF placement given medication
condition." The patient had refused a visit with his
psychiatrist. The patient was argumentative.
8/27/2015 A NP saw the patient and documented that the patient said he
saw a doctor two days ago even though there wasn't a note in
the record. The buttock "sore" was healing but the patient
still had sores on both feet. The patient also had a swollen
lymph node. The NP recommended to clean his wounds with
soap and water and observe for drainage.
8/31/2015 A mental health note. The patient was not seen. He was in
segregation but there was no officer for escort so the patient
wasn't seen.
9/3/2015 A mental health note. The patient was still in segregation. He
said he would refuse mental health medication and refuse to
see the psychiatrist. The mental health worker documented
that his paranoia was less.

187

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Patient #17
9/10/2015 The patient stated "I'm a Christian. I can heal without meds."
The patient intended to refuse psychotropic medication.
Based on the note, the patient appeared psychotic. On the
same day another mental health note documented that the
patient left segregation status.
9/13/2015 An RN saw the patient at 7:30 am. The oxygen saturation was
89%. The nurse took no history of why the patient was being
seen but noted that the inmate "doesn't know how he fell."
The nurse documented BP 160/80; pulse 113; and weight 150.
The patient felt weak. The nurse additionally used a contusion
protocol but the history was so poor that it couldn't be
determined what precisely happened based on the note. The
nurse documented 30 cc of blood but it wasn't clear what this
was from. The nurse placed the patient on the infirmary for
observation. It wasn't clear if a doctor was consulted but the
nurse wrote to do neuro checks every six hours and notify the
doctor of any changes.
9/13/2015 Hospital admission sodium 114; chloride 81; BUN 42;
creatinine 0.87; ALT 74; AST 130.
9/13/2015 At 8:30 pm a nurse documented that the blood pressure was
88/46 and that a doctor was notified, who recommended
increased fluid. At 10:00 pm a nurse wrote another note and
noted that a doctor was called and ordered to start 0.9 NS via
IV. Apparently the patient was sent to a hospital, although
notes are lacking.

188

16

The nurse should have referred to a physician
immediately. Placement on the infirmary might
normally be appropriate but this patient had unstable
vitals with hypoxemia and tachycardia with possible
altered mental status and should have been
immediately evaluated.

11

Either documentation was poor or the medical record is
missing documentation. It wasn't clear how the patient
was sent to a hospital.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 189 of 431 PageID #:12387
Patient #17
9/14/2015 At 6:35 there was a movement form that included
documentation that the inmate fell the day before with a head
injury and fell again this day that was unwitnessed. The
patient's blood pressure was 78/40; pulse 92; oxygen
saturation 92; and there was blood in the patient's stool. It
isn't clear what happened to the patient.
9/14/2015 At 11:00 am a doctor wrote an admission note to the
infirmary. The doctor noted that the patient fell and had a
head injury on 9/13. The sodium was 114. The doctor noted
that the patient was admitted over the weekend. The doctor
started IV fluid without specifying the type of fluid 100 cc
/hour. Notably the doctor did not perform a neurological
examination despite a sodium of 114.
9/14/2015 At 2:30 am the pulse was 117 and blood pressure 114/60.
9/14/2015 At 6:10 a nurse noted that the patient was on the floor and
was incontinent of bowel and bladder. The patient was weak
and unsteady and his stool was positive for blood. The nurse
called a doctor who ordered the IV opened full open and sent
the patient to a hospital.

189

2, 14

Typically, altered mental status with gait disturbance in
a patient with severe hyponatremia requires hypertonic
saline not normal saline. Typically it is safer to admit
this type of patient to a hospital and this should have
been done.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 190 of 431 PageID #:12388
Patient #17
9/14/2015 A hospital consultation note from a GI consultant in the
hospital noted that the patient had history of hepatitis C,
Barrett's esophagus, CAD, HTN, aortic stenosis, Mitral valve
prolapse, CHF, and schizophrenia. The patient was noted to
have been found passed out in his cell with blood around him
and had a hemoglobin of 4.2 in the emergency room. The
patient's INR was 1.2. The patient had a known bleed in
March of 2015. The patient had a serum sodium of 117 and
was in atrial fibrillation. An upper endoscopy showed a coffee
ground bezoar in the stomach with a healing ulcer. Protonix
was recommended. The hospital noted that he had not
received the omeprazole as prescribed at the prison [that the
patient refused so it was discontinued]. The patient required
multiple transfusions. A repeat endoscopy and colonoscopy
were recommended. The hemoglobin corrected to 8.5 on
discharge with a platelet count as low as 149. On admission
the BUN was 48 with a serum sodium of 117, chloride of 89,
AST 161, ALT 74, albumin 2.4. Remarkably the creatinine was
0.66. The EKG was sinus tachycardia with rightward axis and
NSSTT changes.

9/16/2015 The patient returned from the hospital. The doctor didn't
appear to see the patient until 9/18/15.
9/18/2015 The patient was on the infirmary but it wasn't clear how he
got there. There were no notes in sequence related to the
hospital discharge.
9/18/2015 The doctor noted that the patient was transfused four units of
blood and noted the EGD findings. The doctor noted the
follow up with GI in six weeks for EGD and colonoscopy.

190

17

The patient failed to receive ordered protonix or
refused and no one evaluated him for this despite his
mental health condition. This is indifferent. The severe
hyponatremia speaks to lack of monitoring while on
psychotropic medication.

6

Since the patient had severe hyponatremia, serum
sodium should have been ordered.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 191 of 431 PageID #:12389
Patient #17
9/20/2015 The patient told a nurse that he was in the hospital. The
infirmary admission notes were not present in sequence for
this patient. The chart was disordered. The patient had a
wound on top of his forehead.
9/21/2015 Hemoglobin 9.6; sodium 136; BUN 6.
9/21/2015 A doctor saw the patient and noted that the patient was
"feeling OK." The doctor noted no blood in stool. Vital signs
were normal. The patient had trace leg edema, a systolic
murmur. The doctor assessed HTN, CAD, hep C, GERD, PUD,
thoracic aortic aneurysm, AVR, CHF, and psych disorder. The
doctor also assessed "GIB" apparently gastrointestinal bleed
and noted that the 9/18/15 RN note should be reviewed. The
doctor ordered a CBC. The doctor also noted hyponatremia
and ordered another sodium. The doctor documented "? WT
[weight] loss- per pt." but took no history and did not
document the weight. Indeed the patient had lost weight.
The doctor restarted Lasix at 40 mg in the morning and
ordered daily weights. This was the last infirmary note so the
admission and discharge infirmary notes were in a different
PDF of this chart.

191

11

Records were not in order.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 192 of 431 PageID #:12390
Patient #17
9/22/2015 A psychiatrist saw the patient via telemedicine. The
psychiatrist noted the patient saying "Patient indicated he was
admitted on medical furlough for community inpatient
endoscopy and transfusion due to GI bleed. 'It's my fourth, I'm
used to it'." The psychiatrist stated that the patient was "fully
oriented" and "thoughts were well organized, logical, and
sequential. No current symptoms, No odd or bizarre thoughts
and no preoccupations evident." The psychiatrist noted no
acute or gross psychopathology evident. The doctor noted
that there were no records of his recent medical furlough nor
mental health records relating to the past few weeks so he
requested these with a two week follow up.

9/23/2015 Albumin 2.9; sodium 136; AST 40; ALT 47; hemoglobin 10.4.
9/23/2015 A doctor wrote a discharge summary and noted that the
patient was admitted to the infirmary on 9/13/15 and had
sodium 114 with hemoglobin 8.5 and he was admitted where
hemoglobin was 4.2 and sodium 117 . It wasn't clear when
the patient was admitted. The records were disorganized,
with July 2015 and September 2015 mixed together. The
doctor noted that the patient needed follow up with GI in five
weeks for EGD and colonoscopy. The doctor ordered a next
week follow up.
9/24/2015 The patient was described by a mental health worker as taking
all of his mental health medications.
9/29/2015 Sodium 127; chloride 96; hemoglobin 10.1.
10/6/2015 The psychiatrist stopped prolixin and artane, two of the
patient's psychotropic medications.

192

11

Hospital reports were unavailable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 193 of 431 PageID #:12391
Patient #17
10/8/2015 A MAR documented that Prolixin and Artane were
discontinued on 10/8/15.
10/11/2015 A physician assistant saw the patient for hepatitis C clinic. The
PA noted that the patient had ALT of 97 and AST 40 with
platelets 357 for an APRI of 0.28 and was stable. A six month
follow up was ordered.
10/12/2015 Wexford approved a colonoscopy and EGD. There was no
evidence that this occurred.
10/14/2015 The patient signed an "affidavit" that he would refuse contact
with his telemedicine psychiatrist and preferred a face to face
contact which allowed more interaction.
10/17/2015 The patient complained to a nurse of weight loss and burning
in his stomach. The nurse told the patient to avoid "trigger"
foods.
10/23/2015 A doctor saw the patient for HTN clinic. The note was
incomplete. One of the sheets was not in order and couldn't
be located.
10/27/2015 Sodium 130; iron 33 (50-180); transferrin 274 (200-400); IBC
384 (250-450); % transferrin saturation 9 (20-50); hemoglobin
13.2.
11/1/2015 A MAR documented that the patient started refusing
Clonazepam around 11/11/05. The patient was not on any
ordered mental health medication until prolixin and artane
were ordered as enforced medication on 1/28/16.
11/4/2015 AST 25; ALT 20; hemoglobin 12.9.
11/4/2015 The patient told a mental health staff that he wanted to sign a
consent to again see the telemedicine psychiatrist. The
mental health staff told the patient that he was already
scheduled to see the telemedicine psychiatrist and the patient
asked to see him earlier.

193

8

The PA failed to review important abnormal blood test
results including albumin 2.9, sodium 127 and
hemoglobin 10.1.

7

There was failure to complete a recommended
procedure.

16

The nurse should have referred to a physician especially
given the history of Barrett's esophagus and prior GI
bleeds.
Records were not in order.

11

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 194 of 431 PageID #:12392
Patient #17
11/5/2015 A doctor saw the patient, who now weighed 145 pounds.
Ironically, the patient was being seen for a chief complaint of
"weight gain." Someone documented that the patient
weighed 133 on 8/5/15. The patient wanted Tylenol #3. The
doctor took no history related to his medical conditions but
did document "Happy about WT gain." The patient asked
about getting his medication KOP. The doctor took no history,
documented a very brief physical examination and
documented that his note was continued on the next page,
but this page was not present in the medical record.
11/16/2015 A telepsychiatrist saw the patient. The patient was described
as alert, engaged, cooperative, well kempt with fair insight and
fair judgment. The thoughts were organized and there were
no delusions or bizarre content. The summary was that there
was no acute or gross psychopathology. A six week follow up
was ordered.
11/17/2015 A doctor saw the patient. The weight was 144 pounds. The
doctor noted that the patient was recently hospitalized for
transfusion and had esophageal varices and Barrett's
esophagitis. Except for documenting that the patient said he
was OK there was no history. The doctor noted that the
hemoglobin was 12.9 and that the patient signed a refusal for
his PM medication including Prilosec- the following line was
illegible. The doctor documented that "weight gain not a
worry"- however the patient had lost significant weight over
the past two years. The doctor advised the patient not to
refuse his Prilosec. The patient verbalized understanding. The
doctor ordered a CBC in six weeks.

194

2

The patient did not have varices but had a GI bleed from
ulcers.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 195 of 431 PageID #:12393
Patient #17
12/29/2015 The patient was seen while on hunger strike. The patient said
it was religious fasting. The licensed social worker who saw
him documented that he was not delusional and his thought
processes were "linear."
12/31/2015 A NP saw the patient. The weight was 137 pounds; the inmate
was still fasting. The patient was drinking fluid. The NP
ordered the nursing staff to asses daily urine dipstick. The NP
scheduled a visit the following Monday 1/4/16 but did not
order any labs.
1/5/2016 The patient refused to see the NP. The NP noted that the cell
smelled of urine.
1/7/2016 A doctor documented that at a care conference it was agreed
to ask the chaplain to see the patient and to obtain a
competency evaluation by mental health.
1/7/2016 A mental health note documented that the patient was "in
segregation where he continues to reside following refusal of
housing after an initial IDR while residing on HCU-3. The
patient refused to "cuff up to come to interview room." An
assessment occurred in the cell with security present. The
purpose of the contact was to request further explanation
from the patient regarding his "fast." The patient denied any
hallucinations. The patient's judgment and insight were
"questionable as pt.'s decision making is affecting general
health."

8

The patient had weight loss and was fasting. Baseline
labs should have been obtained.

1/8/2016 A doctor documented that the patient was refusing to eat and
told the patient that if he continued to refuse food he would
be force fed. This note was incomplete and the full note was
not in the medical record. There were no further medical
notes on this patient.

8

The doctor should have ordered laboratory tests
because of the fast.

195

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 196 of 431 PageID #:12394
Patient #17
1/10/2016 A licensed counselor saw the patient and noted that the
patient was not eating because of religious convictions. The
patient was described as unstable and the counselor's plan
was to "consider appt. w/ [the psychiatrist] if appropriate."
1/11/2016 A psychiatrist saw the patient via telemedicine. The
psychiatrist dictated his note but this dictated note was not
present in the medical record we reviewed. The psychiatrist
did write a brief note documenting that the MAR was not
present and no primary care mental health records were
present. The psychiatrist re-started Prolixin and continued
Klonopin. There were no MARs indicating that the patient
received Prolixin. A next week follow up was ordered but did
not take place.
1/13/2016 A licensed counselor saw the patient at the request of an
officer. The patient was "remarking that the room vents were
suffocating him. His speech was pressured, he had paranoia,
and his behavior was disorganized. The patient was assessed
as unstable.
1/14/2016 The patient was on 30 minute checks and asked how many
meals he has to eat before he could move "upstairs." It wasn't
clear if the patient was eating.
1/15/2016 A mental health staff documented that the patient was told
that if he ate a meal he could get his clothes back. The inmate
said he hadn't eaten because "this was a lie."
1/16/2016 A QMHP saw the patient and documented that the inmate
"smells like puke." No referral was made.

196

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 197 of 431 PageID #:12395
Patient #17
1/21/2016 Although the patient was being seen daily, on this day the
patient was observed lying on his bed completely covered by a
security blanket. The patient refused to answer questions.
The counselor was unable to fully assess the patient. The
patient was also unable to be assessed on 1/22/16 and
1/23/16 for the same reasons.
1/24/2016 A PsyD saw the patient and noted that the patient said he had
not eaten food since Christmas for spiritual reasons. The
patient was apparently drinking water. The patient was not
weighed. The PsyD documented that the patient said he was
not taking psych meds but this was not checked vs the MAR.
The patient was assessed as unstable.
1/25/2016 A QMHP saw the patient and documented that the patient
refused to move the blanket from his face, refused breakfast
and medication, and was no longer drinking water and would
not speak to his psychiatrist. Remarkably there were no
psychiatrist evaluations documented on this severely ill
patient.
1/26/2016 A QMHP saw the patient and noted that the patient refused to
remove the blanket which was over his face. The patient was
refusing food, liquids, medication, and assessment. The
QMHP was unable to assess the patient and documented the
patient as unstable.
1/26/2016 A form requesting emergency involuntary administration of
psychotropic medication was initiated. The patient was
documented as being on the infirmary.

197

19

Not eating for almost a month is significant and should
have resulted in a physician evaluation and laboratory
testing which were not done. This is lack of access and
indifferent.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 198 of 431 PageID #:12396
Patient #17
1/27/2016 Labs in KSB Hospital sodium 150; BUN 89; creatinine 2.12; AST
35 (8-33); ALT 24; bilirubin 1.9; magnesium 2.8 (1.6-2.3); WBC
16.7 with left shift; hemoglobin 15.2; platelets 161. These labs
were signed as reviewed on 1/28/16.

6, 14

1/27/2016 A licensed counselor saw the patient and documented, "we
are aware pt. is being considered for 'forced feeding.' We are
aware pt. is scheduled for enforced medication 1/28. He is
currently administered psych med under emergency enforced
[illegible] (prolixin). The plan was to "assess staff [with]
assessment for 'forced feeding.'"
1/28/2016 A psychologist documented that the treatment review
committee concurred for enforced medication and notices
were made.
1/29/2016 A QMHP documented that security said the patient was more
cooperative but was unstable and that dayroom privileges
were approved.
1/31/2016 A PsyD documented that the patient said he was OK. It was
not clear if the patient was eating.
1/31/2016 Blood cultures collected on 1/31/16 were reported 2/1/16 and 11, 19
showed 2 bottles were growing gram negative rods. Results
were called to a nurse in the DOC and the lab was told that the
patient had been transferred to St. Anthony's hospital but had
expired.
1/31/2016 A note from a hospital documented that the patient had a
post intubation x-ray so it appeared that the patient was not
hospitalized until 1/31/16.

198

These labs were critical and indicated severe
dehydration causing renal failure, liver damage, and
indicated infection (WBC 16.7 with left shift). These
should have been reviewed promptly and the patient
should have been hospitalized.

It is not clear what happened because documentation
was so poor. While this may have been due to record
keeping, a physician should have been seeing the
patient daily under the circumstances but this did not
appear to be happening.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 199 of 431 PageID #:12397
Patient #17

199

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Patient #17

200

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Patient #17

201

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Patient #17

202

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Patient #17

203

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Patient #17

204

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Patient #17

205

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Patient #17

206

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Patient #17

207

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 208 of 431 PageID #:12406
Patient #17

208

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Patient #17

209

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Patient #17

210

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Patient #17

211

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Patient #17

212

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Patient #17

0.3

213

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 214 of 431 PageID #:12412

10/14/2015 The problem list documented hypertension, diabetes,
COPD, anemia, prostatic hypertrophy, and reflux disease.

The problem list did not document prosthetic heart valve, atrial
fibrillation, alcoholic cirrhosis, chronic kidney disease, and
diabetic nephropathy.

10/10/2013 Ammonia was 165 (<56); hemoglobin 11.4; MCV 106.3; INR
2.

These values are consistent with alcoholic liver disease which
had yet to be diagnosed and was not on the problem list.

11/12/2013 Hemoglobin 10.9 MCV 100.9; platelets 136; INR 1.9.
12/9/2013 BUN 28; creatinine 1.53; bilirubin 2.2; cholesterol 123; HDL
53; LDL 58; folate >25 (>5.8); hemoglobin 11.7; MCV 101.5;
platelets 147; AST 34; ALT 20; INR 2.
1/10/2014 BUN 33; creatinine 1.55; bilirubin 1.5; A1c 6.5; hemoglobin
10.2; MCV 102; platelets 128; INR 2.3.

6

These values show chronic kidney disease, possible dehydration,
and anemia consistent with cirrhosis from alcoholic liver disease
yet these labs were not evaluated. Kidney disease was not a
diagnosis. The reason for the anemia was not on the problem
list.

2/11/2014 Hemoglobin 11; MCV 102.8; platelets 138; INR 2.1.
3/10/2014 Hemoglobin 10.7; MCV 97.2 (80-99); platelets 145; INR 1.8.
3/20/2014 A nurse saw the patient for trouble breathing. The patient
had audible wheezing, a pulse of 40 and respiratory rate of
24 with a PEFR of 350. The nurse noted that a doctor was
seeing the patient that day.
3/20/2014 A doctor saw the patient as a writ return and noted that
1, 2, 6,
the patient was evaluated by cardiology and noted that the
19
cardiology recommended to increase the hydralazine and to
obtain an echocardiogram and event monitor. The doctor
ordered a month follow up and requested the
echocardiogram. The doctor didn't evaluate the shortness
of breath. The doctor did not conduct a physical
examination of the patient.

214

The doctor did not evaluate the multiple serious significant
laboratory abnormalities. The doctor did not evaluate the
patient's shortness of breath even though that was the
presumed reason for the visit. The doctor took no history, failed
to examine the patient, and failed to make an assessment with
respect to the shortness of breath. Care failed to follow
generally accepted guidelines or usual practice. Abnormal labs
and symptoms of trouble breathing should have resulted in an
evaluation to determine the cause.

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 215 of 431 PageID #:12413

3/26/2014 A doctor noted that an event monitor was approved in
collegial.
4/3/2014 EKG showing atrial fibrillation with LAD, probably old
inferior infarct, anterior fasciculare block and bradycardia
47.
4/4/2014 Wexford approved an echocardiogram.
4/4/2014 Wexford approved a 30 day event monitor from UIC
cardiology.
4/8/2014 An NP saw the patient and noted that bumex was on
ordered and would bridge this pending order with Lasix.
4/30/2014 INR 3.1.
5/9/2014 A nurse wrote a note that the patient was placed on the
infirmary. The note was partly illegible. The patient was
placed on IV fluid but it wasn't clear why.
5/10/2014 A nurse noted that the patient was having a hard time
breathing and had respiratory rate of 28. The nurse gave
the patient a wedge to put under his mattress. In a later
note a nurse documented notifying Dr. Sood. A nurse noted
that the patient was receiving IV fluid but it wasn't clear
why.
5/12/2014 BUN 30; creatinine 1.52; bilirubin 1.6; GFR 55; TSH 1.31; A1c
5.9; hemoglobin 10.1; MCV 104; platelets 103; INR 2.3.

Notably atrial fibrillation was not on the problem list.

Illegibility is a reason for an electronic medical record.

19

5/14/2014 A NP saw the patient for a swollen left finger. The NP noted
that the patient also had leg edema and reported not taking
his water pill at night because he became incontinent when
he did. The NP ordered a hand x-ray and requested a Texas
catheter. The NP did not consider giving the Lasix in the
morning. The NP did not address the prior episode of
shortness of breath and since ordering a hand x-ray failed to
include a chest x-ray to assess for heart failure.

6

215

The doctor should have evaluated the patient in person.

These labs again showed possible dehydration, chronic kidney
disease, and macrocytic anemia with low platelets consistent
with alcoholic liver disease.
Despite significant abnormal labs and leg edema with shortness
of breath, the NP failed to form an appropriate assessment of
the abnormal labs and new symptoms. Care failed to follow
generally accepted guidelines as those abnormal labs and
symptoms should have been evaluated.

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 216 of 431 PageID #:12414

6/10/2014 Hemoglobin 11.5; MCV 101; platelets 130; INR 2.3.
6/26/2014 A doctor saw the patient for HTN, DM, and COPD/asthma.
The BP was 120/70 . The doctor noted that the patient had
heart sounds of regular sinus rhythm despite the patient
having long standing atrial fibrillation. The patient had mild
expiratory wheezes and PEFR of 350. The doctor took no
history with respect to COPD/asthma but diagnosed
moderate persistent asthma and made no changes to
therapy. The doctor noted that labs were reviewed but
made no comment about these. The patient's
anticoagulation or cardiac rhythm disturbances were not
addressed.
7/11/2014 Hemoglobin 10.7 MCV 106.1; platelets 130; INR 3.
7/17/2014 At a hospital, hemoglobin 12.3; MCV 96.9 (80-94); platelets
124; INR 3.2; BUN 39; creatinine 1.44; AST 40 (8-33);
bilirubin 2.2.
7/17/2014 A doctor saw the patient and was feeling "out of it." The
doctor took no more in depth history. The doctor noted
that the patient was oriented to person place and time. The
doctor noted facial symmetry and no weakness. The doctor
made no assessments, did not evaluate for the prior
episodes of shortness of breath. The doctor ordered a CBC,
CMP, INR and ammonia. The doctor made several
addendums to this note. The doctor added that the patient
"can't think." On a later note the doctor documented that a
nurse told the doctor that the patient was scheduled for a
dental appointment and faked being sick, canceling the
dental appointment so that he could go to commissary.

7, 17

The doctor failed to establish a reasonable treatment plan in
evaluation of the patient's lung symptoms. A chest x-ray,
consideration of pulmonary function testing, and evaluation for
heart failure should have been done. The patient also had a
26.4% 10 year risk of heart disease or stroke and a high intensity
statin was indicated. Care failed therefore to follow generally
accepted guidelines.

1, 6

The doctor failed to take adequate history. Prior blood tests
were not evaluated. Care failed to follow generally accepted
guidelines or usual practice.

8/8/2014 An echocardiogram was done as requested on 3/20/14 and
approved on 4/4/14.

216

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 217 of 431 PageID #:12415

8/8/2014 A doctor noted that the patient went to UIC for a cardiology
appointment and had a 30 day monitor attached. The
doctor noted that the patient had an echocardiogram.
8/11/2014 Hemoglobin 11.2; MCV 102.7; platelets 106; INR 3.
8/12/2014 A doctor noted reviewing the echocardiogram results and
that the patient had an event monitor placed.
8/27/2014 Echocardiogram showed right atrium and ventricle mildly
dilated; left atrium moderately dilated but L ventricle
normal size but moderately thickened. Moderate
concentric hypertrophy with 50% EF; normal appearing
prosthetic AV with trace regurgitation, moderate tricuspid
regurgitation. Diastolic dysfunction and severely elevated
pulmonary artery pressure.
9/3/2014 A doctor noted that the patient was approved for a
cardiology appointment in collegial review.
9/8/2014 The patient went to cardiology for the 30 day event monitor
more than five months after the collegial. The referral for
this was dated 3/20/14.
9/12/2014 EKG showing idioventricular rhythm with nonspecific
intraventricular block and inferior and anterolateral infarcts
age indeterminate.
9/12/2014 The patient was evaluated in EP clinic for scheduled follow
up. The cardiologist stated that the patient was seen two
months ago for a fib/flutter with slow ventricular response.
The plan was to hold all AVN blocking agents. The
cardiologist reviewed the echocardiogram and last Holter
from 2013. The cardiologist recommended a pacemaker
and that this should be done in the hospital.
9/12/2014 Hemoglobin 11.4; MCV 104.4; platelets 135; INR 3.4.

217

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 218 of 431 PageID #:12416

9/17/2014 A doctor noted that the patient was discussed in collegial
and approved for admission for pacemaker placement.

6

Abnormal labs were not followed up.

11

The hospital report was not available.

9/18/2014 Wexfored approval of hospitalization management prior to
pacemaker placement.
9/26/2014 EKG showing irregular rhythm with no p waves [looks like
atrial fibrillation] with intraventricular block and PVCs
9/26/2014 The patient told a nurse that he was not feeling well. The
pulse was 41. The patient was sent to a local ER via
ambulance.
9/28/2014 The patient returned from the hospital but the nurse did
not note what had occurred at the hospital or whether
there were new orders.
9/29/2014 A doctor noted that the patient returned from the hospital
for shortness of breath and stated that "they didn't adjust
meds or do anything but hold coumadin for upcoming
procedure." The upcoming procedure wasn't specified so it
wasn't clear whether this was the pacemaker placement or
another procedure.
10/3/2014 INR 1.5.
10/14/2014 INR 1.4.
10/15/2014 A doctor wrote a brief chart review note stating that the
INR was 1.4 and increased the coumadin to 7 mg daily with
an INR in seven days.

218

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 219 of 431 PageID #:12417

10/17/2014 The patient was seen for diabetic clinic. The BP was 124/58 1, 2, 6,
and the A1c was documented as 5.6. The doctor took no
12
history with respect to any disease and noted an irregular
heart rhythm and expiratory wheezes. The diabetes was
listed as in good control. The doctor did not address
whether the patient had hypoglycemia, especially given the
low A1c. Anticoagulation and the cardiac arrhythmia were
not addressed. Despite the asthma/COPD being described
as moderate persistent, the doctor had taken no history and
made no changes to therapy.
10/22/2014 A doctor renewed an order for a Texas catheter but it
wasn't clear on prior notes that the patient was using this
device.
10/22/2014 BUN 33; creatinine 1.71; bilirubin 1.7; hemoglobin 11; MCV
105; platelets 113; AST 32; ALT 18; INR 1.6.

6

10/22/2014 INR 1.6.

6

10/23/2014 A doctor wrote that he called UIC heart center as the
patient was on coumadin and a pacemaker was planned for
10/27/14. The INR was 1.6.
10/24/2014 At 9:20 am a nurse documented telling the inmate that
coumadin was to be held from this day through 10/27/14.

219

The doctor failed to evaluate many of the patient's existing
problems including atrial fibrillation, high blood lipids, heart
failure, diabetic nephropathy, anticoagulation, and cirrhosis and
the doctor failed to evaluate the prior abnormal labs. The doctor
failed to adequately evaluate the pulmonary symptoms
presumably assigning these to asthma/COPD when they may
have been due to heart failure, or liver failure. The patient
should have been referred to a cardiologist. Care failed to follow
generally accepted guidelines or usual practice.

These abnormal laboratory values were not followed up on.
They appeared to show cirrhosis from alcoholic liver disease,
chronic kidney disease and dehydration which were all
unidentified. Care failed to follow generally accepted guidelines
or usual practice.
Patients with most mechanical heart valves require an INR
between 2.5 to 3.5. Certain valves (On X valves) require an INR
of 1.5-2.5. This patient's valve type or anticoagulation goal was
never documented but was presumed to be 2.5 to 3.5. The type
of valve and anticoagulation goal needed to be documented in
the record.

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 220 of 431 PageID #:12418

10/24/2014 at 5:20 pm a PA documented that a nurse from UIC
cardiology called to say that the cardiologist recommended
NOT stopping the coumadin and wanted the INR close to 2.
The PA ordered to continue the coumadin at 7 mg.
10/27/2014 A pre-EP procedure history and physical at UIC noted nonobstructive CAD with COPD, HTN, HLD, DM, mechanical AVR
in 1995, chronic a fib/flutter with junctional escapes in for
permanent pacemaker. A pacemaker was placed St Jude
PM 1240 VVI. A two week follow up was recommended.

10

The two week follow up with cardiology never occurred and was
unrecognized as not occurring. Care failed to follow generally
accepted guidelines or usual practice.

10/29/2014 A doctor noted that the patient had a pacemaker installed
on 10/27/14 and had some pain and ordered Tylenol. The
pacemaker function wasn't checked. The hospital report
was not reviewed and follow up was not identified.

10

The doctor failed to follow up on the UIC report. Care failed to
follow generally accepted guidelines.

10/30/2014 Apparently a physician reviewed written paperwork and
noted that a two week follow up with cardiology was
recommended.
11/5/2014 The patient was approved for follow up of the pacemaker.
There were no progress notes following this visit for some
time.
11/14/2014 Hemoglobin 10.1; MCV 104.1; platelets 110; INR 2.4.
12/10/2014 Hemoglobin 11.3; MCV 101; platelets 130; A1c 5.7; INR 1.8.

10

The doctor did not ensure that the patient was referred to
cardiology. Care failed to follow generally accepted guidelines or
usual practice.
Though this referral was approved, there was no evidence that it
occurred. Care failed to follow generally accepted guidelines or
usual practice.

16

The nurse should have consulted a physician.

1/12/2015 Hemoglobin 11.8; MCV 102.3; platelets 126; INR 2.
2/9/2015 Hemoglobin 11.4; MCV 101.8; platelets 123; INR 2.3.
2/27/2015 A nurse evaluated the patient using the shortness of breath
protocol. The oxygen saturation was 95% and respiratory
rate of 12. The patient was listed as being on Xopenex,
albuterol, Atrovent and Alvesco inhalers. PEFRs were
250/200/250. The nurse took no action except to give the
patient a nebulization treatment.

220

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 221 of 431 PageID #:12419

3/3/2015 A doctor saw the patient because a nurse wanted
evaluation of the baclofen. The patient wanted Neurontin
discontinued. The doctor wrote that the patient had no
spinal injury or MS and that the patient was using the
baclofen because his left leg became spastic. The doctor
stopped both baclofen and Neurontin and ordered a follow
up. The doctor took no history of why the patient was put
on these medications and did no physical examination. The
doctor did not address any problems. The patient hadn't
been seen since return from the hospital for his pacemaker
and the doctor did not address whether the patient had his
cardiology follow up.

6, 15

3/10/2015 Hemoglobin 11.6; MCV 103.7; platelets 143; INR 2.1.
4/6/2015 A PA saw the patient for follow up of discontinuation of
baclofen and Neurontin. The PA noted that the patient
complained of hip pain and LLE "shakiness." The physical
examination documented "shakiness" but it wasn't clear
what that meant. The plan was to monitor the shakiness
and "jerkiness," continue physical therapy and Tylenol for
pain.
4/25/2015 A nurse evaluated the patient using the shortness of breath
protocol. The respiratory rate was 14. The PEFR were
250/300/300 . The nurse took no action and the patient
returned to his housing unit.

The doctor failed to review any of the prior abnormal lab results
and failed to follow up on the patient's recent symptoms or
problems. Care failed to follow generally accepted guidelines or
usual practice.

6

The PA failed to follow up on the abnormal labs dating from
11/14/14 which had not been reviewed.

16

The patient had a serious complaint and the nurse should have
referred the patient to a provider.

221

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 222 of 431 PageID #:12420

5/13/2015 A doctor saw the patient for HTN, DM and COPD chronic
1, 2, 3, 6
clinics. No history was taken. The A1c was 5.7. The heart
was described as regular rhythm and the lungs clear. PEFR
wasn't taken. The was no history of symptoms. Though the
patient had mild pitting edema, there was no assessment.
The assessment listed anemia but it was not addressed.
There was no change in plan. The conduction abnormalities
or anticoagulation were not addressed. The status of the
patient wasn't clear from this note.

The doctor failed to address all of the patient's serious medical
problems including his anticoagulation, follow up with cardiology
after the pacemaker, recent shortness of breath and current
edema, diabetic nephropathy, heart failure, high blood lipids, to
address or develop a plan for the anemia. History for these
conditions was not taken, the patient wasn't examined for these
conditions and there was no therapeutic plan. If the patient had
suspected cirrhosis, an ultrasound should have been done. The
patient's pacemaker function was not addressed.

6/5/2015 A NP saw the patient for constipation and ordered Colace.
None of the other patient problems were addressed.
8/8/2015 An annual history was completed by a nurse. The nurse
1, 2, 3, 7
documented that the patient was on apresoline, coumadin,
proscar, cozaar, Xopenex, Aldactone, fibertabs. Problems
were listed as heart failure, type 1 diabetes, aortic stenosis,
prior valve replacement, and prior TURP. A provider
physical examination added no further history. Though the
patient was 70 years old colorectal cancer screening was
not offered. The provider listed HTN, type 1 diabetes, AV
replacement with pacemaker for atrial fibrillation, heart
failure and peptic ulcer disease. No changes to treatment
were made.

The nurse obtaining this history, examination, and plan failed to
address all of the patient's problems including the anemia, atrial
fibrillation and cardiac conduction abnormality, peptic ulcer
disease. The doctor following up with a physical examination
failed to make a diagnosis related to the anemia, failed to
acknowledge or follow up on the cardiac arrhythmia, and failed
to note that the patient had missed cardiology follow up at UIC.
The patient was not offered colorectal cancer screening despite
this being a current standard of care. Care failed to follow
generally accepted guidelines or usual practice.

8/10/2015 A doctor saw the patient. The doctor noted that the patient
was on lactulose for constipation and was having diarrhea.
The doctor continued the lactulose if the patient needed
disimpaction for his constipation. The doctor did not
address any of the patient's other problems.
8/12/2015 The patient experienced a fall. The nurse documented
writing an injury report but there was no progress note for
this problem.

16

222

The nurse should have consulted a physician.

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 223 of 431 PageID #:12421

8/25/2015 The patient asked for a breathing treatment.
8/26/2015 The patient asked for a breathing treatment.
8/27/2015 A nurse saw the patient using a shortness of breath protocol
and noted that the patient was out of his Atrovent for two
months. The PEFR was 200. The nurse sent the patient for
a breathing treatment and strongly recommended that the
patient pick up his Atrovent at medline.

16

The patient had a serious complaint and the nurse should have
referred the patient to a provider.

9/15/2015 A doctor noted that the INR was 2.2 and increased the
coumadin to 8. There was no evaluation of the patient.
9/22/2015 A doctor noted that the INR was 2.7 and he maintained the
coumadin at 8.
10/14/2015 A doctor saw the patient for HTN, DM, and COPD chronic
1, 2, 3
clinics. The doctor noted that the patient was on coumadin
for AVR and had microcytic anemia but the reason for this
was not provided. The only history was that the patient was
"generally well, got here in his wheelchair. Taking his meds
+ coming for AccuChecks + insulin BID." That was the only
history. PEFRs were 230/230/240. The A1c was listed as
6.1. HTN, DM, and COPD were all listed as in good control.
The doctor did not address the anemia, anticoagulation or
arrhythmia. There was no change to therapy.

10/14/2015 The problem list was updated and documented HTN, DM,
COPD, microcytic anemia BPH and GERD. Multiple diseases
weren't included.
11/19/2015 A doctor didn't evaluate the patient but noted that the INR
was 1.9 and increased the coumadin to 8.5 mg.
11/25/2015 A nurse evaluated the patient for nausea for 2-3 weeks
duration. The patient was not vomiting. The nurse took no
action.

The doctor noted that the patient had a microcytic anemia when
the patient had a macrocytic anemia. The doctor failed to
establish a diagnosis for the anemia and failed to acknowledge
other abnormal labs including chronic kidney disease, and
laboratory evidence suggestive of cirrhosis. The doctor did not
address the anemia, anticoagulation, or arrhythmia despite the
patient having recent shortness of breath. The patient had
multiple recent episodes of shortness of breath that were not
addressed. Care failed to follow generally accepted guidelines or
usual practice.

This demonstrates a significant gap in knowledge related to
primary care.

16

223

Vomiting is a serious condition in a diabetic and the nurse should
have referred the patient to a provider.

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 224 of 431 PageID #:12422

11/30/2015 EKG showing pacemaker spikes with underlying atrial
fibrillation and IVCD. QRS consistent with septal infarct
probably old.
11/30/2015 A nurse evaluated the patient for chest pain. The patient
was rushing getting ready for commissary. The pain felt like
a pulled muscle. The nurse ordered an EKG and a doctor
saw the patient.
11/30/2015 A doctor noted that the patient developed L chest pain
1, 3. 7,
while rushing to go to commissary that felt like a pulled
12
muscle. The patient had no diaphoresis or shortness of
breath. The doctor documented that there was a tender
area on his chest with palpation. The doctor noted an
irregular heart rhythm and reviewed the EKG, noting that it
showed irregular rhythm, PVCs and pacing. The plan was
that if the chest pain didn't resolve over 3-6 weeks he
would see the patient in sick call. The doctor ordered an
overread of the EKG but did not order an antianginal
medication. The doctor failed to note that the patient failed
to have follow up with the cardiologist.

12/1/2015 A doctor saw the patient for a complaint of nausea. The
patient was taking Prilosec. The doctor took no history with
respect to chest pain. The doctor diagnosed nausea from
Prilosec and stopped the Prilosec and started Zantac.
Zantac can result in cardiac conduction abnormalities and
should have been used with caution in this patient with
know severe conduction abnormalities.

1

224

The patient with a serious cardiac arrhythmia and chest pain that
was consistent with angina was not adequately evaluated. The
doctor failed to take a risk factor assessment but the patient had
multiple cardiovascular risk factors including diabetes,
hypertension, age, male sex, and had a 10-year heart disease risk
of about 25%. His risk was therefore considerable. While the
doctor felt that this was atypical chest pain, the patient's history
required a higher level of investigation. The doctor ordered no
anti-anginal medication and to give a 3-6 week follow up in sick
call was indifferent. The patient should have been referred for
stress testing or cardiac catheterization to evaluate for acute
coronary syndrome. At a minimum the patient should have been
started on a statin and anti-anginal medication and referred to a
cardiologist. Care failed to follow generally accepted guidelines
or usual practice.

The doctor failed to take a thorough history. Nausea can be an
anginal equivalent. The doctor failed to note the prior
complaints of chest pain and this was not investigated. Care
could reasonably expected to be better.

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 225 of 431 PageID #:12423

12/17/2015 A doctor saw the patient for HTN, DM, chronic clinics. The
doctor mentioned that the patient was on coumadin and
had COPD. The doctor took no history to determine the
status of the patient's progress with respect to any of his
diseases. The A1c was documented as 6.6. PEFR was
documented as 240/230/230. The last INR was
documented as 1.9. BP was 122/64 and the pulse 93. The
doctor noted that the patient had a macrocytic anemia and
appeared to order a B12 level but the note was illegible.
The patient's COPD, cardiac arrhythmia, were not
addressed. The doctor made no changed to therapy.

1, 3

12/22/2015 At 10:10 am the patient complained to a nurse of leg
swelling and shortness of breath with pitting edema. The
nurse notified a doctor.
12/22/2015 At 10:40 am a nurse noted that the patient was lightheaded
and had a blood glucose of 48. The patient was nauseated
cold and clammy. The nurse gave the patient juice and
checked him in 15 minutes and his blood sugar was 102.

225

The doctor failed to take a thorough history of the patient's
conditions. The doctor failed to address the patient's COPD or
cardiac arrhythmia. Even though these were chronic medical
conditions, they were not being followed in chronic care clinics.
The doctor noted the macrocytic anemia and ordered a B12 level
but failed to associate the macrocytic anemia with the abnormal
bilirubin, and thrombocytopenia which can be associated with
cirrhosis. The doctor failed to address the patient's prior
episodes of chest pain even though the patient had history of
cardiac arrhythmias and history of coronary artery disease. The
patient had a 25% risk of heart disease and was not started on a
statin.

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 226 of 431 PageID #:12424

12/22/2015 A doctor saw the patient subsequent to the hypoglycemic
episode. The doctor said he was seeing the patient for low
blood sugar and leg edema with shortness of breath. The
doctor noted orthopnea, and left chest pressure that lasted
10 minutes with gradual onset and no resolution. The
doctor noted 1-2+ lower extremity edema. The doctor
decreased the 70/30 insulin from 25 to 20 units, restarted
the alvesco and ordered a CBC, BNP, BMP and INR and
ordered follow up in a week. The doctor did not order an
EKG. The assessment of the chest pain was "COPD vs
cardiac? not exertional" but the doctor didn't take a history
sufficient to exclude this. The leg edema did not include
rule out diagnoses. Although the doctor documented
shortness of breath and a history of heart failure a chest xray was not done.

1, 8

The doctor failed to take adequate history with respect to leg
edema and shortness of breath. The "chest pressure" was not
addressed adequately as it may have been due to angina. The
patient's possible cirrhosis may have resulted in the
hypoglycemic episode but this was unrecognized. Though the
patient had chest pressure the doctor did not order an EKG or
assess the patient for angina. Though the doctor documented
non-exertional chest pain, the history was insufficient to draw
this conclusion. The doctor failed to establish potential
diagnoses that may have caused the leg edema. Despite
shortness of breath and history of heart failure a chest x-ray was
not done. Care failed to follow generally accepted guidelines or
usual practice.

12/26/2015 A nurse saw the patient who said, "I don't know what's
wrong with me but something isn't right. I can't sleep cause
I'm so short of breath." The nurse recommended that the
patient rest and hydrate. Later that day a pacemaker check
was done.
12/28/2015 EKG showed aberrant intraventricular conduction with
ventricular escape complexes with WPW pattern type A.
Overread was requested.
12/29/2015 EKG showing aberrant intraventricular conduction with
PVCs and WPW pattern and rightward axis.

16

The patient had a serious complaint and the nurse should have
referred the patient to a provider.

226

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 227 of 431 PageID #:12425

12/29/2015 A doctor saw the patient and noted that the patient went to
UIC for pacemaker check in the past and had the pacemaker
placed two years ago. The doctor failed to note that follow
up with cardiology never occurred. The doctor did note
that the patient had leg edema and his weight had
increased by 17 pounds over the past week and that the
BNP was 712 and hemoglobin of 9.1 with an INR of 3.3. The
doctor noted increased shortness of breath, orthopnea, and
edema. The doctor questioned whether the pacemaker was
malfunctioning. and noted that the heart rate was in the
40s. The doctor noted a heart rate of 44, which is
significant bradycardia. The doctor noted recent labs as
BUN 42; creatinine of 1.77; BNP 712. The doctor diagnosed
heart failure exacerbation and increased the bumex to 2 mg
and stopped the hydralazine and zantac and restarted
omeprazole. The doctor wanted to admit the patient to the
infirmary but he was "averse" and the doctor recommended
decrease of salt. The doctor did not order a chest x-ray. An
EKG showed aberrant intraventricular conduction with
ventricular escape. The tracing appears to show 3 pace
maker firings. The doctor's plan included a cardiology
evaluation if his plan failed. However, the patient had
multiple indications for hospital admission based on Heart
Failure Society of America guidelines for admission to a
hospital.

1, 14

12/30/2015 Pacemaker check indicated two alerts: one was a high
ventricular rate (40) was detected and the ventricular
percent pacing greater than limit. The pacemaker was
functioning normally.

The patient had 17 pound weight gain over a week with elevated
BNP and leg edema suggestive of heart failure. The doctor failed
to obtain a chest x-ray. The doctor failed to ask the patient about
chest pain. The doctor ordered an EKG but didn't document
evaluation of the EKG. The EKG showed aberrant ventricular
complexes that made it difficult to evaluate for angina. The EKG
showed three pacemaker firings with a slow heart rate. The
doctor noted a heart rate of 44. The heart rate shouldn't be 44 if
the pacemaker was functioning but this apparently was
unrecognized. The doctor failed to recognize that the patient had
never had cardiology follow up after the pacemaker set up. The
patient had ventricular escape complexes with apparent pacing
spikes. The doctor assessed exacerbation of heart failure but did
not order a chest x-ray, a repeat BNP, or repeat metabolic panel.
Laboratory tests were noted which were not present in the
medical record showing renal failure and elevated BNP. Given
the number of serious cardiopulmonary problems, heart failure
under these circumstances should be admitted to a hospital. This
was particularly true because the doctor documented that he
thought the pacemaker might be malfunctioning. Under these
circumstances, the patient needed to be evaluated by a
cardiologist in a hospital especially in the context of heart failure
and possible angina. http://www.hfsa.org/heart-failureguidelines-2/Care was grossly and flagrantly unacceptable.

A greater pacing rate with heart failure should have resulted in
hospitalization.

227

Patient #18

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 228 of 431 PageID #:12426

12/31/2015 A nurse saw the patient who said, "It's not my lungs, it's my
heart." The patient was being seen for a nebulizer
treatment. The nurse noted that the edema was already
addressed by a doctor on 12/29/15. Although the patient
complained of a heart problem, the nurse took no history
and continued the same care and referred to a doctor the
following morning.

16

12/31/2015 A doctor saw the patient and noted that the patient felt
1, 3, 6
better. The doctor took no history related to the patient's
chest complaint. The doctor assessed heart failure
exacerbation and restarted spironolactone and scheduled
the patient for 1/6/16 with labs.
1/1/2016 A nurse noted receiving a phone call from an officer that the
inmate was not responding. The patient had died and was
in rigor mortis on arrival at 4:30 am. Medics brought the
patient to a hospital where he was pronounced dead.

228

The patient had chest pain but was not referred to a doctor. The
nurse should have referred the patient to a doctor.

The doctor failed to review the pacemaker check alerts including
high ventricular pacing. The doctor failed to take an adequate
history of the patient's history that same day of chest pain. Care
was grossly and flagrantly unacceptable.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 229 of 431 PageID #:12427

10/25/2000 The problem list documented alcohol abuse and chronic
diarrhea secondary to prior surgery for peptic ulcer disease.
1/4/2002 The problem list documented hypertension.
3/6/2014 A chronic care flowsheet documented that the patient
weighed 142 pounds.
6/30/2014 A chronic care flowsheet documented that the weight was 133
pounds.
6/30/2014 The patient was evaluated in hypertension and diabetes clinics
but he did not have either disease. The blood pressure was
104/60. The A1c was 5.5 and the patient was not on any
medication for blood pressure of diabetes. The NP seeing the
patient documented that the patient did not have diabetes or
hypertension and switched the patient to general medicine
chronic clinic. The NP noted that the patient had ulcerative
colitis but took no history and evaluated no labs. The NP did
not note the nine pound weight loss.
10/8/2014 BUN 27; cholesterol 119; HDL 53; LDL 52 (50-129); Albumin
3.5 (3.4-5)
10/15/2014 A nurse documented that it was not possible to take the
weight since the patient couldn't stand. The patient was 81
years old.
10/17/2014 A PA saw the patient saw the patient for his prosthetic leg.
The weight was 133 pounds. The PA noted that the patient
had a poor fitting prosthetic and referred the patient for
orthotic evaluation. Presumably the weight was taken with
the prosthetic.
10/21/2014 A nurse noted that the weight was approximately 133 and was
deferred.

229

1

The NP failed to note the weight loss despite the patient
having ulcerative colitis.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 230 of 431 PageID #:12428

10/28/2014 An annual history and physical examination documented prior
back surgery, prior cholecystectomy, alcohol abuse as medical
problems. The history documented dietary restrictions but did
not document what these were or why the patient needed
dietary restrictions. The nurse taking the history documented
that the patient said he had cataracts and couldn't read the
eye chart. The doctor completing the physical examination
added that the patient had prior surgery for peptic ulcer
disease without specifying what was actually done and noted
that the patient had prior osteomyelitis without more
specificity. The assessment documented that the patient had
a below knee amputation but didn't state why the patient had
an amputation. The doctor noted that the patient had
diabetes in 2012 but wasn't now being treated for this. The
patient refused rectal examination. Colorectal screening was
not done. The weight was 136.

11/10/2014 The patient's weight was 136.
1/27/2015 The patient developed a lesion on the right stump and saw a
doctor. The weight was 134. There was a 1 cm ulcer.
DuoDERM was ordered.
2/2/2015 A nurse noted changing the dressing on the stump that had a
moist wound on the stump with a foul odor.
4/23/2015 A PA saw the patient for a stump wound. The PA noted that
the prosthetic didn't fit "right." There was a 2 cm lesion with
"irritation" on the stump. The PA referred the patient to the
orthotic specialist.
4/29/2015 Wexford approved an evaluation by Rockford Ortho for
refitting of right artificial leg.

230

7

The patient wasn't offered colon cancer screening. The
patient was 81 but screening should stop when the
estimated life expectancy is less than 10 years.
Estimated risk should have been done as part of the
annual assessment. Care failed to follow generally
accepted guidelines or usual practice.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 231 of 431 PageID #:12429

5/13/2015 The patient went to ophthalmology clinic and it was noted
that he was using a wheelchair. The transfer note also
documented that he was on a mechanical soft diet with no
bread and had to sit up straight when he ate and that he had
chronic diarrhea.
5/14/2015 Rockford ortho saw the patient. There was no report except
for comments on the referral form. Those comments noted
that the prosthesis was causing re-occurring sores and skin
breakdown. They believed that the socket no longer fits
adequately and would continue to cause problems. They
recommended a socket replacement for the prosthesis.
6/1/2015 Wexford denied a new socket until a price quote was
available.

6

11

6/3/2015 A nurse evaluated the patient for a toothache and
documented a weight of 129.
6/11/2015 Wexford again denied a new socket until a price quote was
available.

231

What was the patient supposed to do? The prosthesis
was broken. This should have been fixed.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 232 of 431 PageID #:12430

6/15/2015 The patient was seen in General Medicine chronic clinic for
ulcerative colitis, GERD and BPH. The patient weight
estimated at 129 pounds on the flow sheet. The patient was 5
foot 11 inches. There was no history of any of the patient's
medical conditions on the progress note. The BMI was not
calculated on the note but was 18, which is considered
underweight. The nurse practitioner made no mention of this.
Without any history or documentation of status on any of the
patient's conditions, the NP prescribed Lomotil for diarrhea as
needed, Colace, fiber, milk of magnesia, terazosin, zantec,
Tylenol and Maalox. It wasn't clear why the patient needed
these medications as there was no history. The assessment
was ulcerative colitis "controlled," GERD controlled, and
anemia. The etiology of the anemia was not documented and
apparently was not understood. The NP failed to review labs
that showed that the patient had malnutrition with low
albumin. The thrombocytopenia was not acknowledged and
the anemia not worked up.

6/25/2015 The patient obtained a new socket for his prosthesis.
7/9/2015 The patient signed a "living will" that if he had an incurable
and irreversible disease judged to be terminal that procedures
that would prolong the dying process be withheld or
withdrawn.
7/23/2015 Vit B12 674 (180-914); Iron 21 (50-180); ferritin 23 (10-259);
folate 18.4 (>5.8).

232

1, 2, 7 The patient had ulcerative colitis, weight loss, and
anemia yet a colonoscopy wasn't done. This was
especially important since risk of colon cancer is higher
in persons with ulcerative colitis. Also the patient had
pancytopenia that was unrecognized. A bone marrow
should have been considered. At a minimum a repeat
CBC should have been done. The low albumin in
addition to the ulcerative colitis and weight loss
suggested malnutrition but no evaluation was done. The
doctor did not address the broken prosthesis. Care
failed to follow generally accepted guidelines or usual
practice.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 233 of 431 PageID #:12431

8/5/2015 A doctor saw the patient for review of labs and hemoccult.
The weight was 134 pounds. The doctor noted that the
patient was pale. The doctor noted a history of ulcerative
colitis and documented that the patient didn't want a
hemoccult done. The hemoglobin was 9.6 and the B12 and
folate were normal and serum iron was low. The doctor
diagnosed iron deficiency anemia and started iron
supplements. The doctor noted that the patient had no
diarrhea or black stool and had a history of constipation. The
doctor did not order a colonoscopy. The doctor did not note
the possible malnutrition.

2, 3, 7, The doctor should have ordered a colonoscopy given
12
anemia, ulcerative colitis, and weight loss. The patient
had low albumin which was unrecognized and should
have had an evaluation for malnutrition. The doctor
should have considered referral to hematology for
pancytopenia.

8/6/2015 UIC ophthalmology noted "visually significant cataracts both
eyes" and recommended surgery with the right eye first.
8/10/2015 UIC performed right cataract surgery.
8/12/2015 A doctor saw the patient for follow up of a medical writ. The
weight was 124 pounds, which was a 18 pound weight loss
which the doctor did not notice. The doctor noted that the
patient had cataract surgery and needed follow up at UIC in a
week. The doctor did not address any of the patient's other
problems.
8/18/2015 The patient saw ophthalmology at UIC. They recommended
cataract surgery in both eyes. A Dixon physician documented
that the patient would need approval "but does not have DMZ
so don't think he meets criteria."

233

1

The doctor failed to notice the weight loss. Care could
reasonably have been expected to be better.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 234 of 431 PageID #:12432

8/21/2015 A doctor saw the patient. The weight was 123 pounds. The
doctor noted that the weight was 142 pounds on 3/14 and
was 123 pounds "today." The doctor also noted that the
patient had a hemoglobin of 9.6. The history was that the
patient had prior osteomyelitis of his right leg which
presumably accounted for the amputation. The doctor
assessed a 19 pound weight loss over 17 months. The doctor
also noted the albumin of 3.2. Despite the anemia and weight
loss the doctor assessed that the weight loss was due to
needing dentures. The doctor ordered a CMP, TSH, iron,
ferritin, CBC, but did not order colonoscopy or order a
nutritional inventory with a nutritionist. The doctor also noted
anemia and prior pancytopenia and documented that the
patient might have a dyscrasia but did not refer to a
hematologist. The doctor ordered a two week follow up.

2, 7

8/25/2015 BUN 23; sodium 133; albumin 3.5 (3.4-5); iron 34 (50-19=80);
Ferritin 48 (10-259); TSH 3.26 (0.35-4); WBC 7 (3.9-12);
hemoglobin 11.1; platelets 135.

9/8/2015 Patient had follow up for his cataract surgery and UIC noted
that the second cataract was scheduled for 9/5/15.
9/17/2015 A doctor saw the patient who now weighed 120 pounds. The
doctor documented that corrected vision in the post surgical
eye was only 20/80 and he re-referred the patient for cataract
surgery on the second eye. The doctor failed to address the
hematologic abnormalities identified on the 8/21/15 note.
The doctor failed to note the continued weight loss.
10/5/2015 Wexford denied removal of the 2nd cataract as patient "does
not meet criteria" for removal. The denial was appealed and
then approved on 10/2/15.

234

The doctor concluded that low albumin, weight loss, and
anemia were due to needing dentures without
conducting other evaluations. The patient needed a
colonoscopy and needed a nutritional survey to
determine if the patient was getting sufficient nutrients
and food. Care failed to follow generally accepted
guidelines or usual practice.

The labs still showed anemia, borderline albumin and
thrombocytopenia but there was no follow up. Care
failed to follow generally accepted guidelines or usual
practice as abnormal labs were no followed up.

1, 6

The medication renewal process didn't work and the
patient's medication stopped in mid December and
wasn't started again until 1/8/17, about 3-4 weeks later.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 235 of 431 PageID #:12433

11/2/2015 Glucose 129; BUN 27.
11/2/2015 The patient weighed 131 pounds wearing his prosthesis.
11/4/2015 A NP saw the patient who had a "nickel" sized pressure ulcer
on the stump. The patient weighed 130 pounds. The NP
ordered dressing changes for the wound.
11/8/2015 A NP saw the patient in chronic clinic for ulcerative colitis,
1, 3, 6, 7
GERD and BPH. The NP documented that the patient got up 34 times a night to urinate. The NP also did not review any
symptoms related to the GERD or ulcerative colitis. The
weight was 127 pounds which was a weight loss of 15 pounds
since March of 2014. Yet the NP did not note this and did not
discuss this especially in the context of the ulcerative colitis.
The only labs reviewed were a glucose of 129; BUN 27 and
creatinine 1.03. The recent anemia, thrombocytopenia were
not evaluated. The latest low albumin indicating malnutrition
was also not evaluated. The GERD and ulcerative colitis were
assessed as "stable" without having taken any history and
without evaluation of the anemia, thrombocytopenia, weight
loss or low albumin indicative of malnutrition.

The NP failed to note the weight loss despite the patient
having ulcerative colitis. The NP also failed to note
abnormal labs. Given the anemia and ulcerative colitis,
the patient should have been offered a colonoscopy.
The NP also failed to identify the previously abnormal
albumin with respect to the patient's nutrition and
ulcerative colitis. The nutritional status should have
been evaluated. To assess the ulcerative colitis as stable
was not correct as the patient was losing weight and the
doctor took no history to verify stable ulcerative colitis.
Care failed to follow generally accepted guidelines or
usual practice.

11/16/2015 A doctor saw the patient and addressed the orthotic and
stump ulcer but did not address the anemia or malnutrition.
12/9/2015 A doctor saw the patient post orthotic visit. The weight was
128. The doctor did not address the weight loss or abnormal
blood test.

235

Care could reasonably have been expected to be better
as the doctor might have noted the weight loss.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 236 of 431 PageID #:12434

3/1/2016 A nurse saw the patient for nausea. The patient described
feeling weak, vertigo. He was going to the bathroom when he
fell to the floor and became nauseous. He didn't vomit. The
blood pressure was 98/50 but orthostatic blood pressure was
not taken; the nurse documented that she was unable to
assess this for unexplained reasons. The nurse consulted a
doctor who ordered compazine for seven days without
scheduling an evaluation or without ordering lab tests.

14, 19 The doctor should have seen the patient to assess the
patient for syncope, low blood pressure, nausea, and a
fall as these were serious problems. Failure to see the
patient was indifferent. If this was after hours, the
patient should have been sent to a hospital. Care failed
to follow generally accepted guidelines or usual
practice.

4/25/2016 A nurse documented a brief note stating that the prior evening
16
the patient had sudden weakness, dizziness, and problems
walking but these had resolved and the patient didn't want to
be seen. The nurse didn't take vital signs or refer to a
physician.
5/6/2016 A NP saw the patient in chronic illness clinic for GERD,
1, 2, 7,
ulcerative colitis, and BPH. The NP documented dizziness but
8, 12
the only history was that the "only med on that may affect
that is Hytrin." The NP documented adequate hydration and
only rare diarrhea. The weight was 130, a 12 pound weight
loss over two years. The patient also had low albumin
indicative of malnutrition which was not acknowledged or
reviewed. The NP did not discuss diet and nutrition with the
patient despite the significant weight loss with ulcerative
colitis. The BMI was documented as 19 but with a weight of
130 and height of 5 foot 11 inches, the BMI was 18.1, which is
underweight. This would be significant in a person with
ulcerative colitis. The anemia, thrombocytopenia, and
hypoalbuminemia were not acknowledged. The blood
pressure was 98/58, which is low but was not evaluated. The
NP assessed the patient as in good control and continued the
same medications.

236

The nurse should have referred the patient to a
physician.

The NP failed to take adequate history or perform
adequate examination for the dizziness. An EKG should
have been done. The patient's weight loss and anemia
and UC warranted a colonoscopy but this was not done.
The patient was underweight and had low albumin and
his nutrition should have been evaluated by someone
who understood how to do this. The thrombocytopenia
should have been evaluated. Care failed to follow
generally accepted guidelines or usual practice.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 237 of 431 PageID #:12435

6/17/2016 A doctor saw the patient. The weight was 130 pounds. The
doctor noted that the patient had a blister formation on his
coccyx and was experiencing pain. The doctor noted that the
inmate was "thin" and used a wheelchair much of the time.
The doctor noted that the patient had a donut for use but had
redness and thin sensitive skin over the coccyx with a blister
and a small open ulceration without sign of infection. The
doctor diagnosed a "superficial pressure irritation and blister"
on the coccyx. The doctor ordered daily cleaning of the
affected area and advised the patient to sleep on his side as
much as possible. The doctor recommended avoiding sitting
for long periods of time to relieve buttock and back pressure.
However, the patient needed a wheelchair, presumably due to
an ill fitting prosthetic. The doctor did not address whether
the patient could walk, had a good fitting prosthesis, or the
extent to which the patient was using the wheelchair. This
should have been done. The doctor did not assess nutritional
status.

6/20/2016 Wexford approved UIC ophthalmology for pre-op cataract
removal visit.
6/20/2016 BUN 32; sodium 130; calcium 8.2; albumin 2.3; bilirubin 3.3;
alk phos 472; AST 165; ALT 119.
6/22/2016 The patient complained to a nurse of needing something for
pain. The nurse didn't acknowledge what the pain was from.
The nurse assessment was "knowledge deficit" and the nurse
referred the patient to the doctor line for pain medication.

237

1, 3

The doctor failed to take an adequate history with
respect to risk for decubitus in this patient and failed to
take other protective measures. This patient was 81
years old, frail, malnourished, with underlying ulcerative
colitis. He appeared to need housing on a specialized
medical unit. Care failed to follow generally accepted
guidelines or usual practice.

16

The patient now had a decubitus ulcer and was mostly
confined to a wheelchair and should have been referred
to a physician.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 238 of 431 PageID #:12436

6/23/2016 The patient was evaluated in UIC ophthalmology. A brief
comment on the referral form documented that the patient
needed to take AREDS2 vitamins and needed both cataracts
removed. A 7/11/16 follow up was requested. AREDS 2
vitamins are a combination vitamins prescribed for reducing
risk of age related eye disease.
6/23/2016 A doctor saw the patient to evaluate for flex cuffs but did not
see the patient for the coccyx wound.
6/24/2016 A NP was asked by a nurse to see the patient for the coccyx
1, 2, 8,
wound. The patient said, "I am in so much pain, I can't stand
14
it." The patient said the DuoDERM falls off and he had
drainage from the wound. The NP noted that the patient was
a thin and "fragile" man with two pressure sores on his coccyx;
one was 3 by 3 cm and the other 1.5 by 1 cm with surrounding
inflammation. There was serous and purulent drainage. The
NP ordered Augmentin, Toradol, Ultram and recommended
that the patient not lay on his back or sit for long periods but
did not admit to the infirmary.

6/27/2016 A doctor saw the patient for the pressure sores. The doctor
1, 2, 7,
noted that the tramadol helped with the pain and that the
8, 12, 14
patient was getting daily wound care. The doctor noted
decreased appetite with nausea. The doctor noted extensive
bruising of the wrists from cuffing. The patient weighed 127
pounds and the doctor noted weight loss of five pounds from
10/2/15. The doctor added that the patient lost three pounds
since 6/17/16 and would add "Boost" if meets UM or weight
[loss] criteria." The patient was referred for an air mattress
and ordered labs (CBC, CMP and ESR) and ordered flex cuffs
and Compazine. The doctor did not note that the patient was
taking antibiotics and did not document examination of the
coccyx wounds.

238

The NP failed to assess the stage of the ulcer. The NP
failed to assess the nutritional status of the patient.
Although the NP started antibiotics, the NP failed to
order appropriate tests to assess the level of infection
or to rule out osteomyelitis. The NP failed to identify
preventive measure necessary to take to prevent
extension of the ulcer. The patient should have been
placed on an infirmary or skilled nursing unit. Care
failed to follow generally accepted guidelines or usual
practice. This care should have been familiar to staff
given that it housed the geriatric unit.
The doctor failed to take adequate history, failed to
order nutritional assessment or order appropriate
nutritional supplement; failed to adequately examine
the patient or assess the depth of the ulcer and did not
order radiologic testing to assess for osteomyelitis. He
should have been placed on an infirmary. Care failed to
follow generally accepted guidelines or usual practice.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 239 of 431 PageID #:12437

6/28/2016 A nurse documented that the patient complained of a leaking
wound; the patient was wearing diapers. There was no
evidence of daily dressing changes. The drainage was yellow
in color and the nurse documented a plan to continue to do
dressing changes.
6/29/2016 Glucose 116; BUN 22; calcium 7.8 (8.6-10.6); Total protein 5.7
(6-8); albumin 2.3 (3.4-5); WBC 4.2 (3.9-12); hemoglobin 10;
platelets 145 (150-450); sedimentation rate 60.
6/29/2016 The patient complained "it's really draining." The nurse noted
yellow exudate on his pants and underwear. The nurse noted
that a NP assessed the patient who now had a 5 cm coccyx
ulcer with yellow tissue present.
6/29/2016 A NP saw the patient for dressing changes. The NP noted that
the patient continued to have serous drainage from the sound
and thought that the wounds were improved.
6/30/2016 A doctor wrote a lab review in the record documenting that
the ESR was 60; hemoglobin 10; and albumin 2.3. The doctor
ordered boost one can TID. The doctor took no action about
the hemoglobin or especially the ESR of 60 which indicated
probable infection and possible osteomyelitis.

7, 8, 12, The laboratory results indicated serious infection or
14
even osteomyelitis. The patient should have had a CT
scan, probing of the wound, and possibly bone culture.
IV antibiotics should have been considered. Since this
appeared beyond the expertise of local doctors the
patient should have been referred to and infectious
disease specialist, wound care specialist or both. The
doctor took no action. The doctor failed to address
significant low albumin and anemia. The patient should
have been considered for hospitalized as this doctor did
not know how to manage this patient. The doctor did
not appear to have adequate primary care experience,
especially for a geriatric population. Care was grossly
and flagrantly unacceptable.

239

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 240 of 431 PageID #:12438

6/30/2016 The patient told a nurse that the coccyx wound was draining a
large amount and the abdomen was soaked with drainage.
The nurse described the upper coccyx wound a 5 cm in
diameter and the lower wound 1.5 cm with boggy tissue
covering both wounds.
7/5/2016 A doctor saw the patient for a pressure sore that was larger.
6, 11,
The doctor wrote "pt has no 'vaseline.'" The doctor noted that 12, 14
the patient had no fat and that the patient was having a
difficult time staying on his side. The doctor noted a whitish
pressure ulcer. The doctor's plan was to order an egg crate
mattress while waiting for an air mattress. The doctor
ordered daily wound care. The doctor failed to review the
laboratory tests.

7/8/2016 A doctor noted that the nurse doing the dressing changes
noted tunneling of the pressure wound toward the buttock.
The doctor noted that the wound was being packed with 1/2
inch iodoform gauze. The doctor referred the patient to the
UIC wound clinic but ordered no labs, x-rays, or MRI to
evaluate for osteomyelitis and did not initiate antibiotic
treatment despite the elevated sedimentation rate or 60.
There was no referral to wound clinic in the medical record.

The boggy tissue implied that debridement was
necessary but was unnoticed by doctors.

The doctor did not appear to competently evaluate the
stage of the ulcer and develop a competent plan to
manage it. The doctor failed to evaluate prior abnormal
labs including the elevated sedimentation rate. The
patient should have been referred to a surgeon for
debridement, to a wound care center, and/or to a
hospital for evaluation and treatment with IV antibiotics
and evaluation for osteomyelitis. Resources to manage
this pressure ulcer were apparently unavailable but
should be as Dixon has a geriatric unit. As an alternative
to transfer to a skilled nursing hospital, infirmary care
was indicated

8, 12, 14 The wound appeared to be at least a stage 3 ulcer with
a sedimentation rate of 60, should have resulted in
evaluation for osteomyelitis. This did not occur. The
doctor appeared to have referred the patient to a
wound care center but this never occurred. IV
antibiotics appeared indicated. Care was grossly and
flagrantly unacceptable and appeared to result from
ignorance on how to manage the patient. This may be a
credentialing issue.

7/8/2016 A nurse described the wound as being covered with green
flesh-like material. The nurse described tunneling on both
wounds

This wound should have been debrided.

240

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 241 of 431 PageID #:12439

7/9/2016 The patient signed a living will on a preprinted formatted
document which stated that if he had incurable or irreversible
illness and that death was imminent he directed that any
procedures that would prolong the dying process should be
withheld.
7/11/2016 Wexford approved a UIC ophthalmology evaluation the day it
was requested.
7/11/2016 A nurse described that the patient had diarrhea and had only
three more days of Boost.
7/14/2016 The patient told a nurse that "It's totally worthless." The
nurse described a creamy drainage.
7/14/2016 A nurse documented that the patient had diarrhea and
8, 12, 14
presumed it was from the Boost. The nurse consulted a
doctor, who wasn't sure how to treat. The doctor
recommended continuing the boost and to "work around
diarrhea."
7/18/2016 A brief note on the referral form from UIC ophthalmology
documented that the patient needed to see anesthesiology
two weeks prior to his scheduled surgery date and would also
need to be seen the day after surgery or later the same day.
7/19/2016 The patient complained of a painful wound. The nurse noted
deep tunneling of the wound with large thick yellow drainage.
7/22/2016 Wexford approved UIC anesthesiology pre-op evaluation.

241

The wound appeared infected.
The doctor didn't know how to treat the patient and
should have referred to a higher level of care. The
patient needed laboratory testing because of the
diarrhea and needed a level of expertise unavailable at
the prison. Care failed to follow generally accepted
guidelines or usual practice.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 242 of 431 PageID #:12440

7/22/2016 A doctor saw the patient on writ return from UIC
2, 3, 7, 8
ophthalmology. The doctor mentioned that the patient had
some tunneling of the coccyx decubitus. The doctor noted
that the patient had diarrhea. The doctor performed no
physical examination. Remarkably, the doctor wrote, "Please
notify me next week when in wound care so I can see
wounds." The doctor could have and should have removed
the bandages to inspect the wound. The doctor ordered
Imodium and increased tramadol . The doctor ordered no
blood tests or radiological tests. Vital signs were not taken.

This was indifferent. The doctor should have removed
the bandage and inspected the wound. Appropriate
laboratory and radiologic testing was not done. The
plan of care was inadequate. IV antibiotics should have
been considered. Care failed to follow generally
accepted guidelines or usual practice.

7/24/2016 The patient was evaluated in anesthesiology. A brief note by
the anesthesiologist documented that the patient had
bradycardia but that the patient could proceed with surgery.
7/25/2016 A nurse noted that bone was visible within the wound with a
moderate amount of green exudate.
7/27/2016 A nurse documented visible bone with tunneling 7 cm deep.

This indicates a stage 4 ulcer. Osteomyelitis should have
been promptly ruled out.

8/1/2016 A nurse noted that the doctor was present to see the wound
and ordered to discontinue packing and to start wet to dry
dressings only. The doctor did not document a note.
8/2/2016 A doctor saw the patient. The temperature was 96.8. The
doctor noted that the patient was cleared for cataract surgery.
The doctor noted that the wounds on his back appeared
"healthy" without erythema or significant drainage. The
patient noted that the patient was approved for cataract
surgery. However, the doctor had no treatment plan for the
decubitus. The doctor ordered no labs or imaging studies.

242

The doctor should have documented a note.

2, 14

The nurses had documented visible bone. To inspect
such a wound and to describe it as "healthy" appears
incompetent. The patient needed hospitalization to rule
out osteomyelitis. Care was grossly and flagrantly
unacceptable.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 243 of 431 PageID #:12441

8/8/2016 A nurse noted that the air mattress was leaking. The nurse
16, 19
also noted that the patient was losing weight and not taking
his medication. The weight was listed as 100 pounds and the
nurse noted that this was a 27 pound weight loss [it appeared
to be a 42 pound weight loss over two years]. The patient
lacked appetite and was "forgetful." The nurse assessment
was "self care deficit." The plan was to schedule the patient to
see the doctor. The patient was unable to care for himself and
should have been placed on the infirmary or should have been
hospitalized.
8/11/2016 A nurse noted that during a dressing change the inmate
urinated foul smelling urine on the table. The inmate stated,
"I can't help it." The nurse noted that the inmate was unable
to put on his underwear or pants and that he needed a
roommate to assist him with activities of daily living. The
nurse wrote "poss infirmary placement."
8/12/2016 A nurse noted that the wounds were draining purulent
material.
8/13/2016 At 3:30 am a nurse noted that the patient fell and the nurse
wrote an injury report. The nurse did not document an
assessment in the progress note or consult a physician.

16,19 The altered mental status was of serious concern and
suggested sepsis. The nurse needed to refer the patient
immediately to a physician.

16

243

The patient had lost 42 pounds, had malnutrition, a
stage 4 decubitus ulcer with a sedimentation rate of 60.
The patient was now showing signs of altered mental
status which suggested serious sepsis. Care was
negligent. The nurse should have immediately
contacted a doctor but it appeared that doctors didn't
know how to care for the patient.

This was a serious problem and the nurse needed to
consult a physician.

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 244 of 431 PageID #:12442

8/13/2016 At 5:30 pm an nurse noted that the patient's roommate
reported that the patient hadn't eaten in two days and hadn't
voided. The nurse described the patient as weak. The nurse
placed the patient on the infirmary and called the doctor, who
ordered a CBC and CMP and UA and IM Rocephin for seven
days without evaluating the patient. The doctor also ordered
an IV but the nurse was unable to start an IV secondary to
what the nurse perceived was dehydration. At 7:45 pm the
nurse noted that the patient responds to pain. At 7:50 pm a
nurse noted a temperature of 100.1 a pulse of 115 and blood
pressure 100/50. The patient wasn't responsive and the nurse
called a doctor, who ordered the patient to a local hospital.

8/13/2016 A hospital blood culture documented gram positive cocci
growing in two bottles. These were identified as Beta strep
Group A and diphtheroid. There was light growth of
methicillin resistant Staph aureus and streptococcus agalactiaeGroup B strep. The WBC was 15.8.
8/14/2016 A hospital lab report showed BUN 92; creatinine 2.06; sodium
153 (137-145); chloride 116 (98-110); albumin 2.7.
8/14/2016 A hospital history and physical noted that the patient had
been lethargic for 2-3 days and had low grade fever and
mental status changes. The admitting diagnoses were mental
status changes, dehydration, acute kidney injury, stage 3
pressure ulcer, and sepsis. The hospital was told that the
patient was DNR as communicated to them by the Dixon
physician. The patient was described as lethargic for 2-3 days.
8/15/2016 A hospital lab report showed a blood culture growing budding
yeast on gram stain with the aerobic bottle positive.
8/17/2016 A hospital lab report showed WBC 4.9, hemoglobin 8.5;
platelets 55.

244

Patient #19

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 245 of 431 PageID #:12443

8/18/2016 A doctor spoke with the hospitalist who indicated that the
patient had positive blood cultures with bacteria and fungus
with the source likely from his back. The patient was being
returned to the prison for comfort measures only. The
discharge summary indicated that the hospital contacted the
daughter who agreed with nonaggressive care. The patient
was not fully oriented. The patient was returned to the prison
for hospice.
8/19/2016 The patient was admitted to the infirmary on discharge from
the hospital. The doctor ordered Ativan, morphine, and
atropine only. The doctor documented confirming that the
daughter had agreed with hospice care. The doctor did not
discuss palliative sedation with the daughter. On admission
the nurse noted that the patient was crying in pain.
8/21/2016 The patient was discharged from the hospital. The discharge
summary documented that the patient had sepsis from
infected decubitus. The patient was very "debilitated" and the
daughter noted how "much he had gone downhill since she
had seen him last and opted for nonaggressive care." The
patient needed debridement but the daughter opted against
this. The patient was sent back without antibiotics and on
morphine.
8/21/2016 The patient died on the infirmary.

245

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 246 of 431 PageID #:12444
Patient #20
10/28/2016 The patient was discharged from Stroger hospital. The patient
was discharged on 15 mg of morphine every four hours for
pain. The patient reported losing about 80 pounds since the
diagnosis. The diagnosis was likely pancreatic cancer. This
hospital report was printed on 11/9/16, so this report likely
went with the patient to Logan.
11/9/2016 The patient was transferred from Cermak HS on Tylenol,
albuterol, amlodipine, docusate, metoprolol 25 BID; morphine
15 SR BID and 15 mg IR Q 4 hours for pain, olanzapine,
trazodone, pantoprazole 40 mg. Hepatitis A, B, and C were all
positive yet were repeated in IDOC. The patient had an
upcoming appointment at GI on 11/17/16
11/9/2016 The patient was admitted to Logan CC. The patient was 5 foot
5 inches tall and weighed 152 pounds. The nurse history
documented that the patient had asthma, a prior positive TB
skin test but never completed therapy, was a smoker, had a
prior biopsy of her pancreas on October 27th and had a stent
in the liver. The reason for the biopsy of the pancreas or stent
were not explained. The nurse performing the intake
screening scheduled a routine examination though the patient
had a serious problem (liver stent with undiagnosed
pancreatic problem). The nurse did not list medications on the
intake screening. Also, there was no evidence of an order for
medication. This screening was performed by a LPN.

246

1

The history was poor. The patient had HTN but it was
unrecognized. The patient had a high likelihood of
pancreatic cancer and it was unrecognized. The patient
was on morphine but the patient didn't receive it.
Instead the patient received one Tylenol #3 TID instead
of 30 mg SR morphine and 90 mg of IR per day. The
three Tylenol #3 tablets had a morphine equivalency of
only 15 mg of morphine whereas the patient was
receiving 120 mg of morphine. No pain history was
taken. Care failed to follow generally accepted
guidelines or usual practice.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 247 of 431 PageID #:12445
Patient #20
11/9/2016 A nurse admitted the patient to the infirmary. The reason for
admission was not stated. Under subjective the nurse wrote
"colon cancer" without any other explanation. The blood
pressure was 146/107. The weight was listed as 152 pounds.
The examination section allowed for checking boxes as
normal; the entire examination was normal by checking boxes
as so. The assessment was "alteration in comfort r/t colon
cancer."
11/9/2016 GGT 341 (6-60); amylase 55 (25-125); lipase 17 (22-51); CMP
normal except albumin 3.3 bilirubin 3 and alk phos 182 (40125).
11/10/2016 A nurse wrote a brief note documenting blood pressure of
158/93. The patient asked for pain pills for a headache. The
patient stated asked for diapers for leakage of bowels. The
nurse assessment was colon cancer.
11/10/2016 A nurse saw the patient for pain in her head and stomach. The
blood pressure was 145/105. The nurse documented
"continue current plan" although the plan was not specified
and it wasn't clear if the patient was on pain medication.

247

1

The nurses failed to understand the patient's problems.
The failure to take a history of HTN resulted in no BP
medication for the first day.

1

The patient had diarrhea yet the nurse failed to ask why.
To use diapers for diarrhea is a significant problem and
should have resulted in questioning about why this was
occurring.
The patient was abruptly discontinued from morphine
and not provided adequate substitute.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 248 of 431 PageID #:12446
Patient #20
11/10/2016 Comments from oncology on the referral form stated that the
patient had hyperkalemia, HCC, and HCV. The patient was
given kayexalate with directions to NRC to manage the
hyperkalemia. It was recommended to get a triple phase CT
scan, with a follow up in two weeks. The potassium was 5.5.
The oncologist prescribed 15 grams of kayexalate rectal
suppository for two days with recommendation to repeat the
BMP in two days.

11/10/2016 At 10:21 pm a nurse noted that the patient was complaining of
pain and diarrhea. The blood pressure was 167/126. The
nurse administered ordered medication but did not call a
provider.
11/11/2016 At midnight the BP 147/91; the nurse called a doctor, who
increased metoprolol to 50 mg. The patient had been on
amlodipine when she came in. The nurse noted that the
patient had colon cancer.

248

2, 7,12 The patient transferred with notes from Cook County
Hospital and Jail documenting that the patient likely had
pancreatic cancer. The patient had a follow up at
Stroger hospital the second week of November and was
on up to 90 mg of morphine a day. The doctor failed to
continue the work up for the pancreatic mass.
Ultimately, this was delayed such that a diagnosis did
not occur for five months. The patient had a pancreatic
mass for which there was no diagnosis. Because the
biopsy was inadequate, the doctor presumed that the
patient had a benign tumor? The patient should have
been sent for a diagnostic ERCP. Moreover, the patient
had pain and the doctor significantly decreased pain
medication without even performing a pain assessment.
This was indifferent. The doctor took no action for a
patient that had likely pancreatic cancer. The doctor
failed to document review of the discharge hospital
summary. It was unclear why the doctor took these
actions as they were clearly not in the best interest of
the patient and were below standard of care for
someone with an undiagnosed pancreatic mass.

16

The nurse should have called a provider.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 249 of 431 PageID #:12447
Patient #20
11/11/2016 At 4:21 am the BP was 143/96. The patient had breakfast.
11/11/2016 At 1:56 pm the BP was 130/97. The patient had pain and was
given a "pain" pill. The nurse did not document medication
given except described as "pain meds."
11/11/2016 A doctor saw the patient and documented consideration of a
CT guided biopsy when "she is stronger." The doctor wrote to
repeat LFTs next week. The doctor took no history including
of pain. The doctor performed no exam.

11/11/2016 The BP was 170/114. Metoprolol increased to 50 BID.
11/12/2016 A doctor wrote a note only documenting lab values. Again
there was no history. The hemoglobin was 9.4; WBC 5.9;
ferritin 615; normal B12 and folate. Anemia of chronic disease
diagnosed.
11/12/2016 Metoprolol was ordered 25 mg. The order stated that the
medication would need to be reordered or discontinued in
Pearl.
11/14/2016 The patient was discharged from the infirmary with a diagnosis
of pancreatic mass, biliary duct obstruction, anemia of chronic
disease, and HTN. Though the patient had elevated bilirubin
and known biliary duct obstruction, the doctor did not order
an urgent CT scan to determine the whether there was still
obstruction or to determine what the diagnosis was. The only
plan was a CBC & CMP and a low bunk for a year. There was
no imaging study.
11/14/2016 Amlodipine ordered 5 mg BID; the order was electronically
signed on 11/17/16.

249

4

This was nothing but a delay in initiating a work up. The
patient had likely pancreatic cancer. The pain was not
likely to improve and the patient not likely to get
stronger. A work-up should have been started. The
doctor was indifferent to the patient's pain.

1

The doctor again failed to determine the history of the
patient.

8

The doctor failed to obtain an imaging study (CT scan) in
lieu of obtaining a history. The staff discharged the
patient from the infirmary without establishing her
actual status.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 250 of 431 PageID #:12448
Patient #20
11/16/2016 A PA saw the patient for an initial examination. The PA
documented that the patient had a history of a pancreatic
mass and had lost 70 pounds of weight from Dec 2015 to June
of 2016. The PA noted that the patient had an ERCP and bile
duct stent on 10/27/16. The PA noted HTN and hepatitis C
infection. Despite having taken this history the PA checked
the weight loss box as "no." The PA checked all examination
boxes as "normal." The blood pressure was 115/88. The
electronic record allows the examiner to check a box "normal"
for the examination. This is a defective record system as it
does not record the examinations performed. The assessment
was pancreatic mass "benign ERCP biopsy (sub-optimal)," HTN,
+ PPD, and substance abuse. The PA did not list hepatitis C as
a problem even though he documented this in the subjective
section. The PA did not address the nurse finding of asthma as
a history. The plan was to complete gonorrhea and chlamydia
testing, a mammogram, and scheduling for the general
medicine and hypertension clinics. The pancreatic mass was
to be addressed in the general medicine clinic. The PA
referred the patient to hepatitis C clinic but did not include
hepatitis C as a diagnosis in the assessment. The PA did not
mention labs in the record but did make oblique reference to
elevated GGT when referring to the patient's hepatitis C.
There was no physician admission note for this patient.

250

1, 2

A 70 pound weight loss with a pancreatic mass requiring
a liver stent is not indicative of a benign problem. This
patient's old records should have immediately been
obtained and radiologic imaging performed to identify
and serious pancreatic or liver problems. The
assessment was inaccurate.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 251 of 431 PageID #:12449
Patient #20
11/22/2016 At 8:22 pm a nurse saw the patient. The blood pressure was
82/59. The patient was found on the floor having "fell out."
She fell a second time. Remarkably, the nurse took no action
except to tell the patient not to take "sleeping medication."
The patient was on omeprazole, metoprolol, Tylenol #3,
amlodipine, trazadone, and lamotrigine. The nurse did not call
a provider.

16

The patient lost consciousness and should have been
examined by a doctor. This was grossly and flagrantly
unacceptable care.

11/22/2016 A doctor saw the patient. The hemoglobin was 10.8;
1, 2, 3, 6 The patient had a serious medical condition but the
doctor failed to take any action to address the problem.
creatinine 0.76; BUN 8; albumin 3.3; bilirubin 2. The doctor
did not take a history, perform an exam, or develop a
The doctor also failed to address labs.
treatment plan. The doctor noted that the liver function tests
were improved. No action was taken.
12/8/2016 A doctor saw the patient. The patient weighed 149 pounds.
The doctor took little history except that the patient had
increase in pain and was having normal bowel movements.
Remarkably, the doctor did not take a history of the patient's
illness. The doctor didn't qualify the pain. The doctor noted
that the patient had decreased appetite. The doctor still took
no action with respect to the pancreatic mass except to order
a CMP and "observe" the patient.
12/8/2016 Tylenol #3 1 tab TID was prescribed for three months.
12/9/2016 BUN 8 (6-20); albumin 3; CA 19-9 220 (0-37).

1, 2,3

The patient had a serious medical condition but the
doctor failed to take any action to address the problem.

This test showed that the patient likely had pancreatic
cancer.

251

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 252 of 431 PageID #:12450
Patient #20
12/12/2016 The patient was seen in hepatitis C clinic. This note had
1, 3, 6
questions about contraindications to interferon even though
interferon is not used. There was little history, viral load was
not checked. The AST was 22, INR 2, and platelets of 183 were
noted. The patient was determined to be immune to hepatitis
A and B. The NP documented that the patient "needs sober
for 6 months."

The NP failed to take an appropriate history with
respect to hepatitis C. Being "sober for 6 months" is not
a contraindication for hepatitis C treatment by the UIC
protocol. The NP failed to note the CA-19-9 test which
was abnormal and indicated likely cancer.

12/13/2016 A doctor wrote a brief note without seeing the patient. The
doctor noted that the CA19-9 marker was 220 which was high.
The doctor wrote she would consider a CT guided biopsy of
the mass and would discuss in collegial. There was no
evidence of a collegial review and no evidence of a collegial
review in the tracking log.

6

This test shouldn't have been "considered," it should
have been done. The CA 19 test indicated that the
patient had likely pancreatic cancer and given the
history a work up should have been continued.

12/15/2016 A NP saw the patient in HTN chronic clinic. The temperature
was 82.7 with P 67; R 18; BP 128/92 and weight 150. The NP
took little to no history and documented a normal
examination. The BMI was documented as 25. The NP
ordered a six month FU but did not address the pancreatic
mass or asthma. The NP did not address the clearly abnormal
temperature or the anemia which she documented on the
record.

3, 11

252

This demonstrated a systemic problem with the medical
record. This record is defective. It allows dated vital
signs to be re-used in an inappropriate manner. Vital
signs should be documented when they are done. If old
vitals are to be used, it should be noted as such. To do
otherwise is a significant patient safety issue. This
ridiculous example gives a temperature which is
incompatible with life. Yet it wasn't recognized and was
re-used. The NP failed to develop an appropriate
treatment plan for the pancreatic mass.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 253 of 431 PageID #:12451
Patient #20
12/21/2016 A Wexford authorization form. The patient had come from CC
Jail with a recommendation for a repeat ERCP with biopsy.
The CA 19 was elevated. The approval stated, "no definitive
results of path report were noted in records sent-decided will
send this patient to GI to eval and make recommendations as
to plan of care." This would only delay the diagnosis. It
couldn't be clearer what the patient needed. The patient was
approved for a GI consult. Below this in the medical record
was a denial of a CT scan with FNA biopsy based on
insufficient information. What information was required?!!!.
They stated, "records sent in by site and no definitive results
of path report were noted in records sent." Notably, although
this information was present on a referral form, it was not
documented in the medical record as a request. This gives the
appearance that physicians are improperly not working
patients up when the fault lies with the vendor who is denying
requested care.

1/1/2017 A nurse noted that the patient was called to the health care
unit for two health requests but didn't show up. The nurse did
not check on the patient.
1/4/2017 An unsigned referral to GI was written on this date by the
doctor.
1/5/2017 On an optometry note the patient had temperature 82.7 with
P 72, R18, BP 122/86 with weight 150. These vital signs were
identical to those from 12/15/16.
1/13/2017 On a dental vitals were listed as temperature 82.7!! The vitals
were identical to 1/5/17 vitals done for optometry. But not
addressed.

253

7

This referral occurred six weeks after intake. Now the
biopsy would be delayed again until the patient went for
the GI consult. This acts only as a delay of care. The
Wexford collegial review system is a systemic barrier to
care and a significant patient safety issue and needs to
be abandoned.

11

The medical record has systemic deficiencies that is a
patient safety issue. This record should immediately fix
this problem or consider return to paper.

11

The medical record has systemic deficiencies that is a
patient safety issue. This record should immediately fix
this problem or consider return to paper.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 254 of 431 PageID #:12452
Patient #20
1/24/2017 The patient went offsite for an appointment but the nurse
didn't document where the patient went.
1/24/2017 A GI consultant saw the patient on this day. The consultant
noted that an EGD was done on 10/27/16 with a balloon
dilation of the CBD and a stent was placed with a small
sphincterotomy. The patient complained of diarrhea and
abdominal pain. The consultant recommended a CT scan
ASAP and might require ERCP. The doctor noted that the
patient had been on Tylenol #3 but this was changed to
Motrin because of a tooth infection.??? The patient
complained of weight loss up to 70 pounds in the last several
months.
1/25/2017 A doctor wrote a note without seeing the patient. The doctor
noted that the patient saw a GI consultant and had diagnoses
of obstructive jaundice, pancreatic mass, and diarrhea. The
doctor did not document review of a report. The doctor
started pancreaolipase and ordered a CT scan with contrast.
1/25/2017 A CT scan was requested by the doctor but NOT on an urgent
basis despite the recommendation for an ASAP test.

7

Doing this as a routine test was inconsistent with the
recommendation to perform the CT scan ASAP.

1/31/2017 A doctor wrote a handwritten note. The patient had
weakness. The patient weighed 143 pounds. The patient was
still on only one Tylenol #3 pill BID prn. The doctor noted that
the patient was to get a CT scan and GI follow up for probable
ERCP and biopsy. The doctor noted that the patient was found
cheeking Tylenol #3.

3

Pain medication was poorly addressed. Liquid
medication can be given under observation to avoid
cheeking, It was likely that the patient had untreated
pain.

2/1/2017 A CT scan was approved in collegial review.
2/2/2017 Amylase 88 (25-125); albumin 2.8.
2/3/2017 Hemoglobin 10.8; platelets 148.

254

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 255 of 431 PageID #:12453
Patient #20
2/15/2017 A CT scan was done. Only part of the report was available.
The CT scan noted diffuse anasarca and ascites. There was a
4.7 pancreatic mass with encasement and occlusion of
multiple veins resulting in varices. The findings were
consistent with unresectability.
2/16/2017 A doctor saw the patient. The patient weighted 146 pounds.
The doctor noted a nine pound weight gain, but this was
unclear. The doctor noted that the albumin was 2.8 with
anemia of chronic disease. The doctor noted that the CT scan
showed a mass in the head of the pancreas of 4.7 cm with
encasement of the splenic vein causing varices by virtue of
encasement of splenic and superior mesenteric veins and
collaterals. The mass was apparently unresectable based on
the doctor's comments. The doctor noted that "will need
tissue biopsy if chemotherapy is indicated. In view of all her
varices, not sure it is amenable to EGD US guided biopsy." The
doctor referred to an oncologist.
2/21/2017 A doctor saw the patient and noted that the diarrhea was
better on pancreaze. The doctor noted that pain was
controlled with Tylenol #3. The plan was to refer to GI for a
biopsy and then to an oncologist.
2/21/2017 A doctor wrote a referral for a GI follow up as a routine.
2/24/2017 A nurse saw the patient after a fall. The BP was 119/72. The
patient passed out. The patient fell on her face. The nurse
called a doctor, who admitted the patient to the infirmary.
2/24/2017 A nurse documented an infirmary admission note. There were
no orders. The nurse documented that the patient had signed
a DNR that day.

255

12

The patient should have had an urgent referral.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 256 of 431 PageID #:12454
Patient #20
2/24/2017 A doctor wrote an admission note. The doctor took no history
of the pain, ability to eat, comfort measures, or ability to
function.

3

The plan for the patient was insensitive to actual needs
and lacked professionalism. The patient was on blood
pressure medication but passed out, yet the doctor did
not evaluate blood pressure medicine to determine if
these were still necessary.

2/24/2017 At 8:48 pm the patient asked for extra Tylenol due to pain.
The nurse documented that there was no order for additional
Tylenol so none was given. The patient was still listed as
weighing 146 pounds.
2/27/2017 A nurse saw the patient. The weight was 136 pounds. It
appears that the weight on 2/24/17 was not accurate. The
blood pressure was 97/70.
2/28/2017 A nurse saw the patient. The vital signs were identical to the
vitals from 2/27/17. This medical record function needs
disabling.
2/28/2017 Albumin 2.7; cholesterol 89 (100-200); TG 71; HDL 28; LDL 47
(50-129).
3/1/2017 A nurse saw the patient. The vital signs were identical to the
vitals from 2/27/17. This medical record function needs
disabling.
3/2/2017 A doctor saw the patient. The vital signs and weight were
identical to 2/27/17. Yet the doctor noted that the patient
had lost weight since coming into the infirmary. The doctor
noted that the abdominal pain was controlled with Tylenol #3
since it was increased to TID. The patient had no place to stay
after discharge from prison in June. The doctor noted that the
patient had a follow up GI consultation and "May need CT
guided bx." The doctor discontinued the amlodipine and
noted that metoprolol was changed to propranolol.

3

Not treating the patient's pain was below standard of
care.

3

The blood pressure is so low that blood pressure
medication needed to be lowered.

11

The medical record falsely records vital signs and
weights.

11

The medical record falsely records vital signs and
weights.

256

7, 11

The medical record falsely records vital signs and
weights. The patient had been at Logan for almost
three months and had yet to obtain a biopsy of her
pancreatic mass. This is an unacceptable delay.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 257 of 431 PageID #:12455
Patient #20
3/3/2017 A nurse saw the patient. The vital signs were identical to vitals
from 2/27/17.
3/5/2017 A nurse saw the patient. The vital signs were identical to vitals
from 2/27/17.
3/6/2017 A nurse saw the patient. The blood pressure was 61/52. A
nurse noted that the patient almost fell getting on an
examination table. The nurse documented calling the chronic
care nurse to clarify blood pressure medication as pressure
was very low. The nurse documented notifying the doctor but
did not take any orders.

11
11
19

The medical record falsely records vital signs and
weight.
The medical record falsely records vital signs and
weight.
The patient had blood pressure consistent with shock,
yet the doctor ignored the patient. This was indifferent.

3/6/2017 The GI referral from 2/21/17 was approved as a routine.
3/6/2017 A NP saw the patient in HTN clinic. The BP was 102/75. The
NP took no history outside of the check box format, including
the box "if obese advise to lose weight" even though the
patient had pancreatic cancer and had lost over 80 pounds.
The NP took no other history of the patient's other medical
problems.
3/7/2017 A nurse saw the patient. BP 130/95. The nurse documented
"acute pain" but no pain assessment was done.
3/8/2017 At 4:22 am a LPN saw the patient. The blood pressure was
120/89. The patient complaint was "Still the same old
stabbing pains at times on my right side." The nurse noted
that the patient was on one tablet of Tylenol #3. The nurse
documented that the patient reported that the pain
medication was effective.
3/8/2017 At 2:48 pm a nurse saw the patient. The vital signs were
identical to the 4:00 am vital signs.

257

1, 2, 3 The NP failed to take appropriate history. The patient
had extremely low blood pressures previously and
needed medication lowered or discontinued. The NP
did not address the patient's pancreatic mass and
update the status of the workup.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 258 of 431 PageID #:12456
Patient #20
3/8/2017 At 3:34 pm a doctor saw the patient. The vital signs were
identical to those done at 4:00 am. The doctor noted
abdominal pain and that it was hard to sleep. The plan was to
follow up with GI for possible biopsy. Labs were noted
showing albumin of 2.7, and HGB 10.8 but these abnormalities
were not addressed. The doctor did not adjust the pain
medication. The assessment included likely pancreatic cancer
but the biopsy was still being delayed. The doctor
documented anemia and moderate malnutrition but no action
was taken.
3/9/2017 A nurse saw the patient and the vitals were identical to those
from 3/8/17. The patient complained of pain and asked if
there was another pain medication order. The nurse told the
patient that there was no new order for pain medication. The
assessment was "acute pain." The nurse documented a plan
to inform the doctor of the pain.

6, 11, The medical record falsely records vital signs. Abnormal
12
labs were noted but no action was taken. The doctor
took no action to determine how to improve nutrition
or even establish the degree of malnutrition. The
doctor did not evaluate for pain. The GI consult was
significantly delayed.

11

The medical record falsely records vital signs.

3/10/2017 A nurse saw the patient. The vitals were identical to 3/8/17.
The patient asked for pain medication. There was no pain
assessment.
3/11/2017 A nurse saw the patient. The vitals were identical to 3/8/17.
The patient had pain but there was no pain assessment.

11

Vital signs were identical.

11

Vital signs were identical.

3/12/2017 A nurse saw the patient. The vitals were identical to 3/8/17.

11

Vital signs were identical.

3/10/2017 The MAR shows patient received amlodipine. Instead of giving
the patient morphine, Tylenol #3 was ordered one tablet TID
for only two weeks. But there was no discussion of why this
was done. The patient was on 15 ER morphine BID and 15IR Q
four hours as needed. Substituting Tylenol #3 1 TID is a
significant reduction in pain control.

258

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 259 of 431 PageID #:12457
Patient #20
3/13/2017 A nurse saw the patient. The BP was 121/93; the temperature
and respiratory rate were identical to 3/8/17. The weight was
listed as 140 pounds.

11

Vital signs were identical. Notably, these vital signs do
record the date they were done but what this means is
that vital signs are not refreshed when patients are seen
and dated vital signs are used for evaluations.

11

Vital signs were identical.

11

Vital signs were identical.

3/15/2017 A doctor saw the patient. The vitals were identical to 3/13/17.
No pain assessment was done. The plan was still to follow up
with GI. The doctor ordered tramadol but only one tablet
daily. The doctor added Boost one can daily.

11

Vital signs were identical.

3/16/2017 A nurse saw the patient. The vitals were identical to 3/13/17.
The nurse documented that the patient had stomach pain and
asked for pain medication.
3/17/2017 A nurse saw the patient. The vital signs were identical to
3/13/17. The weight was 140. The patient had pain. The
patient's pain improved after tramadol.
3/18/2017 Identical vital signs.
3/19/2017 Identical vital signs.
3/20/2017 The patient complained of abdominal pain. The vitals were T
97.9; P 79; R 18; BP 120/80 and weight 137. The nurse took
no action about the pain.
3/21/2017 The patient complained of pain. T 98.3; P 90; R 16; BP 104/79.
The nurse did not address the pain.

11

Vital signs were identical.

11

Vital signs were identical.

11
11
16

Vital signs were identical.
Vital signs were identical.
The nurse should have called a provider.

16

The nurse should have called a provider.

3/14/2017 A doctor wrote a brief note without seeing the patient. The
doctor noted that the KUB showed an unremarkable gas
pattern with gallstones in the CBD stent.
3/14/2017 A nurse saw the patient. The vitals were identical to 3/13/17.
Pain assessment was not done as usual.
3/15/2017 A nurse saw the patient. The vitals were identical to 3/13/17.

259

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 260 of 431 PageID #:12458
Patient #20
3/21/2017 A GI doctor saw the patient. The doctor noted that the patient
had been diagnosed with a pancreatic mass in Iowa in 2015
but was lost to follow up and subsequently was seen at County
hospital in Chicago where the FNA was nondiagnostic. The
patient had abdominal pain with significant weight loss. The
liver on the CT scan showed cirrhosis. The consultant
scheduled an ERCP and FNA. On hand written notes the
doctor prescribed Fentanyl patch 25 mcg/hr.
3/22/2017 At 11:40 am the patient complained of pain. T 98.3; P 90; R
16; BP 104/79. The nurse did not address the pain.
3/22/2017 At 1:39 pm the patient told a doctor that the Tylenol #3
helped better than tramadol. The patient was in pain and
asked for better pain control. The doctor stopped the
tramadol and started one tablet of Tylenol #3 four times a day.
The vital signs were identical to the 3/21/17 vitals.

The consultant clearly disagreed with the use of Tylenol
#3. He was the second consultant to weigh in on pain
management.

16

The nurse should have called a provider.

3, 11

This bordered on cruelty. Pancreatic cancer pain is
significant and pain management should have included a
narcotic. Apparently for a physician visit, dated vitals
were used.

3/24/2017 A nurse saw the patient. The vitals were identical to the
11, 16
3/21/17 vitals. The patient had stomach pain and asked for
pain medication. The nurse did not contact a doctor about the
pain.
3/24/2017 A nurse saw the patient. Temperature not taken; P 67; R 18;
BP 152/92. No pain history taken.
3/25/2017 A nurse saw the patient. Vitals identical to 3/24/17. The
11
patient complained of pain.
3/26/2017 A nurse saw the patient. Vitals identical to 3/24/17. The
11
patient complained of pain.
3/27/2017 A nurse saw the patient at 1:15 pm. Vitals T 98; P 66; R 16; BP
140/88; weight 140. The patient had no complaints.

Vitals were dated, the nurse needed to refer to a doctor
for pain management.

3/27/2017 A nurse saw the patient at 3:39 pm. Vitals were identical to
two hours before.

Dated vitals used.

260

11

Dated vitals used
Dated vitals used.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 261 of 431 PageID #:12459
Patient #20
3/28/2017 A nurse saw the patient who complained of abdominal pain.
11, 16 The nurse needed to call a provider and dated vitals
The vitals were identical to 3/27/17. The pain was not
were used.
addressed.
3/29/2017 A nurse saw the patient who complained of abdominal pain.
11, 16 The nurse needed to call a provider and dated vitals
The vitals were identical to 3/27/17.
were used.
3/30/2017 A doctor saw the patient at 1:27 pm. The vitals were identical 1, 3, 11 It is hard to believe that the patient, who had
to 3/27/17. The doctor wrote "Saw GI who mentioned about
complained of pain to a consultant and to nurses six
times over the past two weeks was pain free. The pain
biopsy and planned to change plastic biliary to metallic stent."
plan was not addressing the pain. The vital signs were
The doctor did not document review of the report. The doctor
dated.
documented without taking a pain history that the pain was
controlled with Tylenol #3. The doctor documented she would
discuss a biopsy and replacement of the stent at collegial
review.
3/30/2017 A nurse saw the patient at 10:01 pm and the patient said that
"My back and stomach have been hurting all day." The vitals
were identical to 3/27/17.
3/30/2017 A doctor referred the patient for an ERCP for biliary stent
exchange and a follow up GI appointment.
3/31/2017 A nurse saw the patient. The vitals were identical to 3/27/17.
The patient asked for pain medication.
3/31/2017 Albumin 2.3; total protein 5.7 (6-8); CA 19-9 564 (0-37).
4/1/2017 The patient complained of pain all over. The vital signs were
identical to 3/27/17. The nurse gave pain meds as ordered
but did not discuss the pain with the doctor.

11, 16 The nurse needed to call a provider and dated vitals
were used.

4/2/2017 A nurse documented the patient saying "I am doing OK only
have belly pain I always have it." The vital signs were identical
to 3/27/17.
4/3/2017 A nurse documented temperature of 98.1; P 75; R 18; BP
123/86 with a weight of 144.

11, 16 The nurse needed to call a provider and dated vitals
were used.

261

11, 16 The nurse needed to call a provider and dated vitals
were used.
11, 16 The nurse needed to call a provider and dated vitals
were used.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 262 of 431 PageID #:12460
Patient #20
4/4/2017 The nurse documented that the patient said, "I just have the
back pain and pressure like I always do nothing new to me."
The vital signs were identical to 4/3/17. The nurse took no
action.
4/5/2017 A doctor saw the patient. The vital signs were identical to
1, 11, 12
4/3/17. Without much history the doctor wrote "Pain is fair
controlled with Tylenol #3." The albumin was 2.3. The doctor
noted that GI was going to change stents and that the patient
had no metastases.

The doctor used dated vital signs for an evaluation. The
pain history was not consistent with the patient's
ongoing complaints of pain to nurses. The doctor failed
to refer to assess nutritional status. The delay in
evaluation was significant.

4/5/2017 An ERCP and biopsy were approved by Wexford.
4/6/2017 A nurse saw the patient. The vital signs were identical to
11, 16 The nurse needed to call a provider and dated vitals
4/3/17. The patient stated, "just the same old aches and pains
were used.
in my stomach."
4/7/2017 A nurse saw the patient. The vital signs were identical to
11
Vital signs were dated.
4/3/17.
4/7/2017 A doctor prescribed Tylenol #3 1 tab BID for a month.
4/8/2017 A nurse saw the patient. The vital signs were identical to
11
Vital signs were dated.
4/3/17.
4/9/2017 A nurse documented that the patient had stomach pain. The
11, 16 The nurse needed to call a provider and dated vitals
vital signs were identical to 4/3/17. No action was taken.
were used.
4/10/2017 A nurse documented T 97.8; P 81; R 16; BP 139/103; weight
142.
4/11/2017 A nurse documented that her stomach hurt "like it always
does." The vital signs were identical to 4/10/17. No action
was taken.
4/12/2017 A nurse documented identical vitals from 4/10/17.
4/13/2017 A nurse documented identical vitals from 4/10/17.

262

11, 16 The nurse needed to call a provider and dated vitals
were used.
11
11

Vital signs were dated.
Vital signs were dated.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 263 of 431 PageID #:12461
Patient #20
4/13/2017 A doctor saw the patient. The vitals were identical to 4/10/17. 1, 2, 3
The Tylenol #3 was causing constipation and the doctor
decreased the dose to TID. The patient was documented as
anicteric. There was no change to the plan except the
decrease of pain medication.
4/14/2017 A nurse documented identical vitals from 4/10/17. The
patient apparently was to go offsite for a FNA biopsy and
biliary stent exchange.
4/14/2017 At 9:24 pm a nurse documented T 87.5; P 81; R 16; and BP
16
93/65. The nurse took no action regarding the low blood
pressure. The weight was 142 pounds.
4/14/2017 A doctor prescribed Tylenol # 3 one tab TID for two months.

Given complaints of pain to nurses, a decrease in pain
medication seemed cruel. The doctor did not appear to
appreciate the degree of pain the patient was in and
didn't assess for this.

4/16/2017 A nurse noted that the patient complained that the
medications weren't working and she was having
breakthrough pain. The vitals were identical to 4/14/17.
Remarkably, the nurse wrote to continue the current orders
and did not talk to a physician.
4/17/2017 A nurse documented that the patient was having discomfort in
her abdomen and had nausea and vomiting "this weekend."
The T 97.9; P 95; R 14; BP 128/74 and weight 128 pounds.

16

The nurse should have called a provider.

16

The nurse should have called a provider.

4/17/2017 Albumin 2.9; BUN 5; potassium 3.1 (3.5-5.3).
4/18/2017 A nurse saw the patient, who complained that she had
11, 19, 8
vomited twice since the night before. The patient couldn't eat
without pain. The nurse remarkably used the identical vitals
since the day before even though the patient had been
vomiting. The patient had diarrhea, vomiting, and wasn't
eating. The nurse told a doctor about the vomiting and weight
loss.

263

The nurse should have called a provider.

Dated vitals used. Apparently the doctor didn't evaluate
the patient for diarrhea, vomiting, and not eating. This
was indifferent, as the doctor was ignoring serious
medical conditions. Laboratory tests should have been
ordered due to the vomiting to assess for dehydration.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 264 of 431 PageID #:12462
Patient #20
4/19/2017 A nurse saw the patient. The vital signs were identical to
4/17/17. The nurse documented that the patient couldn't
move without pain and that if she ate she vomited the food.
Remarkably, though in the narrative note, the nurse
documented that "increased rate of respirations noted" even
though the vital signs documented were identical to 4/17/17
and the respiratory rate was 14, which is normal.

11, 16, 8 The nurse used dated vitals and failed to call a physician
for serious medical conditions. Labs should have been
ordered because of the vomiting.

4/19/2017 At 10:01 pm a nurse documented that the patient was having 11, 16, 8 The patient had a serious event and the nurse used
"foul smelling vomiting." The nurse noted that a doctor saw
dated vitals. The nurse should have consulted a doctor
the patient and that mag citrate and Zofran were ordered.
and labs should have been ordered.
The vitals were identical to the vitals from 4/17/17.
4/19/2017 At 11:31 pm a doctor documented a note. The patient
11, 14, 8
complained of vomiting since her procedure 4-5 days ago. The
doctor noted identical vitals to 4/10/17. The doctor reviewed
labs from 4/18/17. The potassium was 3.1.; the alkaline
phosphatase was 300; albumin 2.9. The BUN was not given.
The doctor documented that the stent "exchange was
attempted but unsuccessful per verbal report 4/14/17." The
doctor ordered a CMP and advised to decrease narcotics until
symptoms improve. Zofran was ordered along with an
abdominal x-ray.

4/20/2017 At 5:11 pm a nurse saw the patient. The patient hadn't been
seen since the night before. The vital signs were identical to
the 4/10/17 note. The patient had significant pain and
couldn't eat or drink.

There was no report from the GI consultant. The
patient had four days of vomiting with abnormal labs
from the day before. The patient was in pain yet the
doctor discontinued pain medication. The doctor did not
attempt to obtain orthostatic vitals to assess for
dehydration. Under these circumstances admission to a
hospital was indicated. Instead, the doctor stopped
pain medication, ordered an antiemetic, and an
abdominal x-ray. Intravenous fluid was indicated as the
patient was unable to take by mouth. The doctor
should have ordered labs. Care was grossly and
flagrantly unacceptable.

11, 16, 8 The nurse used dated vitals and failed to call a physician
for serious medical conditions. Labs should have been
ordered due to not eating.

264

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 265 of 431 PageID #:12463
Patient #20
4/20/2017 At 11:04 a nurse saw the patient. The vital signs were
11, 16, 8 The nurse used dated vitals and failed to call a physician
identical to the 4/10/17 note. The nurse noted that the
for serious medical conditions. Labs should have been
patient vomited 200 cc. There was no assessment or consult
ordered due to vomiting.
with a doctor. At 11:05 a nurse wrote a second note using the
same vital signs. The nurse documented the patient saying
that the patient was "25." There was no assessment or plan.
4/21/2017 A doctor prescribed 15 mg morphine every six hours.
4/21/2017 A doctor saw the patient. The vitals were identical to 4/10/17.
The doctor told the patient that the biopsy showed
adenocarcinoma. This diagnosis was five months after
incarceration. The patient was sad and crying. The patient
had a June out date. She had two sons and 15 grandchildren.
The patient was agreeable to stronger pain medication. The
doctor documented that she would assist the patient with
application for compassionate release and consult the
oncologist for prognosis and would maximize pain
management. But the pain medication order was not in this
note and it was unclear what maximize pain management
meant. The doctor did not order additional pain medication.

11, 8

The doctor evaluated the patient but used dated vitals.
The doctor started morphine only after obtaining a
diagnosis. There was no therapeutic plan for this
patient. Due to the recent vomiting labs should have
been ordered.

4/21/2017 A nurse saw the patient. The vital signs were identical to the
4/10/17 note. The patient was now on a fentanyl patchy
which was "helping with the pain." The patient had
constipation. The patient was given Miralax.
4/21/2017 Albumin 3.4; potassium 2.9 (3.5-5.3); alk phos 239.
4/21/2017 A morphine fentanyl patch was prescribed for four days.
4/21/2017 A doctor prescribed 0.5 mg morphine QID at 11:09 am.
4/21/2017 A doctor prescribed 5 mg morphine QID at 11:16 am.

3

265

This is an extremely low dose. The morphine should
have been titrated to the patient's pain.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 266 of 431 PageID #:12464
Patient #20
4/21/2017 The MAR showed that the patient received a single fentanyl
patch on 4/21/17. This was good for 72 hours. The
medication was discontinued on 4/24/17.
4/22/2017 A doctor wrote a note that the hypokalemia was worse from
3.1 to 2.9 and that the patient was refusing potassium
supplementation. The doctor wrote that she was unable to
enter orders since the computer was locked by the nurse. The
nurse left the infirmary and the computer was unable to be
used.
4/22/2017 An LPN saw the patient. The patient was able to sleep a little
since the fentanyl patch. The patient wasn't eating. The
patient said the fentanyl patch was helping quite a bit. The
patient was able to tolerate liquid Boost.
4/22/2017 Morphine was prescribed 15 mg Q 6 hours but this was
stopped on 4/24/17.
4/22/2017 A MAR showed the patient received one day of 15 mg
morphine every six hours.
4/23/2017 A nurse saw the patient. The vitals were identical to 4/10/17.
The patient still had pain despite the fentanyl patch.
4/23/2017 A nurse noted that the patient wasn't talking much and the
patient was very weak. The vitals were identical to 4/10/17.
At 2:48 pm the patient was sent to a hospital. It wasn't clear
why.
4/23/2017 At 10:16 pm a nurse noted that the patient returned from the
hospital and ordered to discontinue the patch. The
temperature was 93.6; pulse 120; BP 122/96. The assessment
was hypotension although the blood pressure was not low.

266

11

To have an electronic medical record that locks because
another individual is using it is unacceptable.

11

Vitals were dated, the nurse needed to refer to a doctor
for pain management.

11

Vitals were dated.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 267 of 431 PageID #:12465
Patient #20
4/23/2017 The patient was sent to a hospital. The discharge diagnoses
were hypokalemia, cancer pain, and dehydration.

4

4/24/2017 A nurse documented identical vitals from the day before. The
patient was too weak to sit up. The patient wasn't speaking
and only nodded her head in response to questions. Tylenol
#3 was given for pain.
4/24/2017 At 1:02 pm the patient told a nurse "I need more pain meds I
hurt so bad." The blood pressure was 84/52. The patient
vomited. Morphine was crushed and given in pudding but the
patient vomited after eating. An IV was started and Zofran
was given IV.
4/24/2017 At 6:38 pm a doctor saw the patient. The vitals from 1:00 pm
were used on the note. The patient was now on morphine
sulfate 10 mg every two hours. Family had come for a visit.
The doctor added lorazepam every two hours.

4

4/24/2017 A nurse saw the patient at 11:41 pm and noted identical vital
signs from early that day.
4/24/2017 Morphine sulphate was ordered 10 mg every four hours at
3:44 pm.
4/24/2017 Morphine sulphate was ordered 10 mg every two hours at
6:12 pm.
4/24/2017 Lorazepam 2 mg IM was ordered every two hours for seven
days at 12:55 pm.

4/24/2017 Lorazepam 2 mg IV push every two hours was ordered for
three days. The order was at 6:52.

267

14

4

Given dehydration and hypokalemia, it is clear that
providers at the facility were not appropriately
monitoring the patient's condition. She had vomiting
and did not have laboratory monitoring to assess
whether the vomiting was affecting her electrolyte
status.
The patient needed to be on a stronger narcotic.

The facility was unable to care for this patient who
needed skilled nursing care and a doctor who
understood pain management and end-stage cancer
management. She needed transfer to a higher level of
care.
The patient was placed on palliative sedation with
morphine and lorazepam but it wasn't clear that the
patient was involved in the decision and should have
been.

11

Vital signs were identical

4

This was an extraordinary dose of lorazepam
intravenously. This was clearly palliative sedation and
needed to be discussed with the family and patient, but
it wasn't clear that this occurred.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 268 of 431 PageID #:12466
Patient #20
4/24/2017 A doctor prescribed morphine 10 mg every 2 hours PRN and
lorazepam 2 mg IV every two hours.
4/24/2017 A doctor prescribed .25 mg morphine every six hours. This
was discontinued the same day.
4/24/2017 A doctor prescribed 5 mg morphine every six hours.
4/25/2017 Just after midnight a nurse noted identical vital signs from the
day before. Ativan was given IV.
4/25/2017 At 3:45 am a nurse saw the patient. The vital signs were
identical to the day before. Ativan was being given every two
hours. At 7:00 am the patient was lethargic. Vital signs
continued to be from the day before. At 3:54 pm the patient
expired.

268

11

Vital signs were identical.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 269 of 431 PageID #:12467
Patient #21
11/2/2011 Annual health examination documents prostate cancer, DM,
and HTN as problems. The weight was 174. Refused rectal
examination.
6/26/2012 EKG showing NSR but looks like flat ST segment in lateral
leads.
10/23/2013 Annual health examination documents prostate cancer, DM,
and HTN as problems. The weight was 194. Rectal
examination deferred.
2/4/2014 PSA 10.9 (0-3.9).
3/4/2014 Microalbumin 7 (0-30); glucose 121; A1c 6.1; total cholesterol
181; TG 101; HDL 40; LDL 121; TSH 0.73; creatinine 1.02.
5/13/2014 PSA 2.4; creatinine 0.89.
8/4/2014 A doctor saw the patient in diabetes and HTN chronic clinics.
The weight was 174 pounds. The blood pressure was difficult
to read but appeared to be 131/84. The doctor noted that the
LDL was 121 and the most recent A1c was 5.6. The doctor
took no history and did not address what medications the
patient was taking except to note that the patient had a
current prescription for Lopressor until 1/25/15. The doctor
assessed the patient in good diabetic control. The doctor did
not address apparent weight loss of 20 pounds since the 2013
annual exam. The diabetic medication apparently was
discontinued in July but no mention was made of this. The
doctor did not check recent CBGs . The recent A1c was about
the time the medication was discontinued. The doctor did not
order any follow up. The patient had a 44% 10-year risk of
heart disease and stroke yet was not placed on a statin drug.

11/4/2014 PSA 8.7; creatinine 0.89.

269

1, 17

The history was poor. The plan did not include use of a
statin despite high risk. Weight loss was not evaluated.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 270 of 431 PageID #:12468
Patient #21
12/30/2014 A doctor saw the patient for diabetes and HTN chronic clinics.
The weight was 182. The BP was 131/70. The doctor took no
history. He noted the recent LDL of 121 and A1c of 5.5. Only a
brief examination was done. The only assessment was good
hypertension and diabetes control. The doctor didn't discuss
medications. Apparently diabetic medication was
discontinued in July but the doctor didn't mention this.

1, 17

The history was poor. The plan did not include use of a
statin despite high risk. Weight loss was not evaluated.

3/3/2015 Microalbumin 34; A1c 6.5; cholesterol 199; TG 131; HDL 43;
LDL 130; PSA 1.4; testosterone 23 (300-720); creatinine 0.9.
3/10/2015 EKG showing sinus rhythm with moderate ST depression.
3/17/2015 BUN 21; PSA 1; testosterone 20.
4/17/2015 A NP saw the patient for diabetes and HTN chronic clinics. The
BP was 120/70. The weight was 192. The NP noted a recent
LDL of 130 with cholesterol 199 and HDL 43. The NP noted
that medication for diabetes had been discontinued on
7/15/14. The NP noted that the patient was on Lopressor and
ASA but did not mention a statin drug.
7/5/2015 A nurse evaluated the patient for generalized weakness. The
weight was 193.
7/13/2015 A1c 8.3.
7/31/2015 A nurse saw the patient for medication refill. The weight was
189.

270

3, 6, 17 The patient had a recent EKG with ST depression and
high cardiovascular risk but these were unnoticed. The
patient had a 39% 10-year risk of heart disease or stroke
and should have been offered high intensity statin.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 271 of 431 PageID #:12469
Patient #21
8/20/2015 A doctor saw the patient for diabetes and HTN chronic clinics.
The weight was 187. The blood pressure 128/64. The doctor
took no history. The doctor did note that the recent LDL was
130 and A1c was 8.3. The doctor noted that the patient was
taking HCTZ, Lopressor ASA and metformin 1000 mg BID. At
the last chronic disease clinic the patient had been on no
diabetes medication. The doctor started glipizide 5 mg daily .
The doctor did not address the lipids.
8/28/2015 A1c 7.9; cholesterol 172; TG 145; HDL 34; LDL 105; creatinine
0.9.
9/1/2015 Hepatitis C negative; cholesterol 168; TG 129; HDL 37; LDL
109.
9/22/2015 PSA 3.4.
10/23/2015 Annual health examination documents HTN, DM, prostate
cancer, and blindness in L eye. Weight is 182.8. No offer of
rectal examination.
11/3/2015 A1c 5.7; creatinine 0.79.
12/6/2015 A doctor saw the patient for diabetes and HTN chronic clinics.
The BP was 138/72, recent LD 109; and recent A1c 5.7. The
doctor took no history and did a brief exam and continued
HCTZ, ASA, Lopressor, metformin, and glipizide.
1/6/2016 A clerk documented that the patient was presented to
collegial review for an oncology follow up.
1/7/2016 PSA 3.3; creatinine 0.96; hemoglobin 14.3.
1/12/2016 A doctor noted that the patient returned from Lupron
injection. There was no history, exam, review of the report,
discussion of the status of the patient or discussion with the
patient.

271

1, 17

7

1, 17

10

The patient had high cardiovascular risk but these were
unnoticed. The patient had a 39% 10-year risk of heart
disease or stroke and should have been offered high
intensity statin. The NP should have taken a history of
chest pain or angina equivalents.

Colorectal screening was not offered.

The patient had a 10-year risk of heart disease or stroke
of 47% and should have been offered a statin drug. The
doctor did not ask about any problems with the new
diabetic medication.

The doctor didn't follow up appropriately after the
consultation. The report wasn't reviewed and the
doctor didn't discuss with the patient.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 272 of 431 PageID #:12470
Patient #21
1/17/2016 The patient complained of weakness and being wore out. The
patient complained of night sweats but no weight loss. The
weight was 186 pounds. The nurse took no action except to
give the patient allergy medication and cough syrup even
though the patient did not complain of upper respiratory
symptoms.
2/4/2016 A doctor saw the patient for shortness of breath. The patient
weighed 181. The note was mostly illegible. The doctor
appears to have diagnosed upper respiratory infection and
bronchitis and prescribed amoxicillin for 10 days with an as
needed follow up.
3/13/2016 The patient saw a nurse for a complaint of abdominal pain.
The weight was 179. The patient thought he had possible
blood in his stool. The patient complained also of weakness.
The nurse referred the patient to a physician.
3/16/2016 A clerk documented that the patient was presented to
collegial for an oncology follow up.
3/16/2016 A doctor wrote a brief note stating that the patient had
abdominal pain and constipation. The doctor noted that the
patient was moving his bowel and that there was no bright red
blood. The doctor noted that the patient refused a rectal
exam. There was no other history or examination. The doctor
ordered milk of magnesia and stool softener but no other
diagnostic tests. The doctor did not ask about ability to eat or
identify whether the patient lost weight.
4/5/2016 Cholesterol 191; TG 114; HDL 42; LDL 126; creatinine 0.91.
5/19/2016 The patient went to the oncology follow up appointment.

272

7

The patient had blood in his stool but since there was no
active bleeding the doctor took no action. The patient
was 72 years old and had abdominal pain and blood per
rectum and should have had a colonoscopy.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 273 of 431 PageID #:12471
Patient #21
5/19/2016 A nurse saw the patient after his oncology appointment. The
blood pressure was 160/90.
5/25/2016 A NP saw the patient post-oncology visit. The NP documented
review of the oncology notes and started antibiotics as
recommended by the oncologist.
6/20/2016 A nurse saw the patient for upper respiratory symptoms. The
patient had a cough. The nurse documented a weight of
174.8. The nurse failed to notice the weight loss. The nurse
gave the patient CTM and ibuprofen by protocol without
referral.
7/3/2016 A nurse saw the patient for abdominal pain. The patient
described "occ constant pain" which seems inherently
contradictory. The patient said he had the pain for several
weeks. The weight was 177 pounds. The nurse referred the
patient to a provider.
7/6/2016 A1c 5.3; creatinine 0.92.
7/14/2016 A doctor saw the patient and wrote an extremely brief note.
The doctor wrote that the patient had "burning sensation
upper abd R>L postprandial." That was the entire history.
The doctor did not obtain a weight, determine the quality or
intensity of pain, determine whether the patient was able to
eat normal, had diarrhea, or constipation. The history was
inadequate. There was no assessment or differential. The
doctor stopped Pepcid and started Prilosec with a follow up in
two weeks.

273

16

The patient had respiratory symptoms for several
months with cough. The nurse should have consulted a
physician.

1, 2, 7 The history and evaluation were inadequate. The
patient had abdominal pain for five months. Without
adequate evaluation the doctor ordered an anti-acid
medication. Due to age, prior blood per rectum, and
abdominal pain for five months, colonoscopy was
indicated.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 274 of 431 PageID #:12472
Patient #21
7/29/2016 A NP saw the patient in follow up for the abdominal pain. The
only history was that the patient had recently been started on
Prilosec and was "some" better but the patient still had pain.
The NP documented that the patient had normal bowel
movements. The NP exam was that the abdomen was firm,
with "sluggish" bowel sounds. Based on this limited history
the NP diagnosed "?ulcer" and ordered a KUB with follow up
in two weeks. The blood pressure was 148/80, but the NP did
not address this.

1, 7, 8 The history was inadequate. The severity and duration
of pain was not obtained. Associated symptoms were
not obtained. Precipitants, quality, temporal elements,
and radiation were not obtained. The physical
examination was extremely brief. No laboratory tests
were ordered. A KUB was ordered but this would
unlikely be of clinical value with the patient's complaint.
The NP failed to establish an appropriate treatment plan
and failed to obtain appropriate laboratory tests (CBC,
CMP) or colonoscopy.

8/19/2016 An NP saw the patient. The blood pressure was 170/90. The
weight was not taken. The NP noted that there was no x-ray
report yet. The film had been done on 8/8/16. The NP took
no history regarding the patient's symptoms. The only
examination was to state "abd soft - No reddened skin." The
NP ordered no follow up without even asking if the patient still
had symptoms. The weight wasn't checked. The NP did ask
that the blood pressure be checked twice a week for two
weeks.

3, 15

The NP failed to modify BP meds despite significant
elevation of blood pressure. The NP failed to follow up
on the abdominal pain which the patient had for over
five months and didn't order follow up despite not
reviewing the x-ray.

16

The CMT should have called a doctor as the patient had
a serious condition beyond the scope of practice of a
CMT to address.

8/26/2016 A CMT noted that the patient's BP had four blood pressure
checks including: 146/74; 150/82; 138/84; and 144/76. All of
these were not at goal for a diabetic except for one.
8/29/2016 A CMT BP was 148/78.
9/2/2016 A CMT saw the patient for a dry cough and shortness of breath
for 5-6 days. The weight was 174. The nurse used an upper
respiratory protocol and identified no problems. The nurse
gave the patient over-the-counter medication and sent the
patient back to his unit.

274

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 275 of 431 PageID #:12473
Patient #21
10/5/2016 A CMT saw the patient for weakness, fatigue and cough. The
16
patient weighed 172 pounds. The blood pressure was 150/80.
The patient complained of shortness of breath. The patient
had weight loss, fatigue, and weakness. He also had prior
abdominal pain that was not worked up and the nurse didn't
ask about this. The CMT gave the patient Tylenol with no
referral.
10/30/2016 A NP saw the patient for weight loss. The patient weighed 160 1, 2, 3
pounds. The blood pressure was 140/74. The only NP history
was that that patient lost weight. The only physical
examination was that the patient could walk to the scale, had
a soft abdomen and clear lungs. The assessment was weight
loss. The NP plan was to give the patient a lay in permit with a
slow walk permit. The NP ordered weekly weights for three
months and ordered CMP, CBC and UA with another KUB and
chest x-ray.
11/3/2016 X-ray showing punctate density over lower pole of left kidney
likely representing a stone. US recommended.
11/3/2016 Microalbumin 79; BUN 24 (0-20); sodium 134; creatinine 1.31
(0.5-1.5); A1c 5.6 (4-6); hemoglobin 12.3 (13.2-18).
11/3/2016 An NP wrote that the patient presented to the ER with
abdominal pain with 12 pound weight loss over the past
month. The NP noted that the recent KUB showed stool. The
NP sent the patient to a hospital for right lower quadrant pain.

275

The CMT should have consulted a provider.

The NP took inadequate history and made an
inadequate assessment. The patient had recent
shortness of breath and more remotely abdominal pain
which were not considered. Abdominal x-ray is unlikely
to be useful in an evaluation of weight loss.
Colonoscopy was indicated. CT of the abdomen should
have been considered. The other labs and chest film
were appropriate.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 276 of 431 PageID #:12474
Patient #21
11/3/2016 An incident report documents that the inmate was sent to
Chester Memorial Hospital. There was a CT scan report which
documented a large retroperitoneal mass suspicious for
lymphoma. The hospital documented speaking with Dr.
Siddiqui who in coordination with Dr. Trost and the NP would
coordinate further care.
11/3/2016 A NP noted that the patient returned from the hospital and
had an abdominal mass. The NP sent the patient back to his
cell and ordered a follow up with a doctor on 11/7/16. The
patient's weight was 152 pounds. The NP didn't ask the
patient whether he was eating or about any symptoms.
11/7/2016 The weight was listed as 153.6.
11/8/2016 Security did not bring the patient for his physician follow up
appointment.
11/9/2016 A clerk documented that the patient was to be presented at
collegial for his oncology follow up for his prostate cancer.
Wexford UM cancelled the collegial call for the week. UM was
going to make a decision on their own.

11

Patients should be transported for their appointments.

11/11/2016 An NP saw the patient. The weight was 149 pounds. The NP
10, 11 Follow up of the hospital report was not done because
noted that the patient was scheduled for a follow up of an
there was no report. The NP did not address the weight
offsite visit from Memorial Hospital. The NP noted that there
loss.
were no notes from the hospital in the chart yet. The NP noted
that the patient could walk to the scale and get up out of the
chair and had a good BM after taking magnesium citrate. That
was the extent of the examination. The NP documented that
labs were pending from the hospital. The NP noted that the
patient was to follow up with the doctor.
11/14/2016 A CMT took a weight of 148.2 pounds.

276

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Patient #21
11/17/2016 A doctor saw the patient and the patient was anorexic and felt
weak. The doctor noted that the patient lost 26 pounds over
the past three months. The doctor documented that the CT
scan was noted. There was no history, no evaluation as to
whether the patient was able to function on his housing unit,
whether he was able to eat, or whether he needed a higher
level of care. There was no assessment. The only plan was a
collegial referral to oncology. The weight was 146 pounds.
The patient had lost six pounds over the past two weeks and
should have been considered for infirmary care and had an
expedited evaluation for biopsy.
11/21/2016 The patient was seen at Illinois Oncology Inst for his six month
follow up of prostate cancer. They noted that the patient had
been increasingly fatigued over the past few months and was
only able to walk seven feet before getting fatigue. He had
constipation and only had one BM a week and was drinking
only 20 ounces of water a day. He had low back and
abdominal pain intermittently. They noted that a recent CT
scan showed a large mass in his abdomen. They described the
mass as 10.7 by 9.9 cm in the upper abdomen extending into
the right renal bed and retroperitoneum involving the
periaortic lymph node region with right hydronephrosis. They
recommended a CT guided biopsy ASAP or in the next two
weeks to test for non-Hodgkin's lymphoma. They also
recommended a CT of the brain ASAP. They noted "if his
physical condition deteriorates at the correctional center, I do
recommend transfer him to the infirmary and start him on IV
fluid." They also recommended a three week follow up.

277

1, 3, 8 The doctor took no history and failed to establish a plan
that protected the patient and addressed his needs.
Nutritional status was not obtained. It wasn't clear
whether the patient could function in population. The
doctor ordered no labs to determine the metabolic
status of the patient.

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Patient #21
11/21/2016 An NP noted that the patient returned from oncology. The NP 10, 11, The NP failed to review the oncology notes for a biopsy
documented that orders were noted and that paperwork was
14
and CT brain. The NP also failed to appreciate the note
sent to med furlough. It wasn't clear what this meant. The NP
about hydration and infirmary placement.
ordered a follow up in five days, allopurinol, Pepcid,
dexamethasone, Reglan, ensure, and senakot. The patient
should have been placed on the infirmary.
11/26/2016 An NP documented that the patient was being seen for
medical furlough return. The weight was 141.6. The NP took
no history and noted that the patient appeared pale. There
was no exam except to note that bowel sounds were
hypoactive. The NP ordered a CBC, CMP and two week follow
up. There was no mention of the CT findings.
11/28/2016 A CMT took the weekly weight, which was 141.2. No action
was taken.
11/30/2016 BUN 28; sodium 134; creatinine 2.06; albumin 3.7;
hemoglobin 12.1; platelets 287.

278

10, 11, The NP failed to review the oncology notes for a biopsy.
14
The NP also failed to appreciate the note about
hydration and infirmary placement. It appeared that
the patient may have had a CT of the brain but there
was no report and it wasn't clear what happened.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 279 of 431 PageID #:12477
Patient #21
12/3/2016 A nurse practitioner saw the patient for a quarterly chronic
1, 3, 6,
clinic for diabetes and hypertension. The weight was 132. The
10
nurse noted that the recent A1c was 5.6 and was improved.
The NP noted that the patient was in good control and
decreased glipizide to 2.5 mg daily from 5 mg daily and
metformin to 500 BID from a gram BID. The NP made no
mention of the significant weight loss and did not address the
retroperitoneal mass. With respect to hypertension clinic, the
blood pressure was 110/70. The NP noted that recent LDL
was 126. The NP noted keeping the patient on Lopressor 25;
HCTZ 25; and ASA 81 daily. The NP did not address the
elevated cholesterol. More critically, the NP made no mention
of the significant retroperitoneal mass which had not yet been
biopsied.

279

The NP failed to take adequate history or review the
oncology notes. As a result, the plan was inadequate.
Based on recent labs which were not reviewed, the
patient appeared mildly dehydrated and had worsening
kidney function and had persistent anemia, which were
unnoticed.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 280 of 431 PageID #:12478
Patient #21
12/3/2016 An NP saw the patient. The weight was 132. The NP noted
that the patient had a recent oncology visit. The NP noted that
the patient had a 15-20 pound weight loss, had poor appetite.
The NP noted that the diabetic medication had been
decreased and that the A1c was now 5.6. The NP took no
other history, did not determine whether it was safe to be in
general population and made no effort to determine why the
patient was losing so much weight. The NP documented that
the patient was to follow up with a doctor "regarding code
status - and inmate's concern of life /death options." This was
remarkable given that a diagnosis had yet to be made. There
was no concern about the urgency of the diagnosis. The NP
ordered a CBC, CMP, UA, vitamin D level, A1c and decreased
the glipizide to 2.5 mg daily, continuing the metformin at 500
BID. The NP wrote "referral Dr Trost - code status (CANCER)."
Remarkably, the NP did not initiate any diagnosis and was
presuming it was a cancer.

12/3/2016 A CMT took a weight of 139.2.
12/5/2016 A CMT documented that the patient felt better. The CMT
documented that the patient was to be starting on ensure.
The weight was documented as 146.6.
12/5/2016 A doctor saw the patient but the note was extremely brief.
The doctor noted that the patient had anorexia, was weak,
and had lost 50 pounds. The doctor noted no nausea or
vomiting or abdominal pain. The only plan was to issue
permits. The doctor noted that the patient was to go out soon
for oncology.

280

7, 14

10

The NP was more concerned about code status than
about getting a necessary biopsy of an abdominal mass.
The delay in biopsy was significant and unnecessary.
The patient should have been considered for a higher
level of care (infirmary).

The doctor failed to review the oncology note or
recommendations.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 281 of 431 PageID #:12479
Patient #21
12/5/2016 A doctor referred the patient for a CT of the brain and CT
guided biopsy. There was an approval for a CT of the brain
and another approval for a CT guided biopsy, both dated
12/5/16.
12/8/2016 A doctor presented the patient to collegial for oncology follow
up. Wexford UM cancelled the collegial call and the note by
the clerk documented that UM would make the decision on
this case.
12/14/2016 A clerk documented that the patient was approved for
oncology follow up as authorization # 465355597.
12/15/2016 A doctor saw the patient and noted GERD symptoms. The
1, 2
weight was 138 pounds. The doctor performed no
examination and took to history except for GERD symptoms.
The doctor noted that the patient was to go out for a CT scan
and biopsy of the mass. The doctor ordered two cans of Boost
for six months.
12/28/2016 A nurse saw the patient, who said that he was unable to
14, 19
urinate except to dribble. The patient needed to be taken to
the health care unit in a wheelchair. The nurse noted that the
patient had 3+ leg edema and had a stage II pressure ulcer on
his hip. The nurse placed the patient on the doctor's sick call
for 12/29/16. This patient should have been seen that day.
12/29/2016 A doctor saw the patient, who weighed 150 pounds. The
doctor noted that the patient had an ulcer on his hip. Much of
the note was illegible. The doctor ordered a UA, Flomax, with
a follow up in two weeks. The patient was getting edema but
this wasn't evaluated. The doctor did not admit the patient to
the infirmary even though the patient was clearly unable to
care for himself to the extent of developing a decubitus ulcer.
This was neglect.

281

The history and exam were inadequate. The doctor
didn't determine whether the abdominal mass might be
the cause of the symptoms.

A doctor should have seen the patient. The patient
clearly couldn't care for himself in general population
and was debilitated. He needed to see a doctor and
needed higher level of housing, neither of which
occurred.

1, 2, 3 Care was grossly and flagrantly unacceptable. The
patient had serious problems and complications causing
debility and inability to care for himself, which were
ignored. This was indifferent care.

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Patient #21
12/30/2016 Creatinine 1.47 (0.5-1.5); albumin 3.3; AST 16; ALT 29; alk phos
113; hemoglobin 10.4; platelets 488; normochromic.
1/9/2017 The weight was 160. The large weight gain was likely fluid due
to edema but it appeared unrecognized except by a nurse.
1/23/2017 The weight was 162.
1/30/2017 The weight was 170.
2/2/2017 A nurse saw the patient for diarrhea that was reported to
16
medical staff by the patient's cellie. The patient had been
neglected and should have been on the infirmary. The LPN
noted a pulse of 113; BP 150/96. Remarkably, the nurse took
no action and did not refer the patient.
2/2/2017 A nurse admitted the patient to the infirmary as a chronic
patient based on decline in status based on security complaint.
The nurse documented a weight of 180, which was clearly
inaccurate. The BP was 152/94. The nurse noted 2-3+ edema
of both legs. The nurse did not document review of the
decubitus ulcer.
2/2/2017 An NP performed an admission note to the infirmary. The NP
1, 2, 3
noted decrease in activity of daily living functioning. The NP
did not take further history of what was problematic or what
the patient was unable to do or why this recent change in
status. The NP examination was significantly abnormal. The NP
only noted that the patient was unable to stand without
assistance, was oriented to person and place, but had a slow
response to knowing what time it was.
2/3/2017 A doctor saw the patient. The entire note was SOA No c/o's
confused ambulates OK P [plan] CPM [continue present
management].

282

The nurse should have consulted a physician.

It was remarkable that lay custody officers and the
nurse as opposed to a doctor recognized infirmary care
need. It speaks to the deficiency of the provider staff.

The NP failed to take adequate history, failed to
perform adequate exam, and did not establish a
reasonable therapeutic plan based on the patient's
condition.

1, 2, 3 There was inadequate history, physical examination, or
plan based on the patient's condition. Care was grossly
and flagrantly unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 283 of 431 PageID #:12481
Patient #21
2/4/2017 A nurse saw the patient and noted that the patient was
confused. The nurse wrote that the patient had altered
mental status but a physician did not evaluate the patient.

16, 19 The nurse should have consulted a physician. Confusion
is a significant finding and required immediate
attention.

2/5/2017 At midnight a nurse saw the patient, who was still confused.
The nurse noted that the patient was incontinent. Despite
this, the patient was not admitted to a hospital.

14, 16, The nurse did not consult a physician. A physician
19
needed to immediately evaluate the patient. The
patient needed to be hospitalized. None of these
happened. Care was grossly and flagrantly
unacceptable.
2/5/2017 At 4:15 am a nurse documented the patient stating "come on 14, 16, The patient appeared delirious. Instead of referring to a
doctor, the nurse referred to mental health. The patient
guys. Aw come on." The nurse noted that the patient was
19
apparently talking to people in his cell who weren't there. The
needed admission to a hospital. Care was grossly and
nurse noted that the patient was incoherent. The nurse
flagrantly unacceptable.
assessed alteration in thought process and referred the
patient to mental health without discussing the altered mental
status with a physician.
2/6/2017 A nurse noted that the patient was confused, incontinent, and
was scheduled to see mental health.
2/6/2017 At noon a nurse saw the patient, who was confused with 3+
edema of his legs. The nurse noted a wound on the hip. It
was not clear that there were orders for monitoring or
dressing this as the nurses did not mention the decubitus
ulcer.
2/7/2017 A nurse saw the patient who was still confused with 2-3+
edema. The nurse noted no wounds and apparently the
decubitus was not being evaluated.

283

14, 16, Altered mental status, edema in a patient with a known
19
abdominal mass should have prompted physician
evaluation and admission to a hospital, which did not
occur.
14, 16, Altered mental status, edema in a patient with a known
19
abdominal mass should have prompted physician
evaluation and admission to a hospital,which did not
occur.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 284 of 431 PageID #:12482
Patient #21
2/7/2017 A doctor noted that the patient was lethargic, confused, and
mumbling unintelligibly and had a superficial decubitus ulcer
on his hip. The doctor noted that the patient was having rapid
clinical decline and apparently ordered daily dressing changes.
The doctor took no action with this patient who had altered
mental status, new onset edema, decubitus ulcer, and
undiagnosed abdominal mass. Care was grossly and flagrantly
unacceptable.
2/7/2017 At 10:30 am a nurse cleaned the hip ulcer described as a three
and a half wide area with 1/2 inch deep.
2/7/2017 At 11:35 am the patient was described by a nurse as lethargic
with uneven respirations and tachycardia although vital signs
were not documented. The patient was sent to a hospital.

284

14

The plan of this doctor was incompetent. The patient
needed immediate hospitalization but was ignored.
Care was grossly and flagrantly unacceptable.

This speaks to the neglect of this patient.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 285 of 431 PageID #:12483
Patient #22
2/27/2013 The patient transferred to Menard from Pontiac. The patient
was on enalapril 20; Procardia XL 30; Lopressor 25; ASA.
5/1/2013 Total protein 8.2 (6-8).
6/19/2013 The patient was evaluated by a doctor referred by the
optometrist for an elevated blood glucose of 130. The doctor
failed to note that the patient had fever. The BP was 156/102
and the temperature 100.8. The doctor said that the patient
didn't take his blood pressure medication.

2

The doctor failed to note or evaluate an abnormal vital
sign.

6/19/2013 A1c 6.4.
6/26/2013 Diabetes and HTN chronic clinic; weight 255; temperature
99.4; BP 144/89; A1c 7.9; Procardia was increased to 60 mg.
7/3/2013 RN notes BP 160/98.
7/16/2013 BP 156/86.
7/18/2013 Annual examination weight 250 pounds. No identified
problems. Notably history of IV drug use, prostitution,
multiple partners, blood transfusions, and homosexual activity
were all checked "no." Although the patient did have
gonorrhea in 1986.
7/23/2013 BP 170/100.
7/26/2013 BP 160/98.
8/6/2013 A1c 6.4; WBC 1.8; HGB 13.5 (13.2-18); neutrophils 0.9 (1.37.5); lymphocytes 0.6 (1.3-4.2).
8/18/2013 Chronic clinic flowsheet documents a weight of 260.
8/19/2013 BP 146/84; weight 260; temperature 98.6; chronic clinic for
1, 2, 3, 6 The doctor failed to adjust medications for high blood
diabetes and HTN. No changes to medications. No review of
pressure. The doctor failed to review significantly
CBGs; most recent A1c 6.4.
abnormal white count of 1.8 and took no history and
failed to evaluate.
11/13/2013 A1c 6.1.

285

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 286 of 431 PageID #:12484
Patient #22
12/4/2013 Diabetes and HTN chronic clinic; weight 247; temperature
99.4; BP 126/88; Patient now on 90 of Procardia. A1c 6.1.
3/5/2014 Total protein 8.8 (6-8); A1c 6.2.
4/23/2014 Diabetes and HTN chronic clinics weight 238; BP 136/90; no
changes to medication.
7/2/2014 A1c 6.1.
8/1/2014 Diabetes HTN chronic clinics. BP 137/76 weight 240; 5 foot 10
inches. A1c 6.1. No changes made.
11/9/2014 A1c 6.1.
11/18/2014 CMT note documents weight 230 and BP 136/70.
1/8/2015 Diabetes HTN chronic clinics. BP 124/90 weight 240; most
recent A1c 6.1; no changes made.
3/20/2015 Total protein 8.6 (6-8); A1c 6.2.
5/25/2015 Diabetes HTN chronic clinics. BP 100/70; weight 240; A1c 6.2;
no changes made.
6/5/2015 Hepatitis A ab negative; hepatitis B core negative; hepatitis B
ab negative; hepatitis C antibody negative; total protein 8.1 (68).
7/17/2015 A1c 6.3.
9/5/2015 At 3:30 am an RN saw the patient, who was lying on floor
having urinated on himself. He was weak for the past 3-4 days
and said he thinks he ate some bad food. The pulse was 120;
temperature 103 and BP 146/90. The nurse called a doctor
who ordered stat CBC, CMP and UA; IV fluid and observation
on the infirmary.
9/5/2015 WBC 8.7; HGB 11.4; platelets 151; total protein 7.4 (6.6-8.7);
urine culture grew e Coli.

286

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Patient #22
9/8/2015 A doctor wrote a discharge note to the infirmary. The doctor
noted fever of unknown origin and the diagnosis was R/O
lupus. The patient had been treated with Septra but had an
unexplained fever and a facial rash. The plan was to work the
patient up for lupus or connective tissue disease. Notably
there was no history or physical examination for this
admission. A week follow up was ordered.

1, 2, 12 This was a 45 year old man. Incontinence was not
expected. The patient had anemia, prior leukopenia and
fever. The diagnosis of lupus had no basis. The patient
should have been referred to a infectious disease
specialist as the doctor appeared incapable of making a
diagnosis. In this population, HIV should have been
excluded. Care was grossly and flagrantly unacceptable.

9/16/2015 A nurse saw the patient. The temperature was 102.6, pulse
110, and BP 105/70. The nurse noted that the patient was
brought to the HCU with confusion, was incontinent and was
weak. The nurse referred to a doctor urgently.
9/16/2015 A doctor saw the patient because of mental status changes.
1, 2, 14
Remarkably the doctor took virtually no history. The only
examination was that the patient had warm dry skin and
apparently normal cranial nerves 1-7. The temperature was
104. The doctor assessed an E coli urinary tract infection and
ordered a chest x-ray, urine culture, blood culture, RPR, and
CBC. The doctor started levofloxacin. The patient should have
been admitted to a hospital.

The doctor took inadequate history, performed
inadequate physical examination, and the plan was
inadequate. The patient had confusion and fever and
should have been admitted to a hospital. He was 45
years old. Starting outpatient antibiotics in a confused
man with fever without a diagnosis was grossly and
flagrantly unacceptable care.

9/16/2015 A nurse practitioner wrote the admission note to the
infirmary. There was little history. The patient had fever of
102.6 with pulse 110.

The history was inadequate. The therapeutic plan for
fever was inadequate. The patient should have been
hospitalized.

287

1, 14

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 288 of 431 PageID #:12486
Patient #22
9/17/2015 The doctor discharged the patient on 9/17/15 without any
review of labs. There was no history and no physical
examination. The doctor noted that the patient was admitted
with UTI, fever, and dehydration. The doctor noted that IV
fluid was given with Levaquin. The doctor ordered a week
follow up and discharge diagnoses of UTI, fever, and ?lupus.
Yet the doctor did not order tests to evaluate for lupus. The
doctor did not note the discharge temperature

1, 2, 8, The history was inadequate. The therapeutic plan for
12
fever was inadequate. The evaluation was inadequate.
Additional labs should have been drawn to exclude
infections common in this population including HIV,
blood cultures should have been considered. The
patient's problems were beyond the expertise of this
physician and he should have referred the patient to an
ID expert.

9/17/2015 A doctor noted that the temperature was 103 but took little
1, 2, 12
history except that the patient was voiding. The doctor took
no relevant history and did not examine the patient; and
reviewed no labs stating that he believed the fevers were not
related to a UTI but possible lupus. The doctor noted that the
patient had fevers for "years." The doctor discharged the
patient without any evaluation. This patient should have been
referred to an infectious disease consultant as the physician
didn't know how to evaluate the patient. The doctor did not
evaluate any lab results.

This was incompetent. To presume that fever for years
was normal is incompetent. The history, examination,
and plan was inadequate and the patient's problem was
beyond the expertise of this doctor and he should have
referred to an ID specialist. Care was grossly and
flagrantly unacceptable.

9/17/2015 The patient had returned to his cell and was feeling so weak
he ate sitting on the floor. His pulse was 127 and temperature
102.8. The nurse sent the patient back to the infirmary for 23
hour observation.
9/17/2015 Chest x-ray negative.
9/17/2015 ANA none detected; creatinine 1.11 (0.5-1.5); total protein 7.7
(6-8); WBC 3.5 (3.9-12); HGB 10.9 (13.2-18); sedimentation
rate 88. There was no documentation by a provider of review
of these tests.

14

At this point the patient needed a higher level of care,
as the facility did not know how to manage his care.
Care was grossly and flagrantly unacceptable.

6

The patient had anemia and low white count with a
significantly elevated sedimentation rate but these were
not reviewed.

288

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 289 of 431 PageID #:12487
Patient #22
9/18/2015 A nurse noted that the patient felt better. The temperature
was 98.9 and BP 146/92 with P 70. The patient was kept on
the infirmary until 9/21/15 and was afebrile during that time.
9/18/2015 A doctor admitted the patient to the infirmary. There was no
history except that the patient was being admitted with high
fever. The only examination was that the patient was alert,
oriented, had clear lungs, and had a soft, non-tender
abdomen. The doctor remarkably ordered no diagnostic
studies yet the admitting diagnosis was UTI and "fever of
unknown origin; ? lupus."

1, 2, 8, The doctor failed to examine the patient appropriately
12, 14 for someone with unexplained fever. The doctor should
have ordered RF, HIV, blood cultures, Quantiferon test
or TB skin test, ANA, SPE, and obtained CT scans of the
abdomen and chest. Because of the altered mental
status a CT brain was indicated. The patient should
have been admitted to a hospital and/or referred to an
ID specialist. Care was grossly and flagrantly
unacceptable.

9/21/2015 A doctor wrote a note stating that the patient was afebrile for
72 hours. The only documented history was that the patient
had no complaints. There was no examination, no review of
laboratory tests and no orders for diagnostic studies. The
doctor discharged the patient to his cellhouse with follow up
in a week. On a separate note the doctor noted that the
workup would proceed as an "outpatient."

12

The doctor had no planned "workup" and appeared to
not know what to do. The patient should have been
referred.

10/12/2015 The patient wasn't seen in a week as scheduled. On 10/12 a
CMT wrote that there was a level 1 lockdown and a doctor
appointment was cancelled.
10/26/2015 Annual examination weight 235 pounds. Problems HTN, DM,
history of smoking and drug use but no IV drugs. On this
annual examination the reviewer documented multiple sexual
partners and prior blood transfusions which were not
documented on prior annual history and physical evaluations.
Given prior transfusions.

11

Lockdowns shouldn't prevent scheduled doctor's
appointments.

289

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 290 of 431 PageID #:12488
Patient #22
10/26/2015 Diabetes HTN chronic clinics BP 164/90; weight 232; last A1c
6.3. No changes made.
10/26/2015 The annual physical examination documented that the patient
did not use IV drugs but did have multiple sexual partners and
the patient had gonorrhea in the past.
11/22/2015 A CMT wrote the that the patient said he wanted his blood
pressure medication changed because it made him feel
"different." The patient said he wasn't taking his medication.
The blood pressure was 160/100.
12/7/2015 Diabetes HTN chronic clinics BP 140/80, temperature 99.8
weight 225; last A1c 5.6. HGB noted to be 10.9. No changed in
medication. CBC, CMP, LDH, ferritin, B12, folate and stools for
occult blood ordered.
12/14/2015 A doctor saw the patient and noted that the patient had
anemia with low ferritin and B12 and a "butterfly" rash on his
face. The ANA test was negative. The doctor noted that the
patient had low grade fever and that the white count was 2.1.
There was no history, no physical examination and the doctor
referred the patient to Dr. Trost (apparently the Medical
Director) to consider a colonoscopy. This patient needed an ID
evaluation,as it appeared that the physicians didn't know how
to evaluate the patient. The patient was started on vitamin
B12 injections.
12/14/2015 Ferritin 268 (10-259); WBC 2.1; HGB 12 (13.2-18); platelets
169; neutrophils 1.1 (1.3-7.5); lymphocytes 0.7 (1.3-4.2); B12
125 (180-914).
12/15/2015 Stool negative for occult blood times 3.

290

3
1, 8

The blood pressure was elevated and medication should
have been adjusted.
In light of this updated history the prior history of fever
should have prompted HIV testing.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 291 of 431 PageID #:12489
Patient #22
1/12/2016 A doctor saw the patient and again took no history and
1, 8, 12
performed no physical examination. The doctor noted that
the patient was feeling better but "still believe he may have
lupus." The doctor ordered a B12 level, CBC, CMP,
sedimentation rate and rheumatoid factor with a return in two
weeks as he was going to present something at collegial
review.

The doctor failed to note or take a history obtained at
the annual physical that the patient had multiple sex
partners and prior gonorrhea and should have ordered
an HIV test. The doctor did not have the expertise to
manage this patient and should have referred. The
leukopenia with lymphocytopenia with anemia is
characteristic of HIV infection yet was unrecognized. ID
referral was indicated but the doctor didn't have the
sense to do this either.

1/12/2016 A doctor referred the patient to a rheumatology consultant.
This was approved on 1/22/16.
1/19/2016 B12 1104 (180-914); sed rate 73.
1/22/2016 The scheduling clerk documented that a rheumatology referral
was approved.
1/25/2016 A doctor wrote an extremely brief note documenting only that
lab tests were pending and scheduled a week follow up. The
blood pressure was elevated at 148/100 but no action was
taken.
1/29/2016 A doctor saw the patient and noted that the sedimentation
rate was elevated [either 23 or 72]. The blood pressure was
120/98 but the doctor didn't address the elevated BP. The
doctor ordered an ANA test and scheduled a four month
follow up.
2/2/2016 ANA not detected; BUN 33; creatinine 1.52 (0.5-1,5); A1c 6.4.

4

The patient had no evidence of lupus serologically

3

Blood pressure medication should have been adjusted.

2/26/2016 A rheumatology clinic note documented that the patient
wouldn't be scheduled for rheumatology to evaluate for lupus
because the ANA was negative. The sedimentation rate was
presumed to be from a urinary tract infection. If there was
concern for the skin rash a referral to dermatology was
recommended for biopsy.

291

1, 8

The doctor should have adjusted blood pressure
medication. HIV testing was indicated. A 4 month
follow up was too long given the patient's problems.

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Patient #22
3/14/2016 A nurse wrote that the patient was scheduled to see a
physician but "for some reason MD denied request."
3/15/2016 A nurse noted a blood pressure of 170/102, pulse of 116, and
temperature of 99.8. The nurse noted that the patient
appeared confused as he didn't give correct response when
asked about his medical issues. The nurse documented
referring to a doctor.
3/15/2016 A psychiatrist saw the patient and documented that the
patient was incontinent of urine and feces and was
incontinent while wearing his clothes. The psychiatrist also
noted delusional thinking. The assessment was psychotic
disorder due to medical condition.
3/15/2016 A doctor saw the patient and noted that the patient was
admitted [presumably to the infirmary] for psychosis of new
onset and "connective tissue disorder." The only history was
that the patient had "no lateralizing symptoms." The doctor
admitted the patient for 23 hour observation and that mental
health was going to monitor the patient.

3/15/2016 A nurse noted vital signs of temperature 99.4, pulse 110, BP
148/96, and a weight of 212 pounds. Though this was
approximately a 40 pound weight loss it was unrecognized.
3/15/2016 At 11:45 pm a nurse documented that the patient said, "You
don't understand, I'm a confidential informant. These people
in here are not listening to me!"
3/16/2016 A nurse documented being unable to take the patient's
temperature but documented a pulse of 132 with blood
pressure of 126/70. The patient was unable to answer
questions appropriately. The patient told the nurse that he
was not well but didn't elaborate.

292

1, 2, 14 The patient had confusion, was incontinent, had prior
fevers, had low white count and anemia with elevated
sedimentation rate and the doctor had no plan. HIV
testing was indicated but apparently beyond the
expertise of the doctor. A CT brain was immediately
indicated. The patient should have been hospitalized
for diagnosis. Care was grossly and flagrantly
unacceptable.

16

The patient appeared delirious and should have been
referred to a physician.

16

The nurse should have consulted a physician.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 293 of 431 PageID #:12491
Patient #22
3/16/2016 A nurse documented that the inmate was escorted off the
infirmary by security to be taken to an outside medical
furlough. The patient was brought back the same day.
3/16/2016 A nurse documented that the patient was delusional.
3/16/2016 The patient was seen in the Belleville Memorial Hospital
emergency room for mental status changes. The WBC was
2.5; hemoglobin 11.8; and platelets 144. BUN was 25;
creatinine 0.9; globulin 3.9. The ER documentation noted that
the patient was delusional but answered questions
appropriately.

The records in the chart indicate that the patient was
seen in Belleville Hospital for mental status changes and
that he was delusional. Their history was that the
patient denied fever. They apparently thought that the
patient was delusional for mental health reasons. There
was no comment on their part regarding the low white
count.

3/17/2016 A nurse documented that the patient was "very delusional"
and that it took considerable effort to get the inmate to take
his food tray and medications. The nurse referred the patient
to mental health but a doctor did not examine the patient.
3/17/2016 A doctor wrote an extremely brief note documenting that the
patient was "alert, delusional, tearful at times." There was no
history, no examination, and the doctor ordered no diagnostic
tests. The only plan was "admit."
3/18/2016 A doctor admitted the patient to the infirmary. There was no
1, 7, 8
history except "new onset acute psychosis R/O SLE." The only
examination was "alert, delusional butterfly rash on face,
chest clear BS [normal] cardiac RRR." The only orders were for
an ANA and for mental health to see the patient.
3/18/2016 A doctor wrote a very brief note stating "no c/os mentation
improved." The only plan was ANA.

293

The doctor was fixated on lupus as a diagnosis but the
patient had no serologic evidence for this condition. A
CT brain and HIV test were indicated but not done. The
patient should have been hospitalized. Care was grossly
and flagrantly unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 294 of 431 PageID #:12492
Patient #22
3/20/2016 A nurse documented that the patient was "laying in bed yelling
out intermittently" and "yells and curses for unknown reason."
The inmate refused to converse with staff.
3/21/2016 ANA not detected.
3/23/2016 A doctor saw the patient and wrote an extremely brief note
stating "remains delusional. Medically stable P. ANA."
3/25/2016 A doctor wrote another very brief note which consisted of
"SOA [apparently meaning subjective objective and
assessment] Delusional. Alert P. mental health to see."

12

8

3/28/2016 A doctor's note consisted of "SOA delusional alert in NAD. P
vitals daily."
3/28/2016 A psychiatrist saw the patient and noted that the patient was
intermittently delusional and stated, "medical etiology
unknown at this time," implying that the patient did not have
a mental health problem as the source of his delirium. The
psychiatrist plan was to note that "medical working to find
underlying medical problem" and "suggest serum iron level."

The doctor kept ordering an ANA test but it was done
and was negative. The doctor should have referred the
patient.
The doctor had not excluded physical causes of altered
mental status. A CT of the brain had not been done.

12

The psychiatrist confirmed that a mental condition was
not the cause of the patient's confusion and delirium.
Because the doctor, who was a surgeon, did not have
expertise or training in this area he should have referred
to another physician.

3/29/2016 A doctor saw the patient. The only note was to acknowledge
review of the mental health note and to order an iron study
and to discontinue iron supplementation.

12

3/31/2016 A doctor wrote another very brief note stating that the patient
was alert and delirious. The plan was to continue present
management.
4/1/2016 A doctor wrote another brief note stating "face [with] dry
skin." The doctor prescribe a lotion for his dry skin.

14

The doctor was following the recommendation of a
psychiatrist. Both the psychiatrist and surgeon had no
training in evaluation of confusion with leukopenia,
anemia, elevated sed rate, and fever. The patient
should have been referred.
The patient should have been admitted to a hospital.
Care was grossly and flagrantly unacceptable.

294

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 295 of 431 PageID #:12493
Patient #22
4/4/2016 A doctor wrote a brief note that the patient had no complaints
and was alert and in "NAD." The doctor didn't examine the
patient and discharged him to his cellhouse with follow up in a
week. The doctor had not completed an evaluation for the
patient's delirium. The doctor noted on the discharge
summary that the patient's delirium had "resolved." However,
there was no history, no physical examination, and no
documentation of diagnostic studies related to this problem.
The doctor wrote, "Mental health evaluated patient and felt
he had delirium. Delirium ?etiology cleared."

4/6/2016 A nurse saw the patient, was stated he couldn't walk. The
weight was 200 pounds. The nurse placed the patient on the
infirmary for 23 hour observation.
4/6/2016 At 4:30 a nurse documented that the patient was delusional
with respect to his conversation with the nurse.
4/7/2016 A doctor wrote a very brief note stating "alert, Thought
process organized. Able to ambulate. P. security hold." In a
subsequent note a nurse documented that the patient was
discharged from the medical third floor and was made a
security hold. The patient was not medically monitored while
on security hold, although it appeared that the patient
remained on the infirmary unit.
4/28/2016 Diabetes HTN chronic clinics. BP 130/82; weight 212; last A1c
6.4; No changes made.
4/30/2016 A doctor wrote a very brief note stating, "Butterfly skin rash
face, Refer to Dr. Trost for eval of connective tissue disease."
That was the entirety of the note.

295

14

It was not competent to send a delirious patient with
altered mental status to general population, as he had
not exhibited ability to care for himself. The patient
needed a diagnosis and higher level of care housing and
should have been hospitalized for a diagnosis. Care was
grossly and flagrantly unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 296 of 431 PageID #:12494
Patient #22
5/12/2016 Dr. Trost wrote I/M seen for above. P. Collegial referral." It
wasn't clear what the doctor was referring to.
5/12/2016 Dr. Trost referred the patient to rheumatology for elevated
sed rate of 88 to rule out lupus.
6/21/2016 An NP wrote that the patient was not brought to the clinic for
a B12 injection. The NP ordered a CBC with B12 level with two
week follow up.
6/24/2016 WBC 2.6; HGB 10.5; platelets 131; B12 609 (180-914);
lymphocytes 0.6 (1.3-4.2).
7/8/2016 An NP wrote that ordered labs were not in the chart. The
patient weighed 188. The NP wrote a ? after the weight but
did not investigate the 60+ pound weight loss. The NP
rescheduled the patient "when lab results avail."

6

It was two weeks since the labs were reported yet were
not in the record.

7/15/2016 BUN 23 (6-20); sodium 148 (135-145); potassium 3.9; A1c 5.8.
7/17/2016 A nurse documented that the patient told her, "I need help I
can't hold my bowels." The nurse noted that the patient was
unable to ambulate without assistance. The nurse referred
the patient to a doctor.
7/18/2016 A doctor saw the patient. There was no history, no physical
1, 2, 6,
examination, and no assessment. The doctor ordered labs
14
(CBC, CMP, CRP, and sedimentation rate) and ordered an x-ray
of the LS spine and ordered Motrin, ointment, iron
supplements and a steroid cream all for four months without
documenting why he was ordering these items.

296

The patient was so disordered that he was incontinent.
The doctor took no history, performed no exam, failed
to note recent labs showing pancytopenia. The patient
should have been sent to a hospital. Care was grossly
and flagrantly unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 297 of 431 PageID #:12495
Patient #22
7/22/2016 A different doctor saw the patient, who had a temperature of
101.2. The doctor noted that the patient might have
"probable SLE." The doctor noted that the patient wasn't
"doing personal hygiene." The doctor did not review labs or
assess the weight. The doctor admitted the patient for 23
hour observation and ordered a UA, CBC, and ordered
Levaquin for 10 days without specifying what infection he was
treating.

2, 14

7/24/2016 A nurse documented that the patient was brought to the
infirmary in a wheelchair and showered with "much
assistance."
7/25/2016 A nurse documented that the patient needed assistance to sit
up in bed. The patient was voiding dark amber urine in small
amounts.
7/25/2016 Dr. Trost saw the patient but wrote an extremely brief note
1, 2, 14
writing, "c/o weakness, alert, in NAD. P admit observe labs."
On the same day the same physician wrote an infirmary
admission note. The history was only that the patient had
generalized weakness. The physical examination only
documented, "alert in NAD; moves all extremities; facial rash."
The assessment was weakness and fever of unknown origin.
On the nurses admission note the temperature was 99.8.
7/26/2016 BUN 16; potassium 3.4; WBC 3.1 (3.9-12); HGB 10.1; platelets
139 (150-450); lymphocytes 0.4 (1.3-4.2) neutrophils normal;
sed rate 51 (0-10).

297

The diagnosis of lupus cerebritis would require exclusion
of other causes of psychosis and would require serologic
evidence of lupus, which this patient did not have. If the
doctor thought that the patient had lupus the patient
should have been admitted to a hospital for CT, MRI,
and possibly LP to confirm the diagnosis. Furthermore,
if the lupus was this significant, treatment should have
been immediately initiated and for that reason as well
the patient should have been referred to a tertiary care
hospital, as this condition was beyond the expertise of
these physicians. Care was grossly and flagrantly
unacceptable.

This surgeon had no expertise in managing this type of
condition and did not take an adequate history, failed to
perform, and adequate examination and the therapeutic
plan was incompetent. The patient should have been
admitted to a tertiary care hospital. Care was grossly
and flagrantly unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 298 of 431 PageID #:12496
Patient #22
7/27/2016 Dr. Trost saw the patient and again wrote an extremely brief
note documenting "no c/os; alert in NAD, oriented P. labs
CPM." Notably, nursing noted were describing that the
patient couldn't move from his bed and needed assistance to
even sit up.
7/29/2016 Dr. Trost saw the patient. His only note was "requesting
shower stable. P. CPM."

8/2/2016 Dr. Trost saw the patient. The only note was "No c/os Labs
[change] status to chronic."

1,2, 6, The patient had pancytopenia. The doctor failed to take
14
adequate history, performed inadequate examination,
and had an incompetent plan. The doctor failed to note
pancytopenia and confusion. The patient should have
been referred to a tertiary care hospital. Care was
grossly and flagrantly unacceptable.
1, 2, 6, The patient had pancytopenia. The doctor failed to take
14
adequate history, performed inadequate examination,
and had an incompetent plan. The doctor failed to note
pancytopenia and confusion. The patient should have
been referred to a tertiary care hosp. Care was grossly
and flagrantly unacceptable.

8/3/2016 Dr. Trost saw the patient, who complained of right sided
abdominal pain with deep breaths. There was no other
history. The only examination was "face [with] dry skin abd
nontender." "P CPM."
8/5/2016 A nurse documented that the patient stated he couldn't get up
out of bed. The nurse noted that the patient was observed by
staff to be up out of bed. The patient refused to come to the
door for his meds and food tray and the nurse had the patient
sign a refusal.
8/8/2016 Quarterly DM, HTN chronic clinic. Weight not taken. BP
130/80. Last A1c 5.8. No change in medication.

298

1, 2,

16

The doctor failed to take adequate history for the
complaint, failed to conduct adequate examination, and
made no diagnosis.
The nurse assumed that the patient was malingering.
This was indifferent care.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 299 of 431 PageID #:12497
Patient #22
8/9/2016 Dr. Trost saw the patient and wrote a brief note stating "I/M
requesting wheelchair P. CXR." Why the doctor ordered a
chest x-ray is unclear as the doctor documented no history,
physical examination, or assessment.

1, 2, 14 The doctor didn't even ask why the patient was
requesting a wheelchair. There was no examination and
no diagnosis. Apparently the patient couldn't walk.
There was no diagnosis or plan except to give the
patient a wheelchair and a chest x-ray for inexplicable
reasons. The patient should have been referred to a
hospital. Care was grossly and flagrantly unacceptable.

8/11/2016 Chest x-ray negative.
8/17/2016 Dr. Trost saw the patient and wrote a very brief note
documenting "alert, in NAD, no c/o's facial skin dry flaky P.
CPM."
8/24/2016 Dr. Trost wrote a very brief note documenting "no c/o's P.
obtain assistive device for ambulation."

1, 2, 14 The doctor again failed to take any history, performed
inadequate exam, made no diagnosis, and failed to refer
to a hospital.
1, 2, 14 The doctor again failed to take any history, performed
inadequate exam, made no diagnosis, and failed to refer
to a hospital.
8/31/2016 Dr. Trost wrote a brief note documenting "exam unchanged P. 1, 2, 14 The doctor again failed to take history, examine or
rheumatology consult." This was a strange note as Dr. Trost
diagnose the patient and referred the patient
had almost never examined the patient so it wasn't clear what
incompetently to a rheumatologist for confusion,
"exam unchanged" meant.
pancytopenia, incontinence, and weight loss. There was
no evidence of a rheumatologic disease. The patient
should have been referred to a hospital.
9/7/2016 Dr. Trost wrote a brief note documenting "exam unchanged P. 1, 2, 14
rheumatology consult." This was a strange note as Dr. Trost
had almost never examined the patient so it wasn't clear what
"exam unchanged" meant.

9/7/2016 The scheduling clerk noted that the inmate was scheduled for
a rheumatology consultation on 9/28/16.

299

The doctor again failed to take history, examine, or
diagnose the patient and referred the patient
incompetently to a rheumatologist for confusion,
pancytopenia, incontinence, and weight loss. There was
no evidence of a rheumatologic disease. The patient
should have been referred to a hospital.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 300 of 431 PageID #:12498
Patient #22
9/28/2016 Dr. Trost documented that the patient was requesting a
wheelchair but didn't say why. There was no history and the
only physical examination was "alert in NAD weak dry scaly
skin on face. P. CPM."
9/28/2016 A rheumatologist saw the patient. There was an order sheet
and some prescriptions. The rheumatologist ordered CMP,
CBC, CK, TSH, free T4, sedimentation rate, CRP, RF, anti-CCP
antibody, ANA, DS DNA, SSA and SSB antibodies, RNP
antibodies, Smith antibodies, SCL 70 (scleroderma) antibodies,
and LDH. The rheumatologist also ordered an EMG of the
right upper extremity based on diagnosis of neuropathy.
There was a prescription for methotrexate but it was for a
different patient. This was not picked up and Dr. Trost
ordered methotrexate and the patient inappropriately
received this medication for the first weekly dose.

300

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 301 of 431 PageID #:12499
Patient #22
9/28/2016 A rheumatologist saw the patient and denied any joint
swelling but had tingling in his hands and nonspecific pain in
his legs. The patient complained of numbness in his fingers
and had non-specific weakness. The patient arrived at the
clinic in a wheelchair. The patient had excoriated lesions on
his hands and face, had no obvious synovitis, no significant
joint tenderness with palpation, and mild decreased strength
in his lower extremities. The rheumatologist diagnosed
polyarthralgias and myalgias that were nonspecific. The
possible etiologies were inflammatory myositis vs.
inflammatory arthritis including RA or other connective tissue
disorders such as lupus or lupus like illness "however at this
point I do not see any obvious systemic complaints to suggest
this." The doctor ordered labs and EMG and asked for a follow
up in a month to determine if further treatment was
warranted.
9/29/2016 A nurse documented that the patient said, "they think I have
lupus." The patient had gone on a furlough the day before.
10/3/2016 A nurse took a verbal order from Dr. Trost for methotrexate
12.5 mg weekly with a CMP, CBC, CK, TSH, free T4,
sedimentation rate, CRP, RF, anti-CCP antibody, ANA, LDH.
10/3/2016 Dr. Trost referred the patient to neurology for neuropathy and
a month follow up with rheumatology. The rheumatology
follow up was initially denied but then approved, "since
symptoms persist." The neurology evaluation and EMG was
denied. The UM reviewer asked for the typed rheumatology
notes before proceeding.

301

17

The facility received an inaccurate prescription for a
different patient and gave methotrexate to a patient
with pancytopenia, which place him at significant risk of
harm.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 302 of 431 PageID #:12500
Patient #22
10/4/2016 RF normal; albumin 3.2; CPK normal; CRP 6.6 (0-0.8); WBC
11.8; HGB 9.6; platelets 193; lymphocytes 20 (25-45); sed rate
37 (0-10).
10/5/2016 Dr. Trost saw the patient. He did not document review of the 1, 2, 14
rheumatology note. He wrote a brief note documenting,
"weakness unchanged Tol PO [apparently tolerating oral fluid]
exam unchanged P. rheumatology eval in progress."

10/11/2016 A nurse documented that the patient was "still refusing to sit
up, demanding to have a wheelchair." The nurse noted that
the inmate had a stage 2 open ulcer to his lower back about 6
by 6 inches that was cleaned with saline. The doctor wasn't
notified.
10/11/2016 A nurse documented that the patient was becoming
increasingly weaker. The nurse noted that the oxygen
saturation was in the 70% range on room air and was 90-% on
4 liters of oxygen. The pulse was 128 and blood pressure
90/66. Dr. Trost was notified and the patient was sent to a
local hospital.

302

These lab results are not consistent with lupus.

The doctor again failed to take history, examine, or
diagnose the patient and referred the patient
incompetently to a rheumatologist for confusion,
pancytopenia, incontinence, and weight loss. There was
no evidence of a rheumatologic disease. The patient
should have been referred to a hospital.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 303 of 431 PageID #:12501
Patient #22
10/12/2016 An ID consult at Barnes Jewish Hospital noted that the patient
was transferred from another hospital with HIV infectionnewly diagnosed with respiratory distress and skin lesions.
The patient told the ID consultant that he had night sweats
and weight loss over the past 3-4 months. The patient had
oxygen saturation of 77% on room air. At the local hospital in
Chester Illinois, the patient was in shock with BP 60/40 with
pulse 128 and temperature of 90.9! He was diagnosed with
septic shock. Blood cultures were growing gram positive
organisms. The creatinine was 4.28. The patient was
transferred to Barnes Hospital. Blood cultures grew Meth
Sensitive Staph aureus. The ID consultant noted that the
patient had a pustular lesion on the left leg and right foot,
abrasions on the hip and shoulder, an ulcer on the right hip, a
shallow ulceration on the penis, and macerated skin in the left
groin. None of this was noted at Menard only two days
previous. There were scattered small nodules in the lungs,
some of which appeared cavitary. These were thought to
possibly be septic emboli or metastatic lesions. The consultant
initially thought that the patient had septic emboli from staph
septicemia, possibly pulmonary TB or other fungal infection.
Further work up was needed. The consultant thought that the
patient's encephalopathy might be due to HIV encephalopathy
vs. opportunistic infection or septic brain emboli.

10/12/2016 A dermatologist at Barnes Hospital saw the patient. A biopsy
from that date showed focal parakeratosis that in the context
of methotrexate "could represent medication-related
toxicity."

303

Initial presentation at the hospital show that the patient
was in a state of neglect when he arrived. He was in
shock, hypothermic, and in renal failure with multiple
lesions on his body apparently unrecognized by
providers at the facility. He also had unrecognized
severe malnutrition. Overall care at the facility was
grossly and flagrantly unacceptable. On multiple
episodes the patient had confusion with intermittent
fever and neutropenia and needed acute care
hospitalization, yet this did not occur. These were
grossly and flagrantly unacceptable care.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 304 of 431 PageID #:12502
Patient #22
10/12/2016 A Jewish Hospital note documented that the patient has
severe malnutrition.
10/15/2016 An MRI of the brain had findings consistent with HIV
encephalitis. Incidentally noted was an intramuscular ring
enhancing right sternocleidomastoid mass which was
consistent with an intramuscular abscess or Kaposi's sarcoma.
10/16/2016 A note from the hospital noted that the patient had a CD4
count of 46. The patient has started on azithromycin and
Bactrim for prophylaxis. Lesions from the lungs grew MSSA
and culture of the decubitus ulcer grew MRSA.
10/17/2016 The patient had a cardiac arrest and a Doppler test was done
and identified an acute DVT in the common femoral vein on
the right. The patient also had an abnormal EEG post-cardiac
arrest.
10/20/2016 A chest x-ray showed the patient was still intubated and had
collapse of the right middle and lower lobes. The patient
apparently died on this day. There was no autopsy or death
summary.

304

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 305 of 431 PageID #:12503
Patient #23
3/23/2012 The patient was incarcerated at NRC. The initial weight was
220 pounds. The patient had a history of prior lung cancer
with surgeries and radiation in the late 1990s; hypertension
and hepatitis C.
3/23/2012 AST 82; ALT 66.
5/2/2012 The patient was transferred from NRC to Menard. The
problem list documents only hypertension, DM, prior lung
cancer, and hepatitis C as problems. Cirrhosis was not listed
as a problem.
5/8/2012 A hepatitis C progress note performed by a nurse documented
that further laboratory testing was needed including CBC,
CMP, INR, and HIV tests. There was no history or physical
examination. The status of the patient wasn't documented.
5/23/2012 AST 99; ALT 78; platelets 121.
6/1/2012 AST 96; ALT 72; platelets 129.
6/11/2012 A NP saw the patient in hepatitis C clinic. The patient's
projected release date was > 18 months. The platelets were
documented as 129; AST 96 and ALT 72. This yielded a FIB 4
score of 4.91 likely consistent with cirrhosis. The APRI score
was 1.86, likely significant fibrosis with possible cirrhosis.
Except for noting that hepatitis A and B vaccinations were
done, no action was taken. This patient had probable fibrosis
and cirrhosis, should have been referred for treatment and
should have had routine cirrhosis screening performed
including every six month ultrasound, EGD to screen for
varices, and possible institution of a beta blocker.
6/15/2012 Hepatitis C genotype and viral load was ordered.

305

The APRI was 1.86 indicating likely significant fibrosis
with possible cirrhosis.
7, 8, 12 The patient had APRI indicating cirrhosis. The NP did
not discuss or offer treatment. There was no evaluation
for complications of cirrhosis (i.e. every six months
ultrasound and EGD to screen for varices and treatment
of other complications of cirrhosis). The NP should have
referred the patient to UIC for EGD and ultrasound as
lab testing indicated significant fibrosis with possible
cirrhosis. Care failed to follow generally accepted
guidelines or usual practice.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 306 of 431 PageID #:12504
Patient #23
6/15/2012 A NP filled out a Wexford Initial Hepatitis work sheet. The NP
documented faxing the form "again" to Dr. Paul on 8/26/12
and documented referring to an MD for "discussion of Tx if he
will maintain compliance." It wasn't clear what maintaining
compliance meant.

7/2/2012 AST 96; ALT 74; platelets 125; hepatitis C genotype 1A;
quantitative HCV 2,111,740.
8/5/2012 A NP wrote that information was to be submitted to Dr. Paul
for evaluation for hepatitis C treatment.

9/21/2012 AST 108; ALT 91.
9/26/2012 An RN noted that according to Dr. Paul, the patient could be
referred when he agreed to compliance with therapy. A nurse
documented a history of refusal, but what was refused was
not documented.
10/1/2012 A doctor obtained a signed release for medical records from
Cook County Hospital for treatment of his lung cancer. The
doctor did not address the hepatitis C infection.
10/4/2012 A doctor saw the patient for hypertension and diabetes
chronic clinic. The blood pressure was 150/104. The doctor
increased the Vasotec. The last A1c as documented as 6.2.
The patient was not on medication and it wasn't clear that the
patient had diabetes. The doctor noted that the patient had
2+ pedal edema. The etiology of the edema was not
addressed.

306

12

12

12

The patient had cirrhosis and should have been referred
to UIC. The referral to Dr. Paul had no purpose. We
view this as a delay in necessary treatment. The
meaning of maintaining compliance was confusing.
What compliance were they discussing? Care failed to
follow generally accepted guidelines or usual practice.
The APRI was 1.92 indicating significant fibrosis with
possible cirrhosis.
We view these referrals as delays in referral to UIC.
What purpose does Dr. Paul play? The patient has
laboratory evidence of cirrhosis. Why delay referral?
The patient should have been referred to UIC. Care
failed to follow generally accepted guidelines or usual
practice.
When the patient was ultimately referred to UIC he
apparently agreed to treatment. Was the purpose of
treatment explained to the patient. This was never
documented.

1, 2, 7 The patient had unexplained edema which was not
evaluated. Given that the patient had possible cirrhosis,
the patient should have other diagnostic work up
including for cirrhosis and heart failure. Additional
testing was indicated including ultrasound of the liver
and possible echocardiogram. These should have been
based on history, which was inadequate.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 307 of 431 PageID #:12505
Patient #23
1/3/2013 A provider saw he patient for HTN chronic clinic. The BP was
134/87 and weight was 225 pounds. No changes were made.
1/3/2013 An NP saw the patient for hepatitis C chronic clinic. A high
viral load was documented with genotype 1A. Treatment was
not addressed; there was no reason given for not pursuing
treatment. The patient's likely cirrhosis was not evaluated or
monitored.
1/3/2013 A provider saw the patient for diabetes clinic. The A1c was
documented as "ordered." The status wasn't clear.
1/10/2013 AST 112; ALT 85.
4/8/2013 A PA noted that the inmate wanted to hold off treatment at
this time. It appeared that the patient didn't want treatment
for his hepatitis C at this time.
4/8/2013 The patient signed a refusal for hepatitis C treatment and
workup.
4/11/2013 A doctor saw the patient in hepatitis C clinic. The doctor noted
ALT 85 and AST 111. The FIB4 or APRI scores were not
documented but the patient already had probable cirrhosis on
prior tests. There was no monitoring of the patient's cirrhosis.
The patient was noted to have signed a refusal for treatment
and "conservative follow up" was the plan.
4/11/2013 A doctor saw the patient in hypertension chronic clinic. The
blood pressure was 136/88. The patient was also seen in
diabetic chronic clinic. The A1c was 6.2 and the patient was
not on medication. This A1c level is not diagnostic of diabetes.
There was no change in therapy.
8/27/2013 Albumin 3.3; AST 94; ALT 71; platelets 97.

307

7, 8, 12 The patient should have been referred to UIC where
treatment could be explained to him. He should have
had EGD and ultrasound of the liver. Care failed to
follow generally accepted guidelines or usual practice.

7,8

The patient had APRI indicating cirrhosis. The NP did
not discuss or offer treatment. There was no evaluation
for complications of cirrhosis (i.e. every six months
ultrasound and EGD to screen for varices and treatment
of other complications of cirrhosis).

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 308 of 431 PageID #:12506
Patient #23
8/29/2013 A doctor saw the patient in hypertension and diabetes chronic
clinics. The blood pressure was 132/82. The weight was 225.
The most recent A1c was 6.3. No change in therapy was
made.
8/29/2013 A doctor saw the patient for hepatitis clinic. The platelets
were 99; AST 94; and ALT 71. This yielded an APRI score of
2.37 and FIB4 score of 6.31, both indicating likely cirrhosis, yet
the patient was not evaluated or monitored for cirrhosis. It
was documented that the patient refused treatment, but it is
not clear what was explained to the patient with respect to
treatment. There was no referral to UIC to discuss treatment.
Conservative follow up was the plan but the patient wasn't
treated for his cirrhosis. The doctor noted trace edema of the
lower extremity. No action was taken with respect to the
edema. Treatment wasn't explained to the patient. At this
time new hepatitis C drugs were on the market and made
treatment significantly easier.
11/8/2013 Albumin 3.2; alk phos 136 (40-125); AST 113; ALT 81; platelets
106.

12

The patient should have been referred to UIC where
treatment could be explained to him.

The increasingly abnormal albumin and alkaline
phosphatase indicated more severe liver disease that
was not evaluated.
12/21/2013 A NP saw the patient for hepatitis C clinic. Platelets were 113, 7, 8, 12 The patient should have been referred to UIC where
AST 113, and ALT 81, yet the patient wasn't monitored for
treatment could be explained to him. The NP should
cirrhosis. No action was taken except "conservative follow
also have ordered an EGD and ultrasound or CT scan of
up."
the liver as blood tests were consistent with cirrhosis.
12/29/2013 A NP saw the patient for hypertension and DM chronic clinic.
The BP was 130/62. The last A1c was 6.3. No changes to
therapy were initiated.

308

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 309 of 431 PageID #:12507
Patient #23
3/7/2014 Platelets 98; albumin 3.1; bilirubin 1.6 (0-1.2); alk phos 144 (40125); AST 102; ALT 69.
4/22/2014 A NP saw the patient for hypertension and DM chronic clinic.
The PP was 134/82. The last A1c was 6.2. The weight was
235.
4/24/2014 An NP saw the patient in hepatitis clinic. Platelets were 16;
AST 102; and ALT 69. Yet the patient wasn't evaluated for
cirrhosis complications. Treatment wasn't discussed.

The increasingly abnormal albumin and alkaline
phosphatase indicated more severe liver disease that
was not evaluated.

7, 8, 12 The patient should have been referred to UIC where
treatment could be explained to him. The NP should
also have ordered an EGD and ultrasound or CT scan of
the liver, as blood tests were consistent with cirrhosis.
Newer drugs were now available which made treatment
significantly easier.

6/17/2014 The patient signed a refusal for hepatitis C treatment and
workup but it wasn't clear what was explained to the patient.
7/23/2014 The patient was transferred to Stateville CC.
9/10/2014 The patient was transferred from SCC to Menard.
9/16/2014 Albumin 3.1; total bilirubin 1.2 (0-1.2); Alk phos 132 (40-125);
AST 132; ALT 67; MCV 100.2; platelets 91.

9/24/2014 An NP saw the patient in hepatitis clinic. The APRI was
calculated as 3.10. There was no monitoring of the patient's
cirrhosis. One NP referred to another NP for the increased
APRI. "Conservative follow up" was the plan.
9/24/2014 The patient was seen for hypertension and diabetes chronic
clinics. The BP was 130/94. The weight was 230. The latest
A1c was 6.1. No changes were made to therapy.

309

The low albumin, elevated alkaline phosphatase and
elevation of bilirubin indicated deterioration of liver
function that was not evaluated. The patient should
have had an ultrasound or CT scan of the liver.
7, 8. 12 The patient should have been referred to UIC where
treatment could be explained to him. The NP should
also have ordered an EGD and ultrasound or CT scan of
the liver.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 310 of 431 PageID #:12508
Patient #23
10/1/2014
11/5/2014
11/25/2014
1/14/2015

Albumin 3.2; alk phos 133 (40-125); AST 161; ALT 91.
Platelets 79.
The patient returned to Menard after a writ return.
An annual physical examination showed a weight of 180 or a
1, 2, 3
40 pound weight loss since incarceration in 2012. The patient
had HTN, DM, lung cancer, and hepatitis C as problems. A
provider found a stool that was guaiac positive. Cards for
guaiac testing were given. The NP also documented in the
assessment that the patient had 2+ pitting edema of both legs.
The NP ordered Ted hose but did not start a diuretic and did
not document ascites as a problem so it could be monitored.

1/14/2015 An NP saw the patient for hepatitis clinic and noted that the
patient had APRI of 3.22 but was ineligible for treatment at
this time due to a refusal of treatment on 1/14/15. The
explanation of the refusal was not documented and it wasn't
clear that the patient understood what he was refusing.

The provider failed to take a history of the weight loss.
Indeed it was unrecognized. The patient should have
had a thorough history, physical examination, and plan
for the weight loss. A diagnosis was not made for the
edema and it was possible that the patient had cirrhosis.

7, 8, 12 The patient should have been referred to UIC. The NP
should also have ordered an EGD and ultrasound or CT
scan of the liver.

1/14/2015 A NP saw the patient for hypertension clinic. The blood
pressure was 136/84. No changes were made to therapy.
1/14/2015 The patient signed a refusal for hepatitis C treatment and
workup but it wasn't clear what was explained to the patient.

3/20/2015 Albumin 2.9; bilirubin 1.4 (0-1.2); alk phos 138 (40-125); AST
134; ALT 76.
4/13/2015 A NP saw the patient for hypertension clinic. The BP was
126/84. No changes to therapy were initiated.

310

12

The patient should have been referred to UIC. IDOC
personnel failed to document what was discussed with
the patient. Because of new drugs, treatment was
significantly improved and it is unclear whether this was
understood by IDOC personnel.

6

Recent significant lab abnormalities were not reviewed.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 311 of 431 PageID #:12509
Patient #23
5/1/2015 Albumin 3; bilirubin 1.8; alk phos 144; AST 173; ALT 83;
platelets 83.
5/4/2015 Apparently Dr. Paul wrote a note without seeing the patient
and documenting that the patient had an APRI of 5.21. Dr.
Paul recommended having him called over to discuss his
decision to refuse HCV treatment and have him sign a refusal.
A liver ultrasound and EGD were recommended.
5/6/2015 Wexford approved an EGD with comments that the patient
had an APRI of 5.21. In addition to EGD, Dr. Paul
recommended yearly discussion of treatment with the patient
and liver ultrasound to R/O HCC.
5/6/2015 Wexford approved an abdominal ultrasound.
5/8/2015 An ultrasound of the liver showed cirrhosis, a 2.5 cm mass
"worrisome for a possible malignant lesion" and a second
mass in the right lobe of the liver measuring 2.35 cm. There
was also splenomegaly.
5/14/2015 A NP wrote an email to Dr. Paul that the EGD was delayed as
the doctor who typically performed EGDs was out after an
accident.
5/15/2015 Dr. Paul wrote an email to an NP at Menard recommending a
CT scan of the abdomen to evaluate an abnormal US.

5/15/2015 A CT scan was referred. This was approved on 5/18/15.
5/19/2015 A doctor saw the patient and informed him of the ultrasound
results. The weight was 224. The doctor notified the patient
of a pending CT scan.
5/27/2015 A nurse documented a weight of 230 pounds.

311

12

The patient should have been referred to UIC to have
treatment adequately explained to him.

The patient had a liver lesion possibly HCC but this was
not evaluated with biopsy.

3

If a CT scan were ordered it should have been an
interventional radiology test so that biopsy could be
done. This would only serve to delay evaluation of the
lesion.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 312 of 431 PageID #:12510
Patient #23
5/28/2015 A CT scan report documented a hypodense lesion in the right
lobe of the liver measuring 6.2 cm. This was suspicious for
malignancy. Cirrhosis of the liver was also found with ascites
and splenomegaly.
6/17/2015 An NP saw the patient for hepatitis C clinic. The NP
documented that the APRI was 5.3 and the NP documented
that the patient refused therapy on 1/14/15. The NP
documented that the CT results were given to the patient.
There was no evaluation for complications of cirrhosis.
6/22/2015 A nurse documented a weight of 219 pounds.

8/4/2015 A nurse documented a weight of 240 pounds.
8/6/2015 A doctor documented seeing the patient in follow up of a CT
scan. The note was partly illegible but appeared to refer the
patient to hepatitis clinic.
8/7/2015 The patient had endoscopy showing grade II esophageal
varices. The recommendation was to start beta blocker
medication.
8/14/2015 Albumin 2.5; bilirubin 2.5; AST 67; ALT 34; MCV 101; platelets
71; INR 1.3 (0.9-1.2).
8/25/2015 The scheduling clerk documented that the Wexford UM
physician decided to refer a referral matter to Dr. Paul. The
specific referral was not documented.
8/25/2015 Dr. Trost documented that the patient EGD showed varices
with possible hepatic tumor. The doctor referred to collegial
for an unknown referral but did not start a beta blocker.
8/25/2015 Dr. Trost referred the patient for interventional radiology
biopsy of a liver mass.

312

The patient had a liver lesion possibly HCC but this was
not evaluated with biopsy.

7, 17

The patient should have been sent for his EGD. The
patient should have been considered for a diuretic due
to ascites.

1

The weight loss was unrecognized. As the patient's
cirrhosis worsened, the weight increased likely as a
result of ascites.
This may have been ascites or an error.

17

The doctor should have started a beta blocker due to
the varices.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 313 of 431 PageID #:12511
Patient #23
8/31/2015 Wexford UM physician did not approve a liver biopsy but
requested that the referral be sent to Dr. Paul
9/10/2015 Inderal 20 mg BID was ordered.
9/22/2015 BUN 4; chloride 110 (98-108); MCV 101.8; platelets 81.
9/24/2015 Dr. Trost referred the patient for interventional radiology
biopsy of a liver mass.

7

9/25/2015 MRI was approved by collegial. The approval noted that the
radiologist recommended an MRI.
10/22/2015 An MRI showed right lower lobe pneumonitis, large ascites,
splenomegaly, varices, wedge shaped confluent hepatic
fibrosis of right hepatic lobe.
10/26/2015 An MRI was done.

This was a significant delay in evaluating a possible liver
mass.

6, 7

This was four months from the abnormal ultrasound.
This delay was excessive. Significantly abnormal labs
were not reviewed.

11

A biopsy was ordered but the patient received an MRI.

6

Significantly abnormal labs were not addressed.

17

The patient should have been on a beta blocker due to
his varices.

10/30/2015 BUN 4; calcium 8.3; albumin 2.3; bilirubin 1.7; alk phos 151;
AST 81; ALT 34; MCV 100.9; platelets 59; INR 1.4 (0-1.2).
11/23/2015 A doctor saw the patient for hypertension clinic. The BP was
142/90. The patient weighed 224. The patient asked the
doctor about a liver transplant. The doctor noted edema and
added Aldactone. The doctor noted that the patient was on
propranolol 20 mg BID.
11/25/2015 A MAR documented that the inderal was on hold. It wasn't
clear why.
12/1/2015 Dr. Trost wrote a note. There was no history or physical
examination. The note stated "I/M inquiring about liver
transplant. Process including need for matching donor,
finding, etc. All D/W I/M" P. F/U HRC."

313

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 314 of 431 PageID #:12512
Patient #23
12/3/2015 A doctor saw the patient in hepatitis chronic clinic. The doctor
noted that the patient had a hepatic mass found in May of
2015. The doctor noted that the APRI was 6.3. The doctor
concluded that the patient had liver cirrhosis and a
questionable liver mass. The doctor referred the patient to Dr.
Trost, the Medical Director.

12

The patient should have been referred to UIC or to
another hepatologist for treatment as it appeared
beyond the expertise of the surgeon who was Medical
Director.

12/7/2015 Wexford approved an abdominal ultrasound. Notably
Wexford UM also approved this same procedure on 12/8/15.
12/14/2015 Dr. Trost saw the patient. The entire note was "RIH on exam,
reducible. P. observe."

12/18/2015 An ultrasound of the liver showed cirrhosis, a possible 2.1 cm
liver lesion, and ascites. An MRI or CT surveillance was
recommended to evaluate for hepatocellular carcinoma.
12/24/2015 Dr. Trost saw the patient. The entire note was "No c/o's
Unclear why I/M scheduled. P. F/U PRN."
2/18/2016 A nurse noted that an email was sent to UIC with appointment
sheet and paperwork.
3/24/2016 INR 1.6; albumin 2.1; bilirubin 2.2; alk phos 204; AST 76; ALT
30; MCV 100; platelets 65.

314

1, 2, 3 Given the condition of the patient, the history,
examination, and plan were all inadequate. The doctor
did not appear to know how to care for the liver mass
and cirrhosis.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 315 of 431 PageID #:12513
Patient #23
4/28/2016 A UIC consultant saw the patient and noted that the patient
deferred treatment in the past because "tumor eat you
faster." Notably, the patient was unaware that he had any
associated liver disease. The patient said he was first
diagnosed with hepatitis C at Stateville in 2012 and had
genotype 1A with a RNA level of 2,111,740 on 7/2/12. The
UIC consultant noted that the patient was unaware of having
any complication of his liver disease. The UIC consultant
noted that varices were diagnosed 8/7/15 but that the patient
wasn't treated for these, though a nurse found a prescription
for propranolol that the patient had not picked up. The doctor
noted that a CT guided biopsy was not done "because images
from US and CT were not provided to guide the biopsy in
2015." The failed biopsy was documented as not occurring on
8/28/15. The consultant documented that the US showed an
ill-defined 2.5 cm mass in the liver. A CT scan on 5/28/15
showed no enhancing lesions, although there was an illdefined hypodensity in the right lobe of the liver. The ill
defined lesion was suspicious for malignancy. The CT scan also
showed cirrhosis, ascites, and splenomegaly. The patient
agreed to treatment. The consultant recommended a liver
biopsy, the MRI results, and after the biopsy to have the
patient return to clinic for treatment.

4/28/2016 A doctor saw the for annual hypertension clinic. The BP was
110/80. The doctor found no abnormalities on physical
examination and made no changes to therapy.

315

Notably, the patient agreed to treatment at UIC. The
patient was unaware of his liver disease, making it
appear that there had been ineffective communication
with the patient. The patient was sent without the MRI.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 316 of 431 PageID #:12514
Patient #23
4/28/2016 A doctor saw the patient for hepatitis clinic. The doctor noted
that the patient was ineligible for treatment because of low
APRI. The APRI was 2.92, likely representing cirrhosis and
warranted treatment. Nevertheless, the doctor documented
he would refer to Dr. Trost to refer the patient to the
telemedicine clinic for hepatitis C.

4

5/25/2016 Dr. Paul referred the patient for an MRI. This was approved
on 5/31/16.

6/1/2016 The scheduling clerk documented that an MRI of the abdomen
was scheduled for 6/21/16.
6/7/2016 Albumin 2.1; bilirubin 3.5; alk phos 149; AST 79; ALT 27.
6/21/2016 The patient returned from an offsite MRI. A nurse practitioner
saw the patient. The patient was short of breath and had
oxygen saturation of 79%. The patient was started on oxygen
and admitted to the infirmary for observation. There was no
effort by the NP to identify why the patient had hypoxemia.
Care was grossly and flagrantly unacceptable. The patient
should have been admitted to a hospital. The NP did not
document a complete set of vital signs. A nurse note on the
same infirmary admission documented a blood pressure of
96/64.
6/21/2016 A nurse on the infirmary noted that the BP was 96/64 and the
oxygen saturation 93% on oxygen. Hypoxemia and
hypotension of unknown etiology warranted hospitalization.

316

This doctor did not appear to know what the guidelines
were.

The use of Dr. Paul caused delays and confusion in
therapy. It was understandable that she was involved
because the doctors didn't know how to manage
hepatitis C, but a different system should have been
established.

14

The patient had significant hypoxemia with hypotension
of new onset and should have been admitted to a
hospital.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 317 of 431 PageID #:12515
Patient #23
6/22/2016 At 5:45 am a nurse documented that the patient had fever
(100.4). There was no physician referral but the nurse placed
the patient on the infirmary for observation.
6/22/2016 At 8:30 am a doctor admitted the patient to the infirmary for
decompensated cirrhosis, massive ascites and hypoxemia.
There was no investigation to determine the cause of the
hypoxemia except to order routine labs, and this remained
undiagnosed. The doctor took no other history. The physical
examination documented decreased breath sounds and
massive ascites and 3-4+ peripheral edema. The only
diagnoses were HTN and HCV yet the doctor's plan was to
initiate Levaquin and antibiotic for unnamed reasons. The
doctor ordered a CBC, CMP, and chest x-ray. The doctor failed
to acknowledge the fever, which should have prompted
admission to a hospital for possible sepsis. The doctor did not
even take vital signs, but a nursing note at the same time
documented temperature of 100.8, oxygen saturation 93%
presumably on oxygen with BP 115/78.
6/23/2016 Dr. Trost wrote a brief note documenting that the patient was
still short of breath. The exam was very brief, noting
decreased breath sounds and unchanged edema. There was
no history, limited physical examination, no review of
laboratory tests, no acknowledgement of fever the day before,
and no assessment. The doctor increased the Aldactone but
did not review labs or initiate any diagnostic work up for the
patient's serious illness.
6/23/2016 Albumin 1.4; AST 63; ALT 24; bilirubin 2.4; hemoglobin 10.3;
MCV 103.6; platelets 41.

317

16

Fever, hypoxemia, and hypotension warranted
hospitalization. This nurse didn't refer to a physician.

1, 14

Care was grossly and flagrantly unacceptable. The
patient should have been admitted to a hospital. The
history and therapeutic plan were inadequate.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 318 of 431 PageID #:12516
Patient #23
6/24/2016 A late entry note for 7:00 am documented at 1:30 pm
documented that the patient's respiratory rate was 28, BP
88/60, and oxygen saturation of 84% on 4 liters of oxygen.
The nurse documented talking to Dr. Trost, who advised
admission to a hospital. The patient wasn't transferred for 45
minutes.
6/24/2016 At 3:30 pm a nurse documented that the patient appeared "to
be breathing [with] accessory muscles." This note appeared
inaccurately dated as the patient was already hospitalized at
this time and date.

318

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 319 of 431 PageID #:12517
Patient #24
9/11/2014 HTN chronic clinic; weight 160; BP 132/88; LDL 122. The
patient was on lisinopril 10.
2/6/2015 Cholesterol 189; HDL 77; LDL 106.
3/9/2015 HTN chronic clinic; weight 178; BP 132/84; cholesterol 189;
HDL 77; LDL 106.
4/17/2015 Hepatitis A, B, and C negative. CMP normal; cholesterol 152;
HDL 57; LDL 90.
6/15/2015 Annual history evaluation; no risk factors identified. Was 46
years old. Vaccinations not updated.
8/14/2015 CMP normal.
10/16/2015 Varicella IgG antibody negative.
10/26/2015 The patient developed a generalized rash and was admitted to
the infirmary with apparent varicella zoster. The patient had a
temperature of 99.8.
10/27/2015 The patient had fever of 100.8.
10/30/2015 The patient was afebrile for 48 hours and discharged the
patient to general population. The doctor noted that varicella
titer was negative.
11/13/2015 A nurse saw the patient for symptoms of chicken pox. The
patient had temperature of 99. The nurse noted no rash.
11/14/2015 A nurse saw the patient for symptoms of chicken pox. The
patient had temperature of 98.8. The nurse noted no rash.
11/15/2015 A nurse saw the patient for symptoms of chicken pox. The
patient had temperature of 98.6. The nurse noted no rash.
11/16/2015 A nurse saw the patient for symptoms of chicken pox. The
patient had temperature of 98.6. The nurse noted no rash.

319

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 320 of 431 PageID #:12518
Patient #24
11/18/2015 A nurse saw the patient for symptoms of chicken pox. The
patient had temperature of 98.8. The nurse noted no rash.
11/19/2015 A nurse saw the patient for symptoms of chicken pox. The
patient had temperature of 98.8. The nurse noted no rash.
The patient wasn't referred to a doctor.
11/20/2015 A nurse saw the patient for symptoms of chicken pox. The
patient had temperature of 98.6. The nurse noted no rash.
11/21/2015 A nurse saw the patient for symptoms of chicken pox. The
patient had temperature of 98.8. The nurse noted no rash.
The patient was seen 11/22/15; 11/24/15; 11/25/15;
11/26/15; 11/27/15; 11/287/15; 11/29/15; 11/30/15.
2/24/2016 CMP normal; cholesterol 192; HDL 72;LDL 113.
3/9/2016 Chronic clinic for HTN. Cholesterol 192; HDL 72; LDL 113; BP
122/82.
9/6/2016 HTN chronic clinic; BP 118/82; recent LDL 123.
2/17/2017 Cholesterol 179; HDL 62; LDL 110.
5/12/2017 Cholesterol 194; HDL 63; LDL 121.
5/17/2017 A nurse saw the patient for abdominal pain. The pain was
described as constant of 4-5 days duration. The nurse gave the
patient ibuprofen by protocol with no referral.
5/22/2017 A nurse saw the patient for abdominal pain for the past week.
The patient noticed no bleeding or black stool. The vitals were
normal. The abdomen was soft. The nurse gave the patient
antacids by protocol with no referral.

320

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 321 of 431 PageID #:12519
Patient #24
5/31/2017 The patient complained of abdominal pain which he said he
had since 5/11/17. The pain felt like a knife. There was no
bleeding. The blood pressure was 140/110 with a pulse of 76.
This was an elevated BP for this patient who previously had
normal blood pressures. The nurse noted that the abdomen
was "rigid" around the umbilicus with guarding. The nurse
documented no plan but apparently referred to a doctor.
5/31/2017 A doctor saw the patient. The doctor noted that the patient
had an umbilical hernia. The doctor wrote "It is small. He
won't let me touch it or push it back in." There was no other
history or examination. The doctor gave the patient Tylenol
for six months with no other intervention.
6/19/2017 Annual history evaluation; no risk factors identified. Was 46
years old. Vaccinations not updated.
6/19/2017 HTH chronic clinic; BP 120/72; weight 176.
6/30/2017 At 8:00 am an LPN wrote a note stating that her supervisor
directed her to examine the inmate because the family was
calling concerned that the inmate needed to see the Medical
Director. The nurse wrote that the inmate had been seen
multiple times in nurse sick call and refused part of the
physician's examination. The nurse assessment was "risk for
dehydration" and noted that the patient already had an
appointment for 7/6/17. The nurse assessment utilized a
diarrhea protocol. The inmate complained of diarrhea 4-5
times daily with abdominal pain 8/10. The patient had lost his
appetite. He weighed 176 pounds, which was his usual
weight. The pulse was 95 and blood pressure 150/118. The
abdomen appeared distended and rigid to the nurse.

321

3

A painful abdomen with the patient not allowing anyone
to touch the abdomen needs to be evaluated. To give
the patient six months of Tylenol without diagnostic
evaluation (ultrasound or CT scan) and without follow
up was inappropriate.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 322 of 431 PageID #:12520
Patient #24
6/30/2017 At 4:45 pm a LPN noted that the patient was being transferred
to Carbondale Memorial Hospital. There was no clinical note
related to this communication. The patient remained
hospitalized until 7/6/17.
7/5/2017 A CT scan showed peritoneal/omental masses extending into
the umbilical hernia.
7/6/2017 A nurse documented that the patient returned from the
hospital. The blood pressure was 168/100. The weight was
documented as 177. The nurse did not document the hospital
diagnosis but did document that the patient had a
colonoscopy.
7/6/2017 A biopsy of a descending colonic polyp showed tubular
adenoma with high grade features possibly with atypia.
7/7/2017 A doctor saw the patient and noted that the patient had
biopsy and colonoscopy. Some of the note was illegible. The
doctor admitted the patient to the infirmary and started
hydralazine, Pepcid, and Zofran. On the infirmary admission
note the doctor wrote also that the patient had a CT biopsy.
Much of the note was illegible. The assessment appeared to
state abdominal pathology but it was unclear.
7/8/2017 The blood pressure was 160/100. The nurse noted that the
patient had an abdominal dressing. A band-aid was applied.
Later that day at 4:00 pm the patient had blood pressure of
110/78 with temperature of 99.9.
7/9/2017 The patient asked the nurse for pain medication. The blood
pressure was 140/88. The nurse noted that the patient had
pain in the stomach area and that the patient had a large
abdominal mass "R/O CA." Later that day the patient asked
"when will I get to see a doctor?" The nurse assessed newly
diagnosed cancer.

322

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 323 of 431 PageID #:12521
Patient #24
7/10/2017 A doctor saw the patient and wrote that the patient had slight
abdominal pain. The doctor noted that the patient had
abdominal carcinomatosis. There was no examination. The
doctor noted that oncology appointment was recommended
in collegial. The patient was discharged from the infirmary;
the doctor stated that the final pathology report was pending.
The patient was to follow up in doctor clinic. The nursing
discharge note documented a blood pressure of 140/100 but it
was unnoticed by the doctor. The doctor did not address pain
medication. The doctor also did not summarize the hospital
course or document what occurred in the hospital.

7/13/2017 A clerk documented that the patient was approved for
oncology.
7/17/2017 A doctor wrote an admission to the infirmary for a chronic
patient. The doctor noted that a CT scan showed peritoneal
metastases but a needle biopsy showed no malignant tissue.
The plan was a CEA, CA-19; CBC, CMP, and await the oncology
consultation.
7/18/2017 A nurse documented on her note that the heart was irregular
but took no action.
7/20/2017 A doctor wrote an extremely brief note. The entire note was
"No pain abd carcinomatosis Had requested CA-19 CEA
Awaiting onc consult."
7/21/2017 CEA 0.7 (<3); albumin 3.1; hemoglobin 11.6; CA-19 4 (0-37).
7/23/2017 The patient complained of abdominal pain 6/10. The nurse
documented being given a phone order for Norco on a prn
basis.

323

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 324 of 431 PageID #:12522
Patient #24
7/24/2017 The patient complained of stomach pain to a nurse. The
inmate was afraid to take the pain medication because of
constipation. The doctor did not evaluate the patient.
7/26/2017 The patient went for an oncology appointment.
7/26/2017 An oncologist saw the patient. The oncologist wrote that the
patient was a poor historian and "no records that we have
received from the prison is a 60 document was 2 pages of labs
and four pages of handwritten physician documentation." The
patient told the doctor he had cancer. The CT scans were
unavailable to the oncologist. The patient had massive tense
ascites. The oncologist stated that he would request the CT
scans from the hospital and would try to get more records. A
two week follow up was requested with more information.

7/27/2017 A doctor saw the patient and noted that there was no
oncology report. The doctor noted that the CEA and CA-19
were negative. The doctor took no history of the patient and
did not examine the patient. He noted that the patient had
abdominal carcinomatosis "? no Path prognosis very poor,
refer to Carbondale for repeat Bx.(initial Dx no tumor seen)."
7/30/2017 The patient told a nurse "I'm hurting" but the nurse took no
further history.
8/1/2017 The patient told a nurse, "What do I need to do to get some
help. I'm deteriorating." The nurse did not refer to a physician
and a physician had not seen the patient for almost two
weeks. The patient complained of stomach pain.

324

11

Adequate information needed to be sent with the
patient for his appointment.

11

Hospital records were unavailable and the doctor didn't
know what occurred at the hospital. Follow up of
oncology was not being done. They had recommended
return if the patient decompensated, which had
occurred.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 325 of 431 PageID #:12523
Patient #24
8/2/2017 A doctor wrote that the patient had abdominal carcinomatosis
but that there was no pathological diagnosis. The needle
biopsy done in Carbondale was not diagnostic and "have
requested for repeat bx for path diagnosis abd remains
distended tense with umbilical hernia." That was the entire
note. There was no history from the patient and no updated
laboratory or physical examination.
8/2/2017 The patient told the nurse he was "worn out." The nurse
noted that his pain was unrelieved but that he didn't want his
prn pain medication at this time.
8/4/2017 A nurse documented the patient saying, "You gotta help me.
These pain pills don't work." The nurse noted severe pain
despite Norco. A doctor was notified that the patient had a
large abdomen that was tender to touch. The patient was
sent to a hospital.
8/4/2017 A clerk documented that Dr. Siddiqui's referral for repeat CT
guided biopsy was approved. A second referral for oncology
follow up was approved as well.
8/8/2017 The patient was readmitted to the infirmary as a chronic
patient. The doctor admission noted that the patient had a
repeat needle biopsy and that CA-19 and CEA were negative.
The patient was on hydrocodone 7.5 mg QID and Zofran. The
doctor noted that the biopsy results were pending.
8/8/2017 A doctor noted receiving a call from the surgeon who told him
that the biopsy needle may have hit a small bowel loop. The
doctor noted an abdominal x-ray [ordered at Menard] showed
no free air. The doctor noted that the patient had an oncology
appointment in two days.

325

1, 2, 3 The doctor failed to take history, evaluate the patient,
or make a plan consistent with the patient's pain. The
patient had not been seen for a couple weeks and the
doctor did not even evaluate the patient.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 326 of 431 PageID #:12524
Patient #24
8/9/2017 The patient told a nurse that the pain medication wasn't
helping and that he had trouble breathing. The nurse noted
that she had difficulty listening to his lungs due to the patient
making noise. The nurse called a doctor who ordered an
additional dose of Norco.
8/9/2017 A doctor wrote that the patient still had abdominal pain and
constipation. He ordered MS contin and Vicodin and Miralax.

8/9/2017 A nurse wrote that the inmate was mumbling, was confused
and unable to answer questions. The patient was sent to a
hospital.

326

19

The doctor should have evaluated the patient who
stated he couldn't breathe.

1, 2, 3 The doctor did not apparently evaluate the patient and
instituted a plan without evaluation of the patient. The
patient's trouble breathing was not evaluated.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 327 of 431 PageID #:12525
Patient #25
4/14/2017 The dentist saw the patient and documented referral for
evaluation of radiolucency.
4/17/2017 A referral for evaluation of a radiolucency of the left jaw by a
dentist. The dentist diagnosed dentigerous cyst r/0
ameloblastic changes of the L mandible.
6/22/2017 Pathology reported Diffuse large B cell lymphoma with bone
involvement
6/27/2017 A referral form to oncology noting that a left mandibular cyst
showed diffuse large B cell lymphoma with bone involvement.

12

It took over two months to get a biopsy of an abnormal
bony lesion.

12

It took four months to start chemotherapy. This could
have been more timely.

6/29/2017 A scheduling clerk noted that Dr Siddiqui presented at collegial
for oncology for a mandibular cyst. The referral was
approved.
7/3/2017 A scheduling clerk noted that an appointment was scheduled
with Illinois Oncology on 7/7/17.
7/7/2017 Part of an oncology note was present. The oncologist
recommended CT scan chest, abdomen, pelvis, PET scan,
MUGA.
7/13/2017 A scheduling clerk noted that Dr. Siddiqui referred the patient
for bone scan, CT scan and MUGA scan. These were approved.
7/14/2017 A Wexford approval for a bone scan, MUGA scan, CT of neck,
thorax, abdomen and pelvis.
7/25/2017 CT chest abdomen and pelvis showed no lymphoma.
7/31/2017 An US of the abdomen was not done due to lockdown.
8/4/2017 Wexford approved a referral to oncology.
8/8/2017 A MUGA scan showed uptake only in the mandible.
8/11/2017 An oncologist stated that he would start CHOP which would
start on 8/18/17. The patient was to receive six cycles every
three weeks of cyclophosphamide, doxorubicin, vincristine
and prednisone. The regimen included use of pegfilgrastin
after chemotherapy.

327

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 328 of 431 PageID #:12526
Patient #25
8/17/2017 A scheduling clerk noted that chemotherapy was approved for
every three weeks.
8/18/2017 WBC 5.9; HGB 15.6; platelets 189.
8/25/2017 WBC 7.1; HGB 15.5; platelets 188; HCV undetectable.
8/31/2017 An untitled note documented that an oncologist ordered cipro
for 10 days, Ativan, prednisone on days 1-5 of each 21 day
cycle, and Compazine. The oncologist also ordered Rituxan
every three weeks. The oncologist also ordered neulasta 6 mg
after each CHOP treatment as directed and asked that the
oncologist be notified if approved.

It appeared that the patient received chemotherapy on
this day but we could not find all chemotherapy reports
in the record.

9/1/2017 A NP wrote that Boswell was substituting Granix for Neulasta
and ordered it daily for seven days every three weeks after
"treatment," presumably chemotherapy for three months.
9/8/2017 A nurse wrote that the patient returned from chemotherapy.
There was an order for ciprofloxacin.
9/8/2017 WBC 0.4; HGB 13.2; platelets 69; and the ANC was 100 which
was critical.
9/11/2017 A nurse evaluated the patient for abdominal pain post
chemotherapy. The patient said he had bright red blood in his
stool. The patient was apparently on Motrin. A nurse noted
that the patient was unable to stand and had a distended
abdomen which was hard and painful to touch on the left side.
9/11/2017 A nurse noted that the patient was brought to the HCU for
abdominal pain and received a verbal order for an abdominal xray, a UA for culture, with orders for fiberlax and MOM with a
PRN follow up.
9/21/2017 The patient returned from chemotherapy.

328

There was no evidence we could find in the record that
the patient received Granix although it was on the MAR.

8, 6,

A doctor did not see the patient post chemotherapy and
the white count post chemotherapy was not checked.
These labs were from the oncology office.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 329 of 431 PageID #:12527
Patient #25
10/3/2017 A doctor noted that the patient had NHL and was being
6, 1, 11
treated with CHOP and the next chemotherapy was 10/12/17.
There was no status update for the patient. The note was
extremely brief. There was no physical examination. The
doctor wrote "?CBC." The doctor noted that the patient was
to start prednisone for five days. The doctor didn't review
blood counts or the oncology report.

The doctor failed to review the history of what
happened in oncology clinic and did not review the
report. We could not find an oncology report for this
date. The doctor failed to check the white count despite
that this was critical as the patient was subject to
neutropenia.

10/12/2017 The patient returned from a medical furlough.
10/13/2017 A nurse documented that the patient returned from a medical
furlough. The oncologist note documented that on 11/2 the
patient was to receive Rituxan and neulasta.
10/31/2017 The October MAR listed Granix but there was no evidence that
it was administered.
11/1/2017 A doctor noted that the patient was seen by oncology for
chemotherapy. The doctor did not update the status of where
in treatment the patient was.
11/2/2017 A oncology order documented that the patient would return
11/22/17 for the next chemotherapy infusion.
11/9/2017 The patient told a nurse he was concerned about adverse
effects of prednisone.
11/11/2017 A doctor saw the patient. The note was illegible but brief.
11/21/2017 WBC 6.7; hemoglobin 10.4; platelets 221.
11/22/2017 On return from chemotherapy the blood pressure was 86/56
and a nurse notified a doctor who sent the patient to a
hospital.

329

6, 8

The doctor did not order or review CBC counts to ensure
the patient wasn't neutropenic.

This was a pre-chemotherapy CBC.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 330 of 431 PageID #:12528
Patient #25
11/22/2017 The patient went to Chester Memorial Hosp for weakness,
dizziness, and diaphoresis. The hospital note documented that
the patient was on amlodipine, filgrastim 480 mcg, ibuprofen,
metoprolol, prednisone, prochlorperazine and ondansetron.
The WBC was 6; HGB 9.7; platelets 196. The patient was
diagnosed with dehydration and sent back to Menard.
11/26/2017 A nurse saw the patient for nausea. The temperature was
101.6. The patient was too weak to stand. The nurse placed
the patient "on the third floor."

11/28/2017 A doctor saw the patient and noted that the patient was on
chemotherapy and had nausea and diarrhea which had
resolved. The doctor assessed dehydration and ordered IV
fluid and Levaquin. The patient had a 101 fever and a pulse of
113. Without an diagnostic effort the doctor ordered
Levaquin. There was no diagnosis and it wasn't clear what the
doctor was treating. The doctor did not order a white count
or ensure that the patient was receiving gramix. The doctor
ordered Levaquin daily for five days, stopped amlodipine and
metoprolol, started IV saline and Zofran.
11/29/2017 A nurse noted that the patient had blood pressure 90/60 and
temperature 98. The patient felt sick and had diarrhea.

330

1, 8

The patient had a fever to 101.6 which if present in a
neutropenic patient constitutes a neutropenic fever. It
was imperative for the doctor to take a history to
identify any signs of infection and to obtain a stat CBC to
determine if the patient was neutropenic. This error
was grossly and flagrantly unacceptable.

8

The patient still had fever of 101. It was imperative to
exclude neutropenia, which the doctor did not do. Care
was grossly and flagrantly unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 331 of 431 PageID #:12529
Patient #25
11/29/2017 At 8:00 am doctor wrote an infirmary admission note and
noted that the BP was 90/60. The doctor noted that the
patient had dehydration after developing nausea and vomiting
after chemotherapy. The doctor noted that the blood
pressure medication was discontinued.

8

Hypotension in the context of possible neutropenia can
indicate infection, particularly if the patient is on
prednisone, which this patient was taking. It was
imperative for the doctor to order an immediate white
count to ensure the patient wasn't neutropenic. Care
was grossly and flagrantly unacceptable.

11/29/2017 At 9:00 am the patient said his ear hurt and the nurse notified
the doctor. The nurse documented that there was drainage
from the ear which was painful. The nurse admitted the
patient to the infirmary. The temperature was 99.8 and pulse
102. This was not noted by a doctor. The doctor ordered a
CBC and CMP.
11/30/2017 A doctor noted that the patient had pus coming from the left
ear and changed the Levaquin to IV, but since Levaquin was
unavailable, he started Rocephin. The diagnosis was Otitis
externa.
12/1/2017 A doctor noted that there was still pus from the ear and did
not change therapy.

16

The nurse should have notified the doctor even though
the doctor had just seen the patient.

8, 14

The doctor should have obtained an immediate CBC to
ensure that the patient was not neutropenic or send the
patient to a hospital.

8, 14

The doctor should have obtained an immediate CBC to
ensure that the patient was not neutropenic or send the
patient to a hospital.

12/3/2017 A NP saw the patient who was found unresponsive with blood
on his mouth, and blood draining from his penis. The NP sent
the patient to a hospital. The patient had fever of 101.2, BP
96/60; pulse 120, respirations as high as 42.

331

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 332 of 431 PageID #:12530
Patient #26
8/26/2008 Cholesterol 158; HDL 47; LDL 99; ACA 10-year risk 7.1 % and
no indication for a statin.
9/3/2008 An NRC reception physical examination documented no
medical problems except alcohol use.
9/3/2008 The patient was transferred to Menard.
1/27/2010 Cholesterol 158; HDL 47; LDL 99; ACA 10-year risk 7.1 % and
no indication for a statin.
2/24/2010 A doctor saw the patient and noted that the patient passed
out and fell but said, "I was informed that I was hit in the face
by a guard." The doctor ordered a facial x-ray that showed no
fractures or dislocations. The doctor ordered ibuprofen for
pain. The doctor apparently presumed that the patient
sustained blunt trauma and did not pass out. No other
diagnostic studies were performed (EKG, Holter monitor,
glucose).
3/13/2012 Total cholesterol 134; HDL 29; LDL 96.
3/13/2012 Cholesterol 134; HDL 29; LDL 96; ACA 10-year risk 7.6% and
indication for moderate to high intensity statin.
1/27/2014 Cholesterol 144; HDL 40; LDL 95.
1/27/2014 Cholesterol 144; HDL 40; LDL 95. ACA 10-year risk 9.2% and
moderate to high intensity statin indicated.
12/31/2014 Dr. Trost wrote that the "I/M [without] S/S of chickenpox. P.
RTC prn." It wasn't clear what this meant as there was no
history or physical examination.
12/14/2015 Albumin 3; cholesterol 168; HDL 42; LDL 117.
12/14/2015 Cholesterol 168; HDL 42; LDL 117; ACA 10-year risk 10.8% and
indication for moderate to high intensity statin

332

7, 8

The patient passed out and should have had an EKG and
glucose test. The doctor should have considered a
Holter monitor.

17

Since 2012 the patient had a 10-year risk of heart
disease of at least 7.5% and should have been offered
statin therapy to reduce cardiovascular risk.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 333 of 431 PageID #:12531
Patient #26
1/23/2016 The patient had biannual examinations in 2010; 2012; 2014;
and on this date in 2016. At each of these the patient was not
offered standard colorectal screening. The patient did refuse
a digital rectal exam which apparently was being offered as
colorectal screening. The patient was above 50 years old at
each of these examinations and the patient was 67 years old
at this examination.
3/20/2017 A doctor wrote that the patient was short of breath. There
was no other history. The doctor wrote "vitals questionable.
Patient very pale, hands cold." That was the entire
examination. The vitals were not documented except a
oxygen saturation of 97% and a number 199 which was
unintelligible. The assessment was "anemia" and the doctor
ordered a CBC and CMP stat. In a later note the doctor noted
that the labs "are within an acceptable limit. However patient
gets extremely fatigued with any type of physical exertion."
The assessment was shortness of breath. The doctor ordered
a chest x-ray and abdomen x-ray and UA.
3/21/2017 The problem list documented heart failure and atrial
fibrillation. No other problems were listed on the problem list.
3/21/2017 A NP noted that the patient was an add on to clinic. The NP
documented that the chest x-ray showed "?pneumonia." The
BP was 152/100 and respiratory rate 38-40 with a
temperature of 96.2. The NP ordered a stat EKG.

333

7, 17

The patient was not offered colorectal screening
consistent with contemporary guidelines and was not
offered a statin medication.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 334 of 431 PageID #:12532
Patient #26
3/21/2017 An EKG showed atrial fibrillation with a rate of 91. A chest xray showed moderate sized pleural effusion right with a
smaller pleural effusion left. Patchy opacities are seen
perihilar regions suggesting heart failure or pneumonia.
3/21/2017 The patient was admitted to Memorial Hospital in Chester IL, a
25-bed hospital. The evaluation in the ER was that the patient
had an irregular heart rate with 2+ pitting edema and bilateral
trochanteric ulcers worse on the right. The BUN was 25; CK
MB was 7.3 (1-7); troponin <0.01; albumin 2.7; hemoglobin
13.7; WBC 6.4; INR 1.31; an EKG showed atrial fibrillation with
a ventricular rate of 93; bilateral pleural effusions,
cardiomegaly, bibasilar infiltrates and heart failure. The
hospital note documented consulting with a primary care
provider and the NP at Menard who sent the patient, and the
NP agreed to accept the patient back to the facility. The
patient was in heart failure with new onset atrial fibrillation
and the patient should have been sent to a regional center for
management, as it was not safe to accept the patient back at
the facility. The only diagnostic testing done was a chest x-ray
that showed "large bilateral pleural effusions and there is mild
to moderate bilateral compression atelectasis caused by the
effusions." There was a 14 mm hypodense nodule in the
thyroid gland and there was a prominent suprahilar node. The
heart was enlarged. Pneumonia couldn't be excluded.

334

14

The NP accepted a patient back to the prison when it
was not safe to do so. The patient had pneumonia,
pleural effusions, heart failure, and new onset atrial
fibrillation.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 335 of 431 PageID #:12533
Patient #26
3/21/2017 A NP admitted the patient to the infirmary for dyspnea and
anemia. The examination only noted that the patient was
pale, dyspneic, without breath sounds on the right. The NP
noted that the patient was sent to a hospital in the morning
and had a diagnosis of atrial fibrillation, heart failure, and
decubitus ulcer. The NP noted that the patient was on Eliquis,
lisinopril, and Lasix. The NP ordered a CXR, CBC, CMP, HIV,
hep C, RPR, Hep panel, FLP, AFT, sed rate, CRP, magnesium,
TSH, B121 and referral for cardiology, and CT of abdomen. The
pulse was 108; respirations 16; and BP 130/82. The NP did not
discuss the EKG or perform another EKG.
3/21/2017 A NP referred the patient to a cardiology consultation for A
fibrillation. The NP also referred the patient for a CT of the
chest and abdomen because the patient appeared thin.
3/22/2017 A nurse noted that the patient was incontinent of stool. The
patient had a respiratory rate of 30 with blood pressure of
86/60 with 2 + pitting edema and was short of breath with
exertion. The patient was sent to a hospital.
3/22/2017 AFP 0.9 (<9); CRP 0.6 (0-8); cholesterol 127; HDL 36; LDL 84;
magnesium 1.5 (1.8-2.4); TSH 4.12 (0.35-4); sedimentation
rate 68 (0-10); HIV negative; syphilis non reactive.
3/22/2017 Cholesterol 127; HDL 36; LDL 84. The ACA 10-year risk was
13.1% and indication for moderate to high intensity statin.

335

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 336 of 431 PageID #:12534
Patient #26
3/23/2017 The patient was hospitalized at Memorial Hospital in
Carbondale, a 125-bed facility. The patient had an NSTEMI
and had systolic heart failure with renal failure and low
albumin and required bowel resection with colostomy for
ischemic bowel. The surgery included partial colectomy with
colostomy, splenectomy, and construction of a stoma. The
patient developed sepsis due to aspiration pneumonia. A
venous Doppler was done showing no evidence of a deep vein
thrombosis. The patient had MGUS. The bone was negative
for lytic lesions and the urine was sent for electrophoresis. A
chest x-ray showed a slight improvement in both lung bases
with mild decrease in the infiltrates. There was mild
cardiomegaly and perihilar markings were still prominent.
Pneumonia could not be excluded. Based on hospital records,
it appears that the ischemic bowel was identified on 3/28/17
after developing GI bleeding on 3/26/17. It is uncertain when
the ischemic bowel started. The ischemia was in the
rectosigmoid area.
3/28/2017 Wexford UM denied the cardiology consultation and CT chest
and abdomen because the patient was currently in the
hospital.
4/18/2017 The Wexford Regional Medical Director wrote a note that the
patient was in preparation for hospital discharge. The doctor
wrote a list of medications that the patient was on, including
lisinopril, pantoprazole, Lasix, Eliquis, docusate, MS ,
ondansetron, lorazepam, and hold scopolamine patch.

336

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 337 of 431 PageID #:12535
Patient #26
4/19/2017 The patient was admitted to the infirmary from the hospital
for comfort care. The admitting diagnoses were ischemic
colitis, atrial fibrillation, acute renal failure and a comment
"*see additional list." The orders were for oxygen, condom
catheter, turn the patient every two hours, follow up with Dr.
Gonzales in 1-2 weeks, keep the incision clean and dry and
colostomy care.
4/19/2017 An undated note a nurse wrote a discharge note. This was
immediately after the admission note on 4/19/17. The note
had no vital. The discharge summary was s/p hospital stay
ischemia colitis, ARF, CHF. The objective note was "I/M
discharged dlt death." The discharge location was "funeral
home." This note appears to have been written before the
inmate died.
4/20/2017 A nurse entered his room at 3:55 am to find the patient
unresponsive.

337

Patient #27

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 338 of 431 PageID #:12536

2/4/2005 EKG showed moderate voltage criteria for LVH and inf infarct
age indeterminate
1/24/2011 On this annual physical examination the blood pressure was
130/80.
1/31/2014 Amlodipine 10, carvedilol 50 BID, HCTZ 50, losartan 50 BID,
spironolactone 50 daily, terazosin 7 mg.
2/12/2014 Potassium 3.7 (3.5-5.3); cholesterol 165; HDL 34; LDL 110.
2/31/14 Amlodipine 10, carvedilol 50 BID, HCTZ 50, losartan 50 BID,
spironolactone 50 daily, terazosin 7 mg.
3/5/2014 HTN chronic clinic BP 210/140. The doctor noted shortness of 1, 2, 8, The blood pressure was significantly elevated The
breath which the patient attributed to anxiety. The doctor did 12, 15 doctor did not evaluate for encephalopathy or renal
not check for end-organ damage despite the significantly
damage. Although the doctor made a change in therapy,
the doctor did order a timely follow up for this degree
elevated blood pressure. The doctor added Cozaar to Norvasc,
of hypertension and did not ensure that the patient's
Aldactone, and Coreg and stopped HCTZ and Hytrin. The
blood pressure was lowered to a safe level. The doctor
doctor referred to psychiatry. The doctor did not order follow
took no history of compliance. The patient was on five
up to ensure that the blood pressure returned to a reasonable
level.
antihypertensive medications with extremely high blood
pressure. The patient should have been sent for
evaluation of secondary hypertension to a specialist.

3/18/2014 A doctor saw the patient. The blood pressure was 180/110.
The doctor did not examine the retina, or check for renal
damage. The doctor discontinued Norvasc and documented
that the patient was on nifedipine 120, Aldactone 100, HCTZ
50, carvedilol 50BID, Cozaar 50 BID, minoxifil 2.5 mg daily, and
Hytrin 10 mg daily. The nifedipine and minoxidil appeared to
be added to the regimen but the doctor didn't reflect this in
his note.
3/27/2014 A nurse saw the patient and noted that the patient
complained of his heart skipping beats.

338

Patient #27

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 339 of 431 PageID #:12537

3/27/2014 The patient complained to a nurse that his blood pressure of
234/140 was related to anxiety. A doctor saw the patient but
didn't document a change in therapy.

3/31/2014 Carvedilol 50 BID, losartan 50 BID, Aldactone 100, HCTZ 50,
BID, minoxidil 7.5 daily, Hytrin 10 Q day.
4/22/2014 A doctor increased minoxidil but took no history and no
physical exam.
4/22/2014 The patient told a nurse that his blood pressure of 210/140
was related to stress.

15

The blood pressure was significantly elevated. The
doctor did not ensure that the blood pressure was
lowered to a safe level. The doctor did not evaluate for
end organ damage and did not schedule the patient for
follow up in a few days to ensure that the patient was
safe. The doctor took no history of compliance.

16

The patient should have been referred to a doctor due
to the extremely elevated blood pressure.

12

This patient had clear indication for evaluation for
secondary hypertension and should have been
approved for that.

4/23/2014 Dr. Trost wrote an extremely brief note and referred the
patient to on outside hypertension clinic. The blood pressure
was 170/104.
4/24/2014 Dr. Trost noted that at collegial he was to give all meds DOT.
4/28/2014 Wexford denied referral to an outside hypertension clinic
based on "insufficient information." A recommendation for
DOT was made and to represent if needed.
5/3/2014 The inmate complained about getting DOT medication.
5/18/2014 Calcium 7.9; sodium 136; potassium 4.6. No LFTs done.
5/22/2014 Wexford denied a visit to HTN clinic asking that medication be
DOT and to represent in a few weeks if needed. The reason
for denial was insufficient information. This was appealed and
apparently approved on this date.
5/31/2014 Carvedilol 50 BID, losartan 50 BID, Aldactone 100, HCTZ 50,
Cozaar 50 BID, minoxidil 7.5 daily, Hytrin 10 Q day, Nifedipine
120 daily.
6/4/2014 Potassium 3.1; BUN 5.

339

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6/15/2014 The inmate refused medication, not wanting to take DOT
medication.
6/25/2014 Dr. Trost documented that the patient would review
medication if not DOT. The doctor noted BP 220/120,
resumed KOP meds and referred the patient to an outside
HTN clinic.

6, 17

The doctor did not note the prior low potassium. Low
potassium in the context of difficult to control blood
pressure should lead to an evaluation for secondary
hypertension. Medication should have been adjusted.
Because of the extremely high blood pressure the
doctor should have scheduled follow up in a few days to
assess whether it returned to normal.

6/30/2014 Carvedilol 50 BID, losartan 50 BID, Aldactone 100, HCTZ 50,
BID, minoxidil 7.5 daily, Hytrin 10 Q day, Nifedipine 120 daily.
7/10/2014 An NP saw the patient for HTN chronic clinic. The BP was
1, 2, 3,
226/142. The NP took little history and noted that the patient 8, 12,15,
was scheduled to see a hypertension specialist. The patient
17
refused to take Norvasc so the NP made no changes and
referred to Dr. Trost. A statin should have been started but
was not. Medication compliance was not discussed.

7/16/2014 Dr. Trost noted that the patient was taking BP medication.
The BP was 230/126. There was no history or physical
examination. The plan was to refer to HTN clinic consultant.

The 10-year risk of heart disease was 29% and a statin
should have been started. The patient had hypertensive
urgency and should have been assessed for end-organ
damage and monitored in the clinic until the blood
pressure returned to a lower level or a couple day
follow up was indicated. Modification of blood pressure
regimen was indicated. The patient should have been
referred for evaluation of secondary hypertension.

1, 2, 8, Given the blood pressure the consultant visit should
12, 15 have been sooner. The patient had hypertensive
urgency and apparently was taking medication yet the
doctor did not add medication or monitor the patient
until the blood pressure returned to a lower level. The
doctor ordered no follow up to ensure that the blood
pressure returned to a lower level. The doctor did not
take history or perform examination to exclude endorgan damage.

340

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7/31/2014 Carvedilol 50 BID, losartan 50 BID, Aldactone 100, minoxidil
7.5 daily, HCTZ 50, spironolactone, Terazosin 10.
8/27/2014 The patient went to an outside HTN consultant at Barnes
Hospital.
8/27/2014 The patient went to Barnes Hospital HTN clinic. The doctor
had no labs available. The doctor documented that the
patient stated that he was anxious. The BP was 212/147. The
doctor noted that the patient wasn't currently taking
medication. The doctor recommended that the patient start
back on HCTZ, spironolactone, and to add other medications
back slowly. The doctor said she would try to call to discuss.

11

8/30/2014 A doctor saw the patient after the Barnes consultant visit. The 1, 2, 3,
blood pressure was 208/156. The doctor noted that the
8, 10,
patient had anxiety problems and that the consultant would
13, 15
speak with Dr. Trost but that there were no notes about these
communications in the chart. The doctor referred the patient
to psychiatry to evaluate his anxiety. The doctor did not
evaluate for end-organ damage by history or physical
examination. The doctor did not adjust blood pressure
medication or ensure that a follow up was ordered to ensure
that the blood pressure safely was reduced.

The labs were not sent with the patient specifically the
low serum potassium was not known to the consultant.

The doctor did not document review or did not talk to
the consultant about care. Referral to psychiatry was a
questionable strategy. The patient had hypertensive
urgency yet the doctor did not evaluate for end-organ
damage or ensure that the blood pressure was reduced
to a safer level. The doctor should have added blood
pressure medication and assessed for compliance.

8/31/2014 Carvedilol 50 BID, HCTZ 50, Losartan 50 BID, Minoxidil 7.5 mg
daily, Aldactone 50.
9/12/2014 A NP documented that the patient was only taking Aldactone
and HCTZ. The NP took no action and blood pressure wasn't
taken.
9/17/2014 A NP noted the BP was 204/104. The NP did not assess for
1, 2, 3, 8 the NP should have checked compliance, evaluated for
end-organ damage, and scheduled a follow up to ensure
end-organ damage or ensure that the blood pressure was
15
lowered before discharging the patient. The NP consulted the
blood pressure was coming down.
Medical Director but no action was taken. Compliance was
not checked.

341

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9/20/2014 A doctor noted the patient would refuse all medication until
something was found that works. The BP was 210/124. The
doctor referred the patient to Dr. Trost. The doctor stopped
all treatment.

1, 2, 3, The patient had hypertensive urgency but the doctor
8,15 took no history and performed no examination to
exclude end-organ damage. The doctor did not ensure
follow up would occur to safely follow up on this patient
with extremely elevated blood pressure. Probably, the
patient should have been placed on the infirmary.

9/30/2014 HCTZ 50, Aldactone 100, Hytrin 10 mg, minoxidil 7.5, Cozaar
50 BID, carvedilol 50 BID.

The medication renewal process didn't work and the
patient's medication stopped in mid December and
wasn't started again until 1/8/17, about 3-4 weeks later.

10/1/2014 Potassium 4.1.
10/11/2014 A psychiatrist documented the patient saying he didn't need to
see a psychiatrist and felt fine. The psychiatrist documented
no follow up.
10/22/2014 A doctor saw the patient for elevated BP 178/124. The doctor
noted that the patient needed to see a psychiatrist for his
anxiety. The doctor assessed anxiety reaction.
10/22/2014 A provider saw the patient for HTN clinic. The BP was
178/124. No history was taken. The doctor documented
referral to psychiatry and made no changes to medication.
Medication compliance was not discussed.

13

1, 2, 3, The doctor failed to assess for end organ damage in a
8, 12, 17 patient with hypertensive urgency. The doctor did not
assess for compliance. The 10-year risk of heart disease
was 24% and a moderate to high intensity statin should
have been started. The BP meds should have been
adjusted as the blood pressure was elevated. This
patient should have been referred for evaluation of
secondary hypertension.

11/1/2014 A MAR documented that the patient was on Remeron at night,
which he remained on although the patient mostly refused
this medication.
12/10/2014 Potassium 3.5 (3.5-5.3); BUN 6; creatinine 1.07; cholesterol
178; HDL 32;LDL 119.

342

Patient #27

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1/20/2015 On this annual physical examination the blood pressure was
130/88.

17

2/4/2015 Dr. Trost sent the patient to a hospital for "exercise
intolerance and PND." He documented that the EKG showed
SVT for which there was no evidence.
2/4/2015 An EKG showed st flattening but sinus rhythm with rate of
about 100.
2/4/2015 Potassium 3.7; cholesterol 180; HDL 36; LDL 117 urinary
glucose 300; serum glucose 110.
2/4/2015 EKG showed possible LAE and LAD.
2/4/2015 EKG showed sinus rhythm with PVCs; LAD and voltage criteria
for LVH.
2/5/2015 The patient returned from Carbondale Hospital.
2/5/2015 A discharge instruction sheet from the hospital recommended
an appointment for cardiology and nephrology in two weeks
but a written comment on this document states that "no F/U
request per Trost."

343

2

The 10-year risk of heart disease or stroke was 15% and
the patient should have been started on a moderate to
high intensity statin.
The doctor misdiagnosed an EKG tracing.

Hospital records were unavailable and the doctor didn't
know what occurred at the hospital. Follow up of
oncology was not being done. They had recommended
return if the patient decompensated, which had
occurred.

Patient #27

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2/5/2015 A hospital note documented an elevated glucose of 115 and
120; potassium of 3.1; elevated troponins. The patient felt
short of breath and had similar episodes but there was never a
work up according to the hospital chief complaint. There was
no chest pain. The patient was a former smoker. The patient
described stopping anti-hypertension medication because
they were not helping him. The discharge summary
documented diagnoses of hypertensive urgency with mild
troponinemia due to hypertensive urgency and episodes of
shortness of breath due to HTN, hypokalemia, and resistant
hypertension with hypokalemia concerning for
hyperaldosteronism. Labs were sent out. An echocardiogram
showed concentric hypertrophy and thickened LV wall. A
follow up with nephrology to rule out hyperaldosteronism was
recommended. The aldosterone was in normal range but the
patient was on Remeron, though mostly refusing it. The renin
was normal. The normetanephrine was elevated to 1.13 but
not over 2 x normal (0-0.89). In the hospital the cholesterol
was 148; HDL 23 and LDL 96.

2/5/2015 EKG showed possible LAE and nonspecific STT changes.
2/6/2015 Dr. Trost saw the patient post hospital return and sent the
patient back to his cellhouse but failed to make referrals to
cardiology and nephrology as recommended and did not make
note of the hypokalemia or elevated metanepherines.
3/5/2015 A doctor saw the patient in hypertension clinic and the blood
pressure was 200/140. The doctor presumed that the blood
pressure elevation was due to anxiety and referred the patient
to a psychiatrist. The doctor stopped HCTZ and Hytrin but
started Cozaar.

344

10

The doctor failed to review the hospital notes failing to
note the recommendation to refer to nephrology to rule
out hyperaldosteronism and to cardiology.

Patient #27

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3/6/2015 A doctor saw the patient for his elevated BP of 170/108. The
10
doctor mentioned that Carbondale hospitalists recommended
referral to cardiology and nephrology in two weeks and that
Dr. Trost made no referral. However the doctor took no
action.
3/7/2015 A psychiatrist documented that the patient was a no show to
clinic and rescheduled the patient.
3/8/2015 The KCL supplement was discontinued.
3/16/2015 A doctor saw the patient for HTN clinic. BP was 190/128. The 1, 2, 3,
cholesterol was documented as 180, HDL 36, and LDL 117, but 8, 10, 17
a statin was not started despite a 27% 10-year risk of
cardiovascular disease. The doctor checked the retina but did
not evaluate for other potential end-organ damage. The
doctor referred to Dr. Trost. The doctor noted that the
hospital recommended referral to nephrology and cardiology
but that this didn't happen. Medication compliance was not
addressed.

3/31/2015 Benicar 40 daily, diltiazem 180, hydralazine 75 TID, isordil,
metoprolol 25 BID, KCL, spironolactone 25 daily.
4/16/2015 An EKG showed rate of 68 with nonspecific STT changes.
4/31/15 Aspirin, diltiazem 180 daily, hydralazine 75 TID, isordil,
metoprolol 25 BID, spironolactone 25 daily. The Benicar was
stopped.
5/31/2015 Aspirin, diltiazem 180, hydralazine 75 TID, isordil, metoprolol
25 BID, spironolactone 25 daily.
6/31/15 Aspirin, diltiazem 180, hydralazine 75 TID, isordil, metoprolol
25 BID, spironolactone 25 daily.
7/1/2015 The Remeron appears to have stopped.
7/13/2015 The patient wrote a note to health care on a piece of paper
saying he might have a bronchial infection with "shortness of
breath attacks."

345

The doctor decided not to refer as recommended to a
nephrologist and cardiologist.

The doctor did not assess for end-organ damage except
for a retinal examination. The patient's blood pressure
medication should have been adjusted. The doctor did
not assess for compliance. The doctor should have
ensured that the blood pressure was lower prior to
discharge from the clinic or admitted the patient to the
infirmary. The patient should have been started on a
statin. The doctor should have documented why the
referrals to cardiology and nephrology were not done.

Patient #27

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7/14/2015 A doctor saw the patient and noted that the patient was short 1, 2, 3,
of breath. BP 190/118 but oxygen saturation 94%. The doctor 8, 10,
14, 15
wanted to rule out heart failure and ordered an EKG, chest xray CMP and BNP but these were not done stat and a week
follow up was ordered. The patient wasn't seen in a week and
wasn't evaluated until a NP saw the patient apparently on
10/9/15.
7/14/2015 Potassium 3.3; glucose 114; BNP 13 (<100).
7/31/2015 Hemoglobin A1c 7.3.

6

7/31/2015 Aspirin, diltiazem 180, isordil, hydralazine 75 TID, metoprolol
25 BID, spironolactone 25.
8/24/2015 Potassium 3 (3.5-5.3); glucose 139.
8/31/2015 Aspirin, diltiazem 180, hydralazine 75 TID, isordil, metoprolol
25 BID, spironolactone 25 daily.
9/20/2015 The patient wasn't seen in cardiac clinic because of the doctor
coming in late.
9/30/2015 Aspirin, diltiazem 180, hydralazine 75 TID, isordil, metoprolol
25 BID, spironolactone 25 daily.
10/9/2015 An NP saw the patient for shortness of breath. BP was
1, 2, 3,
220/120 and pulse 87. The NP noted a potassium of 3. The
6, 8, 15
NP ordered an EKG which showed nonspecific STT changes and
PVCs. A chest x-ray was not done. The retina weren't
checked. The patient had no edema.

10/9/2015 An EKG showed nonspecific STT changes with PVCs.
10/9/2015 Potassium 3.2; glucose 169.

346

The doctor did not evaluate for end-organ damage or
appropriately manage hypertensive urgency. The
patient should have had stat testing and been placed on
the infirmary. The patient appeared lost to follow up
for 3 months and ordered tests weren't done. The
doctor failed to modify blood pressure medication.

A provider signed this lab as reviewed on 8/5/15 but
took no action. The lab result indicated that the patient
had diabetes but the patient was never treated for this.

The blood pressure indicated hypertensive urgency.
Even though the patient had shortness of breath, the NP
did not evaluate thoroughly for heart failure. No other
end-organ evaluations occurred. The NP did not
monitor the patient until the BP improved and did not
house the patient on the infirmary. the NP did not
adjust medication. noted the low potassium but took no
action. The NP failed to note an A1c of 7.3 indicating
diabetes which was therefore untreated.

Patient #27

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10/19/2015 Cardiac chronic clinic was cancelled because the MD was not
in.
10/23/2015 Blood pressure was 164/88. A doctor noted that the patient
had anxiety and referred the patient to mental health. The
doctor noted that a chest x-ray was negative and the A1c was
now 7.3. The doctor took no action on the elevated A1c. This
was the same doctor who saw the patient on 7/14/15 but was
following up three months late.
10/25/2015 A doctor referred the patient to cardiology.
10/25/2015 A provider saw the patient in HTN clinic. BP 200/130. The
doctor took no history but wrote that cardiology needs to
follow the patient and referred to cardiology and increased
metoprolol and added diltiazem. Medication compliance was
not addressed.
10/31/2015 Aspirin, diltiazem 360, Lopressor 50 BID (10/25), hydralazine
75 TID, isordil, spironolactone 25. Diltiazem was increased.
11/30/2015 Aspirin, diltiazem 360, Lopressor 50 BID (10/25), hydralazine
75 TID, isordil, spironolactone 25.
12/30/2015 Aspirin, diltiazem 360, Lopressor 50 BID (10/25), hydralazine
75 TID, isordil, spironolactone 25.
1/6/2016 Dr. Trost saw the patient in HTN chronic care. There was no
history. The BP was 140/100. No change to therapy was
made. The patient was not on a statin.

3, 6

The doctor failed to note the low potassium which
suggested secondary hypertension. The patient had
diabetes and the doctor took no action to treat which is
inappropriate.

12

The diltiazem increased to 360 daily, the referral to
cardiology never occurred.

1, 2, 17 The doctor took no history, did not make an adequate
assessment, as he failed to diagnose or treat diabetes,
failed to note the low potassium which can be
associated with hyperaldosteronism, and failed to start
a statin despite a high 10-year risk of heart disease.

347

Patient #27

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1/28/2016 A doctor noted that the BP was 212/140. The patient refused 1, 2, 6,
observation housing. The doctor referred to Dr. Trost, the
8, 17
Medical Director. The patient refused clonidine. The doctor
increased the hydralazine to 100 TID and Lopressor to 150 BID.
The doctor noted that the A1c was 7.3 but took no action. The
doctor did not assess the patient for end-organ damage but
did try to place the patient on protected housing.
1/31/2016 Aspirin, diltiazem 360, hydralazine 100 TID, Lopressor 150 BID
( 1/28/16); Aldactone 25.
2/24/2016 Potassium 3.1; glucose 97; cholesterol 174; HDL 32; LDL
cholesterol.
2/28/2016 Aspirin, diltiazem 360, hydralazine 100 TID, Lopressor 150 BID
spironolactone.
3/9/2016 An NP saw the patient in HTN clinic. The retina was not
1, 2, 6,
examined. The patient was not assessed for end-organ
3, 12,
damage with labs. BP was 201/110. The NP added Maxide
15,17
but stopped hydralazine. The potassium was noted to be 3.1
but no action was taken. The cholesterol was 174; HDL 32 and
LDL 120, yielding a 49% 10-year risk of heart disease and
stroke. Apparently the patient was compliant with
medication as the medication compliance box was checked.

3/9/2016 Maxide was started despite hypokalemia. There was no
potassium supplement.

348

The doctor failed to assess for end-organ damage by
history, physical examination or lab testing. The doctor
noted a hemoglobin A1c of 7.3 but did not treat the
patient for diabetes.

The therapeutic plan was inappropriate. The patient
had a low potassium and in the context of difficult to
control hypertension, hyperaldosteronism should have
been ruled out. The patient should have been referred
to a nephrologist for better blood pressure control and
for possible hyperaldosteronism, and the patient should
have been on a high intensity statin because of high risk
for heart disease. Also, the patient had diabetes which
was unrecognized and untreated. The NP failed to
evaluate for end-organ damage despite hypertensive
urgency. The NP failed to ensure that the blood
pressure came down before leaving clinic, did not admit
to the infirmary or ensure the patient had follow up.
Starting maxide in a person with hypokalemia without
adding potassium supplement was an error also.

Patient #27

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3/29/2016 A nurse saw the patient for an episode of shortness of breath
that resolved. BP 240/140. The nurse called Dr. Trost, who
took no action.
3/31/2016 The MAR showed that the patient was on aspirin, diltiazem
360 ER daily, isosorbide, spironolactone 25 daily (stopped in
March), Maxide 75/50, metoprolol 25 BID,

3

4/29/2016 An NP saw the patient for BP 260/130. The NP gave a couple 1,2,3, 8,
stat doses of clonidine, increased metoprolol, and
15,
documented consulting with Dr. Trost. The blood pressure
came down to 170/118, but the NP should have ensured the
blood pressure came down further before discharge. The NP
did not assess for end-organ damage except to note that the
patient had no headache. An elective EKG was ordered. A
two week follow up was ordered, although this interval should
have been less due to the degree of elevation of the blood
pressure.
5/25/2016 A NP noted BP 230/110 and wrote "cardiologist visit before
that has not helped." The NP started clonidine 0.1 BID which
the inmate subsequently refused. The NP took an appropriate
history for end-organ damage but ordered no tests, (renal
function). The NP ordered an EKG but did not review. The NP
should have placed the patient on the infirmary. The follow
up in a week was insufficient given a blood pressure of
230/110.
5/31/2016 The patient was on 180 Diltiazem daily, isordil, metoprolol 50
BID, Maxide 75/50, started clonidine 0.1 BID 4/26.
6/1/2016 The patient refused to take clonidine and a nurse referred him
to a physician clinic.
6/2/2016 An EKG showed marked sinus arrhythmia with probable old inf
wall infarct.

349

The doctor should have adjusted medication.

The NP did not evaluate for end organ damage or
ensure that blood pressure was reduced to a reasonable
level before discharge or did not admit to the infirmary.
The NP did not order timely follow up given his blood
pressure level. He should have been admitted to the
infirmary.

8, 15

Hydralazine was stopped.

Patient #27

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6/3/2016 An NP documented that the BP was 150/100. The NP wanted
to give the patient stat clonidine but he refused. A two week
follow up with Dr. Trost was ordered. The NP ordered a GFR
and TSH.
6/6/2016 A nurse obtained blood pressure of 220/110 but did not
consult a provider.
6/7/2016 The BP was 200/100 but the nurse did not consult a physician

16

The nurse should have consulted a doctor

16

The nurse should have consulted a doctor.

6/10/2016 A nurse documented BP 200/100 but did not consult a
16
physician
6/10/2016 Creatinine 1.24.
6/12/2016 A nurse documented that the patient was refusing medication.
This was later documented as clonidine.
6/14/2016 An NP noted the BP was 170/100 The NP reviewed the MAR
and noted that the inmate was refusing only clonidine because
it was DOT.
6/16/2016 An NP documented that BP was 234/138. The NP noted that
1, 2, 3,
he refused clonidine, so she increased the metoprolol. The NP
8,
documented that the inmate refused infirmary admission. The
history and lack of testing was inadequate for evaluation of
end-organ damage.
6/21/2016 Dr. Trost note stated in its entirety "BP same as always." The
BP was 220/120. He ordered a "prn" follow up.

6/31/16 Aspirin, diltiazem 180, metoprolol 50 BID increased to 100 Bid
on 6/16, Maxide 75/50, clonidine stopped 6/16/16, Aldactone
50 BID started 6/16.

350

The nurse should have consulted a doctor.

The NP should have evaluated for end-organ damage
(renal function, EKG, better history and examination of
retina).

1, 2,3, This was indifferent care. The doctor did not evaluate
8,13, for end-organ damage. The blood pressure needed
control and the doctor should have referred to a higher
level consultant to manage the patient. The doctor
failed to rule out hyperaldosteronism and failed to
discuss the degree of noncompliance and it possible
impact on blood pressure control.

Patient #27

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7/30/2016 Aspirin, clonidine 0.1 BID, diltiazem 180 daily, metoprolol 100
BID, Maxide 75/50, Aldactone 50 BID.
8/12/2016 Potassium 3.3; glucose 96.
8/30/2016 Maxide, aspirin, diltiazem 180 , metoprolol 100 BID,
spironolactone 50 BID.
10/3/2016 Officers brought the patient to nursing sick call for a low bunk
gallery because the patient was unsteady and was almost
falling off his bunk. The BP was 250/140. The inmate refused
to go to the health care unit and the nurse made a referral to a
doctor.
10/13/2016 The patient was no show to a doctor clinic.
10/19/2016 The patient was a no show to clinic. The CMT wrote that the
inmate refused.
11/11/2016 The patient was unresponsive. CPR was started but the
patient died. There was no timeline of CPR.
11/12/2016 An autopsy found normal adrenal glands, no disease of the
pancreas, or GI tract. The coronary arteries showed varying
degrees of atherosclerosis including 75% RCA, LAD 95%; 50%
circumflex. The cause of death was atherosclerotic and
hypertensive cardiovascular disease.

351

16

The nurse should have consulted a doctor and have the
patient brought to the clinic.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 352 of 431 PageID #:12550
Patient #28
8/6/2014

A doctor noted that the patient had been in the infirmary
since 8/6/14 due to falling in general population and
decreased mobility. The patient had no medical issues listed.
The patient apparently was in a wheelchair. The doctor did
not list the patient's medical problems.

8/10/2014

A nurse stated that the patient was alert but thought it was
September when it was August. The one consistent item
nurses monitored was whether the patient fell.
A doctor saw the patient but noted none of the patient's
medical problems so it was not possible to know what was
wrong with the patient. The doctor wrote "see MD note
4/10/14 for HP infirmary and PMHx." But that note was not
available.
A nurse noted that the patient was up for his insulin. So I
could know that he had diabetes, but neither nursing notes
nor physician notes list his problems. Nurses do not document
vitals or CBGs on their notes.

8/14/2014

8/15/2014

352

1, 2,

The doctor didn't take a history or make an assessment
even though the patient was on the infirmary.

1,2

The doctor didn't take a history or make an assessment
even though the patient was on the infirmary.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 353 of 431 PageID #:12551
Patient #28
8/20/2014

A doctor's note was more informative. The assessment
documented that the patient had been in the infirmary since
1/28/13 [this contradicts the note from 8/6/14 although
written by the same doctor] due to falls in population. The
patient had multiple falls using a cane and walker and was said
to be "noncompliant" with the walker and "resisting
instructions in correct use" and "in late May 2013 put himself
in an empty wheelchair subsequently refusing walker
entirely." The patient had a special needs placement form for
handicapped prison done 1/28/13 but apparently there was
no place for him to go. The doctor listed problems as type 2
DM, mild heart failure, HCV, knee arthritis, and postamputation of right fore foot from osteomyelitis and ASPVD
and neuropathy. The doctor did not monitor sugars or note
any clinical benchmarks for this patient.

8/27/2014

A doctor saw the patient but noted no problems. There was
no history, no assessment of existing problems, and no
documented therapeutic plan.
Albumin 2.8; alk phos 171 (40-125); ast 53 (10-40); WBC 3.3;
HGB 8; platelets 144 (150-450); A1c 6.1.
A doctor saw the patient but documented no problems. There
was no assessment of problems and no therapeutic plan.

9/2/2014
9/2/2014

353

3

There was no therapeutic plan for this patient.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 354 of 431 PageID #:12552
Patient #28
9/9/2014

A doctor saw the patient apparently for hepatitis C clinic. The 2, 6, 7,
doctor noted that HCV was diagnosed in 2007 at Stateville.
8, 12
The doctor noted that the patient consistently declined
interferon therapy but made no mention of whether the
patient wanted or didn't want treatment with the newer
antiviral medications. The doctor noted that the patient had
been vaccinated for hepatitis A and B. The APRI was 0.92. The
doctor noted that the patient had cirrhosis, type 2 diabetes,
mild heart failure, HTN, degenerative arthritis, post forefoot
amputation in 1995 from osteomyelitis, macrocytic anemia
with low body weight but the anemia had become microcytic.
The doctor noted that the patient still did not want interferon
and was discontinued from HCV telemedicine clinic since
September of 2010. The doctor ordered stool for guaiac
three times. These cards were completed and negative
according to nursing notes. The doctor did not refer to Dr.
Paul, did not refer to UIC telemedicine clinic, did not order an
EGD or US for the cirrhosis.

9/15/2014

Doctor note addressed no medical issues. A brief examination
was done. But the only assessment was that the patient was
an infirmary patient since 2013 and referred to a 8/20/14 note
for details.
A nurse noted that the patient was incontinent of urine.

9/17/2014

354

The patient had likely cirrhosis with an APRI of 0.92, a
low albumin, elevated alk phos, low platelets, low white
count, and anemia. The doctor did not document
whether the patient had an EGD or ultrasound to screen
for varices or hepatocellular carcinoma. the patient
should have been referred to UIC telemedicine clinic
unless there were contraindications.

This demonstrates altered mental status.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 355 of 431 PageID #:12553
Patient #28
9/22/2014

A doctor saw the patient in diabetic clinic. The patient was
noted to be 81 years old and had been on insulin since age 60
and was now on NPH 14 am and 8:00 pm with 4 Reg TID after
meals with metformin 500 mg pm. The doctor noted that the
patient refused a diuretic for mild heart failure and HTN, and
had macrocytic anemia with low B12 levels. BP was 123/62
and weight 179. The doctor could not feel the distal pulses
and the patient could not feel the monofilament. Not clear if
the patient ever had ABI. The doctor noted that the recent
A1c was 6.1 and that the patient had good control. The meds
were insulin, metformin, aspirin, lisinopril, B12, and vit B6.
The doctor didn't document recent lipid values, recent
microalbumin level, recent creatinine.

9/30/2014

A nurse noted that the patient was alert but thought that
Thanksgiving was two weeks away.

10/2/2014

A doctor saw the patient. The assessment did not include an
assessment of his problems. No problems were listed. The
doctor performed an examination but made no assessment of
existing problems. These evaluations appear to be every two
week evaluations that are not clinically relevant.

10/17/2014 A doctor saw the patient and repeated the same assessment
virtually verbatim, stating that the inmate was in the infirmary
since 1/28/13 due to falls in population with a cane and that
he was "non-compliant" with a walker in the infirmary and had
no acute issues. The doctor referred to prior notes for the
past medical history. The doctor as usual did not address any
interval status of the patient's clinical problems.

355

1, 7

If the patient could not feel a monofilament test the
patient should have had ABI to evaluate the distal
vasculature. It was not clear what the patient's mental
status was. The doctor made no mention of the
incontinence in his note. It appeared that the patient
might have dementia that was unrecognized.

1

The patient appeared to have some degree of dementia
but it wasn't documented in the record and did not
appear to be tracked.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 356 of 431 PageID #:12554
Patient #28
11/4/2014

Albumin 2.8; alk phos 205; AST 47 (10-40); cholesterol 104;
HDL 59; LDL 39 (50-129); HCV 2,050,457.
11/17/2014 Fibrosure score indicative of cirrhosis at 0.77 (0-0.21).
12/4/2014 A1c 6.2.
12/8/2014 A nurse evaluated the patient using a "cough" protocol for
congestion and appearing drowsy all day. The temperature
was 98.1. The nurse gave the patient OTC medications by
protocol.
12/11/2014 A doctor saw the patient. As usual the doctor wrote a
1,2, 3, 6,
descriptive history of the patient's reason for being on the
7, 8
infirmary but did not address any of the patient's medical
issues. The doctor noted that a special needs placement form
was completed 1/28/13 but apparently hadn't yet been
addressed. The patient needed a nursing home but there was
no where to go so he remained on the infirmary.

12/22/2014 A nurse documented that Dr. Paul saw the patient in hepatitis
C clinic and referred to her progress notes.

356

The doctor did not take an adequate history or assess
the patients problems. The doctor did not address
recent labs. If the patient had cirrhosis, EGD should
have been done and every six months ultrasound to
screen for hepatocellular carcinoma. The albumin was
low and there was no assessment of nutritional status.
The alkaline phosphatase was elevated but not
addressed. It was not clear why the patient was not
referred to UIC for treatment.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 357 of 431 PageID #:12555
Patient #28
12/22/2014 A hepatitis C chronic clinic. Dr. Paul saw the patient and noted 7,8,12 The patient had cirrhosis but wasn't being provided
that a fibrosure was done on 11/17/14. The provider noted
typical care. For reasons not stated the patient didn't
that the hep C viral load was 2,050,457 and the A1c was 6.2.
receive EGD, ultrasound, or colonoscopy to work up his
The doctor noted the recent labs including albumin of 2.8; alk
anemia. The statement that he was frail is not an
phos 171; INR 1.2; WBC 3.3; HGB 8; platelets 144; and
indication not to work up his anemia. The statement
assessed F4 fibrosis. The provider noted that the patient was
that he had anemia since 2013 demonstrated significant
delay. The statement that liver ultrasound would be
anemic since 2013 and "needs anemia FU ACAP → T/C Cdone when the anemia was resolved but then to not
scope but patient frail." The provider [presumably a NP]
work up the anemia was making excuses for not
stated the it was for Dr. Bauer [presumably the Medical
working the patient up. This was all a significant delay
Director] to decide if anemia precluded HCV treatment or
in colonoscopy, ultrasound, and EGD. Also the patient
work up. Dr Paul said, "will need EOD liver ultrasound once
should have been referred to UIC.
anemia resolved." The anemia was persistent for years. The
patient had fibrosis consistent with cirrhosis but this wasn't
diagnosed and the patient wasn't scheduled for EGD and semiannual ultrasound or CT scan to evaluate for HCC. The patient
certainly should have been referred to UIC hepatology but it
wasn't clear who was to do this.

12/29/2014 Diabetic chronic clinic. There were no changes to medications.
The weight was 160; BP 137/62; the doctor noted a right fore
foot amputation. The form contains a preprinted
recommendation that ABI is indicated when pulses are low.
This was true at a prior evaluation but ABI was not ordered.
The pulses and feet were not checked at this visit.

357

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 358 of 431 PageID #:12556
Patient #28
12/30/2014 The doctor at this visit documented history and some
7,8, 12
additional assessment based on a review of the 12/22/14 Dr.
Paul note. The doctor noted macrocytic anemia with low B12
and B6. The doctor noted that the patient was "referred by
Dr. Paul for anemia since 2013." It wasn't clear what that
meant. The doctor noted that the patient "denies sources of
blood loss. Refused /AMA for DRE 11/12/12 and 11/14/14,
will recheck CBC." The doctor noted that the patient had prior
pancytopenia due to hepatitis C. The plan was to get three
stool samples for guaiac, CBC reticulocytes, iron studies and
other tests. The doctor wrote down all the CBC results dating
from March of 2012; there were 12 all showing anemia with
the lowest hemoglobin 8 and the highest 10.9. Yet the patient
hadn't had a colonoscopy!!
12/30/2014 Iron 13 (49-181); TIBC 454 (250-450); WBC 2.2; HGB 7.7;
platelets 108; neutrophils 35% or 0.8 (1.3-7.5); vitamin B12 74
(70-180) whole blood.
1/5/2015
B12 135 (180-914) plasma.
1/9/2015
The doctor noted that the patient had pancytopenia WBC 2.2, 2, 6, 7, 8
hemoglobin 7.7, and platelets 108. The serum iron was low
and TIBC high; three hemoccult cards were negative. The
doctor documented that labs were consistent with iron
deficiency anemia but because three hemoccult cards were
negative there was no source of blood loss. The only
treatment was to prescribe iron supplementation. This is
inconsistent with standards as the patient should have had
endoscopies. To say that there was no source of blood loss
without looking for it diagnostically was inaccurate.

358

The doctor was using DRE as screening for colorectal
cancer, which is inappropriate. The patient should have
been scheduled for colonoscopy since he had anemia.
The patient also should have had ultrasound screening
and EGD since he had cirrhosis. The patient should have
been referred to UIC telemedicine clinic.

The patient had pancytopenia yet the doctor made no
diagnosis and came to no conclusion why the patient
had pancytopenia. The patient had iron deficiency
anemia yet the doctor did not order colonoscopy and
endoscopy. The doctor should also have ordered an
ultrasound of the abdomen to screen for hepatocellular
carcinoma. The only treatment was to order iron
supplements.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 359 of 431 PageID #:12557
Patient #28
2/9/2015

A new doctor saw the patient and didn't follow up on the
anemia and listed only two problems: DM and ID [it wasn't
clear what ID was]. This doctor took no history and made no
assessment of the status of any condition.

2/10/2015

Iron 13 (49-181); TIBC 470 (250-450); WBC 3.4; HGB 7.7;
platelets 143; neutrophils 50.8%.
A doctor saw the patient and documented all problems
including anemia/pancytopenia without documenting an
updated status and plan for any problem except CHF, noting
that the patient was on diuretic and lisinopril.

2/19/2015

2/26/2015

A doctor saw the patient and noted that the hemoglobin was
still 7.7 with microcytic indices. The doctor noted that the
patient still had pancytopenia (3.4; 7.7; 143) and stated that
there was "no source" of bleeding found. The doctor
documented the low reticulocyte count. The doctor wrote
that though the patient was taking B12 and B6 supplements
the B12 was still low and he wrote "?absorption?" and wrote
that he would try B12 injections. The doctor added vitamin C
to the iron to try to increase absorption. The doctor did not
refer for a colonoscopy or upper endoscopy.

3/2/2015

The patient fell off the bed onto his hand. The patient had a
2.5 cm laceration on the palmar surface of the phalanx with
visible tendon. The right middle PIP was deformed and
subluxed. An X-ray showed a dislocated PIP but "no acute
fracture seen." The patient couldn't flex his right finger. The
doctor assessed a laceration and dislocation and sutured the
finger but could not reduce the dislocation, so sent the patient
to an ER. The patient returned from the ER with instructions
to return in 10 days to remove sutures.

359

1, 2, 3 The doctor took no history, made no assessment and no
plan. The doctor failed to follow up on the
pancytopenia and iron deficiency anemia and addressed
none of the patient's problems.

2, 3

The doctor made no diagnosis based on abnormal labs
and no therapeutic plan for the given abnormal labs.

7, 8

This did not appear competent. The patient had
pancytopenia and iron deficiency anemia yet the doctor
did not refer for endoscopy and colonoscopy. Because
of the cirrhosis, ultrasound screening should have been
done.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 360 of 431 PageID #:12558
Patient #28
3/2/2015

The patient was seen in the ER at the Sarah Culbertson
Memorial Hospital. An x-ray showed a subluxation of the third
finger on the right; fracture was not definitively seen. The
wound was sutured and the patient returned to the prison.

3/2/2015

X-ray of the right third finger showed dorsal dislocation
without obvious fracture.
A doctor saw the patient and noted that there were no ER
records; he asked for them to be obtained. The doctor did not
document knowing what was diagnosed or done in the ER.

3/4/2015

A subluxed finger requires reduction of the subluxed
finger. This required follow up with an orthopedic
surgeon for possible surgical reduction.

11

The failure to obtain records resulted in clinical
deficiency

3/9/2015

A doctor saw the patient whose hand was now swollen. The
doctor documented a verbal report from the ER that the
patient did not have a dislocation but stated that the x-ray
report showed a 6 mm subluxation. The doctor prescribed
empiric treatment with Keflex for 10 days and a repeat x-ray.
It wasn't clear if the patient had seen a hand surgeon or
orthopedic surgeon. Blood tests were not done.

12

The doctor needed to consult an orthopedic surgeon as
the patient had a subluxation. A subluxation with
swelling indicates possible infection.

3/11/2015

A doctor noted that the right middle finger was still dislocated
with the middle phalanx subluxed. The doctor documented he
would discuss in collegial review but didn't state for what
reason.
A doctor noted that the finger was still swollen and that there
was some drainage in the morning. No changes were made.

12

The doctor needed to consult an orthopedic surgeon as
the patient had a subluxation.

Wexford denied referral for urgent wound clinic evaluation.
Wexford asked to get foot x-rays and wound culture if not
done and re-present the patient in the next collegial review.

12

The Wexford utilization decision was grossly and
flagrantly unacceptable. The patient had an subluxation
with infection and this needed immediate attention.
Because the wound was open and sutured, it appeared
to be the equivalent of an open fracture.

3/12/2015

3/13/2015

360

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 361 of 431 PageID #:12559
Patient #28
3/16/2015

A nurse documented a "grossly swollen" right middle finger.
Later that day five sutures were removed from the finger by a
nurse. Later, a doctor saw the patient and noted that the
finger was swollen and that the patient was unable to flex the
finger. The doctor documented that he referred the patient to
orthopedic or hand surgery for closed reduction. This was
approved.

3/16/2015

A doctor referred the patient to an orthopedic surgeon for
closed reduction of the finger.
A Wexford doctor approved the orthopedic surgeon visit.

3/20/2015
3/26/2015
3/27/2015

12

The referral was two weeks after the injury. The delay
likely resulted in extension of the infection. The referral
needed to be immediate, not even urgent, as the
patient was likely infected.

12

The referral was delayed almost a month for an open
dislocation. The UM process was grossly and flagrantly
unacceptable and resulted in osteomyelitis, a
preventable condition.

Ferritin 28 (10-259); iron 29 (50-180); WBC 3.7; HGB 8.8;
platelets 158; B12 1049 (180-914).
A nurse noted some yellow discharge from the finger wound.

3/30/2015

A doctor noted that the patient was at the hand surgeon's
office and spoke with the surgeon who said that the patient
had an open dislocation with pus coming from an open
wound. The joint was visible. Surgery was indicated "tonight."
The patient had surgery and returned on vancomycin IV on the
infirmary upon return.

3/30/2015

An orthopedic doctor wrote in the ER that the patient
sustained an open dislocation of the finger and said, "I am
uncertain as to why this was not reduced prior to now but at
any rate would recommend [the hand surgeon] address this
issue." Surgery was done that evening.

361

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 362 of 431 PageID #:12560
Patient #28
4/1/2015

4/2/2015
4/6/2015

A doctor noted that the patient had ORIF of the finger
[apparently there was a open fracture with pus]. The patient
needed six weeks of treatment for osteomyelitis.
Osteomyelitis was diagnosed.
A doctor referred the patient for post-op follow up orthopedic
visit.
A post operative follow up was approved in collegial review.

4/9/2015

A doctor noted that the hand surgeon wanted to see the
6, 7, 10
patient in the ER for a follow up visit, which the doctor noted
couldn't be done. The doctor noted anemia was improved and
the HGB now 8.8 from 7.7. No action was taken except to
continue iron and B12 supplements.

4/15/2015

A nurse documented soaking the affected finger in a solution
of Epson salts for 20 minutes. Not sure if this was ordered
treatment.
Urine microalbumin 140; albumin 2.9; alk phos 202; AST 69
(10-40); A1c 5.3; cholesterol 118; HDL 61; LDL 47 (50-129).

4/16/2015

4/20/2015

The patient sustained an open fracture dislocation of this right
middle finger and was being seen in the ED for a suture
removal. The fracture was healing adequately.

4/20/2015

A doctor noted that the patient was seen post orthopedic visit
but that the notes were unavailable. The pins were reportedly
removed and the patient had a follow up in a month. The
doctor asked medical records to obtain a dictated report.

4/20/2015

A hand surgeon saw the patient in the ER and removed
sutures and the patient was discharged.

362

11

Follow up of the anemia was unacceptable. The patient
had iron deficiency anemia and colonoscopy and EGD
were indicated but not done for undocumented
reasons. Follow up with the surgeon was also indicated
and not done because apparently IDOC would not take
the patient to the ER.

The doctor was unable to determine the status of the
patient because consultant notes were unavailable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 363 of 431 PageID #:12561
Patient #28
4/22/2015
4/22/2015

4/22/2015

4/27/2015
4/29/2015

5/6/2015
5/13/2015

A doctor reviewed the orthopedic notes that the sutures were
removed and the wound healing.
A doctor renewed medications as NPH 14 am and 8:00 pm
with aspirin, lisinopril 5 mg daily, metformin 500 with dinner
B12 and B6 supplements.
Diabetic chronic clinic. The doctor noted mild CHF, DM,
chronic hep C, anemia, and mobility disorder. BP was 142/86;
a foot exam was done but did not take off his shower shoes.
The A1c was 6.2. The patient was documented as in good
control and no action was taken.
Glucose 59 (65-110).
A doctor saw the patient and noted that the patient still had
anemia. The doctor noted that the last CBC on 3/26/15
showed HGB of 8.8 and that he would continue the same
therapy.
Iron 30 (50-180); % transferrin 8 (20-50); WBC 2.9; HGB 9.2;
platelets 105.
Dr. Baker referred the patient to a hand surgeon after a failed
closed reduction. The patient was unable to flex the right
middle finger at all.

5/13/2015

A doctor noted that the patient completed the vancomycin
and that referral was made for ortho follow up.

5/13/2015

A doctor referred the patient to the hand surgeon for follow
up.
The patient told a doctor he couldn't bend the finger. The
doctor took no action.

5/22/2015

363

7

1, 2, 6, The patient's recent labs showed pancytopenia with iron
7,
deficiency anemia. The doctor should have referred for
EGD, colonoscopy, and ultrasound of the liver to screen
for hepatocellular carcinoma. The doctor appeared to
fail to review the labs.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 364 of 431 PageID #:12562
Patient #28
5/28/2015

6/4/2015
6/8/2015

A doctor noted that weight was 158; did not address any labs
and noted that the patient still needed to be scheduled for
ortho follow up. The doctor didn't address any of the patient's
other problems.
A doctor saw the patient but didn't address any of his
problems.
An orthopedic surgeon saw the patient. The patient had intraarticular fracture of the third PIP on the right. There was
advanced DJD of the DIP and PIP joints. The orthopedic
surgeon stated that he needed to investigate options for the
patient and might need to refer to a hand surgeon. The
patient said the finger was useless and he would rather have it
amputated than continue in the current situation. The x-ray
showed residual irregularity of the joint; infection could not be
excluded.

6/8/2015

The hand surgeon saw the patient. The doctor noted that the
patient had pins removed from the ORIF several months ago.
The patient said he wanted amputation of the finger instead of
other care. The surgeon said he needed to investigate options
and would get back to the prison.

6/9/2015

Glucose 313; albumin 3; alk phos 214; AST 55 (10-40); ALT 38
(10-50); WBC 2.9; HGB 10.8; platelets 108.
A doctor saw the patient and noted that the patient saw the
surgeon and told the surgeon to cut off the finger as it was not
useful. The surgeon said he would get back to them. The
surgeon report wasn't available so the doctor asked for it.

6/10/2015

6/16/2015

A doctor saw the patient and documented that he
documented a hepatitis C note that day but it was not in the
medical record chronologically.

364

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 365 of 431 PageID #:12563
Patient #28
6/16/2015

A doctor saw the patient for hepatitis C clinic. The doctor said 12, 7, 8
that the patient was followed by Dr. Paul in HCV telemedicine
clinic and was last seen 12/22/14. The doctor noted that the
WBC was 2.9; HGB 10.8; platelets 108, and APRI 1.27. The
doctor stated that the patient would not be treated because
of frailty, anemia, and was followed by Dr. Paul, who decided
the patient wasn't a treatment candidate. The doctor noted
that Dr. Paul was to see the patient "this month?" Though the
patient had cirrhosis, the doctor did not assess this. Nor did
the doctor order EGD or screening ultrasound for HCC.

7/1/2015

A doctor said that the orthopedic surgeon would research
options for a nonfunctional finger and get back to them.

7/9/2015

A doctor wrote a note with considerable history about the
finger issue but failed to address any of the patient's other
problems. The patient's injured finger was tender and the
doctor empirically treated with Bactrim even though there
was no sign of infection.
A1c 8.2.
As of this date the doctor stated that the orthopedic doctor
had not gotten back to him with options. The doctor did not
address any of the patient's other issues except through
chronic clinic notes, including the pancytopenia or cirrhosis.
Cirrhosis wasn't even documented as a problem.

8/11/2015
8/12/2015

8/21/2015

The patient had a runny nose with cough and the doctor
prescribed CTM.

365

12

The patient should have been referred to UIC for
assessment. Frailty is not a contraindication to
treatment. In any case, the patient should have
received EGD to screen for varices, and ultrasound or CT
scan to screen for hepatocellular carcinoma. The
patient had iron deficiency anemia and should have
received colonoscopy. The pancytopenia was likely a
result of the cirrhosis but is of concern.

The doctor failed to refer the patient to an orthopedic
surgeon. There was no attempt to determine how the
finger affected ability to function. This was a
preventable injury.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 366 of 431 PageID #:12564
Patient #28
8/26/2015

A doctor saw the patient in diabetic clinic. The A1c was 8.2.
The doctor increased the metformin to 500 BID and increased
NPH to 16 am and 10:00 pm.

9/7/2015

The patient thought it was close to Halloween. The patient
was encouraged to change clothes and shower. The nurse
noted that the patient's pants smelled of urine.

9/22/2015

A different doctor began seeing the patient and wrote an
extremely brief note noting that the patient now agreed to
take metformin. There was no assessment.

9/29/2015

10/6/2015

7, 8

The doctor did not address the pancytopenia, anemia,
cirrhosis, or other conditions. The patient should have
been referred for colonoscopy, EGD and ultrasound.

1, 2, 3 The doctor failed to review nursing notes and address
the patient's incontinence. If this was due to dementia
it was unrecognized. If it was due to something else it
was undiagnosed.
The new doctor saw the patient and noted that the patient
1, 2, 7. 8 The doctor was a new doctor for this patient yet failed
had DM and an "ortho foot problem [secondary] to falls." The
to establish a reasonable plan for his cirrhosis and
doctor did not address any of the other patient problems
anemia. They took inadequate history, made no
including pancytopenia, cirrhosis, CHF, or low albumin.
assessment of the patient's problems, and failed to
establish a reasonable plan. The doctor failed to refer
the patient for EGD and colonoscopy and ultrasound.
The new doctor saw the patient and noted that the patient
had DM and "ortho foot problems." The doctor did not
address any of the other patient problems including
pancytopenia, cirrhosis, CHF, or low albumin. The doctor
noted 1-2+ edema on exam but made no assessment or plan
for this.

1, 2, 7, 8 The patient had apparent new onset edema yet the
doctor took no history, made no attempt at diagnosis,
and failed in the assessment to address any of the
patient's conditions. The doctor should have referred
for EGD, colonoscopy, ultrasound, and considered an
echocardiogram based on the history.

10/13/2015 A doctor saw the patient and noted that the patient had DM
and a "ortho foot problem." The A1c was documented as 8.2.
The doctor ordered a CMP and A1c with a week follow up.
10/14/2015 A1c 8.2.

366

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 367 of 431 PageID #:12565
Patient #28
10/20/2015 A doctor saw the patient and noted elevated A1c 8.2 and
increased the metformin to a gram BID, which was a
significant increase.
11/3/2015 A1c 8.5.
11/4/2015 A doctor saw the patient and noted that the last A1c was 8.2
on 10/14; a repeat had not returned yet. Without evaluating
CBG levels the doctor increased metformin to 850 TID. For an
elderly man this was a large increase.
11/11/2015 A doctor saw the patient and ordered another A1c and said he
would add another drug if the A1c was still high. No other
problems were addressed.
11/13/2015 A nurse documented that the patient had periods of
forgetfulness without any evaluation.
11/14/2015 Annual physical examination documents hepatitis C, mild CHF,
ASPVD, DM, arthritis of knees, and the weight was 162.

11/18/2015 A doctor saw the patient. The doctor noted that the A1c was
8.5 but that the patient refused any increase of insulin. The
doctor addressed no other problems.
11/18/2015 A1c 8.6.
11/25/2015 A doctor saw the patient and noted only diabetes, fall risk, and
a partial foot amputation as problems.
11/25/2015 Albumin 2.9; alk phos 231; AST 57; ALT 37; phosphorus 2.9;
WBC 3.1; HGB 11.3; platelets 115.
12/3/2015 A doctor saw the patient and noted that the patient had
hepatitis C and diabetes. The doctor referred the patient to
the hepatitis C clinic with BMP, T4 and TSH.

367

1, 7, 8 The provider failed to review the nursing history of
forgetfulness and prior incontinence and integrate that
information into the problem list. The provider failed
on the annual physical to obtain an EGD, colonoscopy,
or ultrasound. Nutritional assessment was not done.
The patient's functional capacity was not assessed.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 368 of 431 PageID #:12566
Patient #28
12/3/2015

12/8/2015

12/9/2015

A doctor saw the patient in hepatitis C clinic. The doctor
12, 7, 8
noted albumin 3; HGB 10.8; platelets 108; AST 55 and ALT 38.
The doctor didn't note that the patient had cirrhosis and
referred the patient to see Dr. Paul in hepatitis C clinic.
Ironically, the doctor was seeing the patient in hepatitis C
clinic. It appeared that the doctor didn't know how to manage
cirrhosis.
A doctor noted that the patient had a "skin tear" on the
3
bottom of his left foot and was walking using shoes. The
doctor noted a 2 1/2 cm tear on the skin and ordered betadine
soaks of the left foot with daily dressing changes and tetanus
update. The doctor did not off-load the foot.
A doctor saw the patient and noted that he was disoriented
and confused. There was no history with respect to the
altered mental status. The doctor noted that the patient
didn't have pain and had a tear on the foot with no evidence
of infection. The plan was only antibiotic ointment. The
patient continued to walk on the foot.

12/9/2015 A1c 8.7.
12/15/2015 A nurse noted that the patient had a "scant" amount of
drainage and that the tissue between the toes was white with
an odor and that there was an open area on the side of the
foot that "remains swollen slightly and discolored."

368

The patient hadn't seen doctor Paul for a year. The
patient had cirrhosis. He should have been referred to
UIC to determine whether treatment was indicated. He
should have been referred for EGD, colonoscopy, and
ultrasound.

The patient was diabetic. A foot wound in a diabetic is
cause for concern and typically needs off-loading to
reduce use of the foot. This was not done and exposed
the patient to continued damage to the foot.

1, 2, 7, The patient was confused but the doctor failed to take a
8, 14 history and performed no examination with respect to
the altered mental status. The doctor should have
obtained a metabolic panel, ammonia level, and
probably obtain a CT brain. Alternatively, the patient
should have been sent to a hospital.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 369 of 431 PageID #:12567
Patient #28
12/15/2015 A doctor saw the patient and continued the antibiotic
2, 3, 7, 8 The patient had a diabetic foot with pus. The doctor
ointment. The doctor noted that the wound was healing well.
should have probed the wound, obtained sedimentation
rate and CRP test, and x-ray or CT scan to assess for
osteomyelitis. The patient should have been off-loaded.
Although the patient was in a wheelchair, he should not
have been walking on the foot. Antibiotics should have
been started.
12/16/2015 A nurse noted that the patient was forgetful when it comes to
the time of day. The patient asked what time it was after
saying that it was night. A doctor saw the patient that day and
noted that the foot was healing well. The doctor continued
wound care.

1, 2, 8 The patient had altered mental status but it was
unrecognized. The doctor didn't review the nursing
note or take any history of the patient. No diagnosis of
the altered mental status was made. The patient should
have had a serum ammonia, CMP, and CT scan.

12/16/2015 A1c 8.5.
12/22/2015 A doctor saw the patient and noted that the foot was healing
and that the patient had DM with neuropathy and a healing
wound. The doctor didn't check the distal pulses, order an
ABI, or probe the wound. No labs were ordered. No change in
therapy.
12/23/2015 A doctor saw the patient in diabetic clinic. The A1c was
3, 7, 8
documented as 8.5. The patient was listed as having type 1
diabetes, which he didn't have. The doctor did not document
a change in medication. The doctor noted that the A1c was
8.5 and that the patient refused any increase in insulin. Except
for noting no edema, the foot wound wasn't examined. The
doctor assessed only type 1 diabetes and ordered a BMP.
12/24/2015 A nurse noted that the inmate had periods of forgetfulness.
12/29/2015 A1c 8.

369

The patient had a diabetic foot with pus. The doctor
should have probed the wound, obtained sedimentation
rate and CRP test and x-ray or CT scan to assess for
osteomyelitis. The patient should have been off-loaded.
Although the patient was in a wheelchair, the plan
should have been to completely off-load the foot.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 370 of 431 PageID #:12568
Patient #28
12/30/2015 A doctor noted that the weight was 158 and increased NPH to
16 units in the am and pm, which was a significant increase.
The only assessment was DM with neuropathy. The doctor
made no comment about blood sugars. The doctor
documented that there were no ulcers on the L foot or R
stump even though the patient had a diabetic foot.
1/5/2016
1/6/2016

1/6/2016
1/8/2016

A1c 7.8.
A doctor saw the patient. The BP was 143/53. The A1c was 8
4, 15
decreased from 8.5 on 12/29/15; the patient had 2 + edema
but the doctor didn't examine the foot with the tear. The
doctor ordered weights every visit and added HCTZ and
ordered an EKG and BMP.
HCTZ was started at 25 mg.
A nurse noted after a shower that the inmate had an open
1, 2, 3,
ulcer with peeling edges on the left foot and reported it to an
7, 8
NP. An NP saw the patient and documented a dime sized ulcer
with no drainage and 2 + pulses. The patient told the NP that
the wound "just won't heal." Left foot ulcer was diagnosed
but no action taken except wet to dry dressings.

1/8/2016

A nurse noted that the inmate had periods of forgetfulness.

1/9/2016

A nurse noted that the inmate smelled of BM and urine and
was advised to take a shower. The ulcer was dressed.

1/10/2016
1/11/2016

A nurse noted slight drainage from the ulcer.
A nurse noted that the patient was washing soiled sweatpants
and had periods of confusion.
A nurse noted that the inmate had unsteady gait.

1/13/2016

4, 15

370

The doctor appeared to follow up a diabetic foot for
which the patient was being treated. This did not
appear to be a competent evaluation.

The doctor failed to follow up on the diabetic foot. The
doctor noted 2+ edema but did not document a foot
examination. It appeared that the diabetic foot problem
was lost to follow up.

The patient had a non-healing diabetic ulcer for over a
month. The NP should have probed the wound.
Although pulses were palpated, an ABI was indicated
due to the non-healing nature of the wound. The
patient should have been off-loaded. Sed rate, CRP,
blood count, and x-rays or MRI should have been done
to exclude osteomyelitis. Antibiotics should have been
started.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 371 of 431 PageID #:12569
Patient #28
1/13/2016

A doctor saw the patient. The doctor noted that the patient
1,2, 7, 8
had an ulcer on the right foot of the metatarsal area and heel
and ordered a culture, BMP and CBC and clindamycin BID with
follow up in a week.

1/13/2016

WBC 3.75; HGB 11.3; platelets 128; a wound culture showed
many proteus susceptible to Rocephin and Clindamycin. But
this was a wound culture.
A nurse noted unsteady gait and periods of confusion and that
the left foot had scant drainage.
A nurse noted that the patient took off the left foot dressing
and there was an open area.
A doctor noted that the patient had a plantar ulcer on the first 1, 2, 3, The patient had recent episode of confusion and
metatarsal area and that it was not healing; he ordered a
7, 8 unsteady gait. The doctor took no history, performed
BMP, A1c, CBC, and follow up.
no pertinent examination, and did not order appropriate
diagnostic testing (ammonia, CT brain). The doctor also
did not probe the bone, order sedimentation rate or
CRP, or order x-rays or MRI to exclude osteomyelitis.

1/14/2016
1/15/2016
1/21/2016

1/27/2016

1/27/2016
1/27/2016
1/28/2016

A doctor referred the patient with a diabetic foot ulcer
resistant to normal care for wound care. There was extension
of the wound. The doctor documented prior amputation for a
prior diabetic foot ulcer.
A nurse called a doctor in to see the wound which had scant
drainage with peeling edges.
A1c 7.6; WBC 3; HGB 10.6; platelets 115.
Wexford denied referral for urgent wound clinic evaluation.
Wexford asked to get foot x-rays and wound culture if not
done and re-present the patient in the next collegial review.

371

12

The patient had recent episodes of forgetfulness and
incontinence which were not even noted. The patient
should have been worked up for altered mental status.
The patient should have had ABI, and radiologic study to
evaluate for osteomyelitis.

Wexford UM denied referral for a diabetic wound when
the local doctor did not know how to care for the
wound. Care was grossly and flagrantly irresponsible.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 372 of 431 PageID #:12570
Patient #28
1/28/2016

A clerk documented denial of urgent wound care referral with
alternative plan an x-ray and wound culture.

1/28/2016
1/28/2016

A doctor noted that there was no osteomyelitis on x-ray.
A doctor apparently ordered Rocephin because a nurse
administered this drug, but there was no physician note. Later
that day at 6:00 pm the Rocephin was changed to gentamycin.
Again there was no note documenting why. On later notes it
appeared that the patient was receiving both gentamycin and
Rocephin without documented reason. Apparently it was for
the foot ulcer.

1/28/2016

Medical records wrote a note that urgent wound care was
denied and x-ray and wound culture was recommended.

1/30/2016

At 7:30 am the patient came for meds in his wheel chair and
he was lethargic and unable to wheel himself with slurred
speech. The blood pressure was 74/35 and the patient was
sent to a hospital.
The patient was referred from Rushville for hypotension
(74/35) and lethargy to a hospital.

1/30/2016

372

Plain x-rays may not show osteomyelitis until late in the
course of osteomyelitis. Also, wound culture of an open
wound is not useful, as the culture will likely be
contaminated.
11

This is a documentation problem. It wasn't clear why IV
Rocephin was started as there was no documentation in
the medical record.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 373 of 431 PageID #:12571
Patient #28
1/30/2016

Magnesium 1.6 (1.8-2.4); BNP 473; WBC 2.2; HGB 10.5;
platelets 83; neutrophils 89.2%. Sedimentation rate 29 (0-15);
PO2 63 (80-100); HCO3 12 (22-26); PCO2 19 (35-45); glucose
146; calcium 7.5; Total protein 6.1 (6.4-8.2); albumin 2.4; ALT
41 (16-63); AST 76 (15-37); ALK PHOS 237; total bili 1.2 (0-1)
and blood cultures at four days were negative. These labs
were done at the hospital. The patient was admitted with
altered mental status and hypotension. A CT scan showed
colitis- colonoscopy was recommended. CT of the brain
showed no acute process but small vessel ischemic changes.
EKG showed right atrial enlargement.

1/31/2016

A doctor in the hospital wrote a consultant note documenting
that he was asked to see the patient for lactic acidosis and CT
scan showing colitis. The patient had profound lactic acidosis
with HCO3 of 8.8; the patient refused colonoscopy and it was
recommended to continue cipro and flagyl. The patient had
no masses in the liver on a CT scan but the CT scan was
without contrast.

2/4/2016

At St John's Hospital an abdominal ultrasound showed a 2 cm
hypoechogenic lesion which "may represent a cyst or other
etiologies are not entirely excluded," diffusely coarse
echotexture of the liver with nodular surface and moderate
ascites.
The inmate returned from the hospital and had a Foley
catheter. The assessment was colitis.
A nurse documented that the patient had 1+ edema. A doctor
had yet to see the patient on return from the hospital. It
wasn't clear what the discharge diagnoses were.

2/6/2016
2/7/2016

373

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 374 of 431 PageID #:12572
Patient #28
2/7/2016

A nurse called a doctor who ordered blood cultures by phone
and ordered Levaquin by phone. A doctor had yet to see the
patient and it wasn't clear what the patient's diagnoses were.
In a later note a nurse noted that Levaquin wasn't available so
the doctor ordered IV Rocephin by phone. It wasn't made
clear why the doctor was prescribing IV antibiotics.

2/7/2016

A nurse noted that the patient's temperature remained above
100.4 after Tylenol. The doctor was called and the nurse
documented that blood cultures were drawn
A doctor wrote an admission note to the infirmary. The
doctor noted that the patient had cellulitis of the foot and had
diarrhea and 10 pound weight loss. The doctor did not
acknowledge what occurred at the hospital. The patient had
3+ edema of both legs. New medications included Lasix,
Levaquin, nebulization treatments, Rocephin. The admitting
diagnosis was heart failure but it wasn't clear what occurred at
the hospital or why the patient was being treated with two
different antibiotics. It may have been the foot cellulitis. but it
wasn't clear. The problem list was incomplete.

2/8/2016

2/8/2016
2/8/2016

2/8/2016

A nurse noted 2-3+ edema of the leg , blistered areas with
discoloration of the right lower leg.
A doctor wrote an additional note that the patient had
tachypnea, shortness of breath, and orthopnea. The doctor
noted rales in the base and 3-4+ edema. The doctor assessed
heart failure and UTI. The doctor ordered IV push Lasix,
nebulization with albuterol, decreased salt intake, and BNP
and BMP and EKG.
Lasix 20 mg BID was started.

374

3, 11

8

There was no hospital report and the doctor didn't
understand what occurred at the hospital or understand
the therapeutic plan. The doctor was unable, therefore,
to develop a therapeutic plan.

The doctor should have added a chest x-ray.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 375 of 431 PageID #:12573
Patient #28
2/9/2016

A doctor noted that the patient was breathing easier. The
doctor noted no wheezing, a protuberant abdomen, swollen
scroum and 3-4+ leg edema. The diagnoses were cellulitis of
the foot, heart failure, ascites and COPD. The doctor
increased Lasix and ordered BNP.

2/9/2016

A nurse wrote that the patient had 1+ edema of the hand, was
incontinent of bowel, the scrotum was swollen and the
abdomen was distended. COPD and heart failure were the
diagnoses as documented by a nurse.

2/9/2016

BUN 22; sodium 134 (135-145); potassium 3.2; creatinine 1.58
(0.5-1.5).
A nurse noted that the patient was forgetful and on fluid
restriction. The patient refused to wear his oxygen cannula.
The nurse documented that the patient had open areas on the
buttock without drainage and the scrotum was swollen. Later
the patient needed to be assisted to the bathroom and had a
liquid BM.

2/10/2016

2/11/2016

A doctor saw the patient. The doctor still did not document
the summary from the hospital. The doctor noted DM and
cellulitis of the right leg. The doctor noted that the patient
had generalized abdominal pain. The patient refused to go to
the hospital. In the assessment, the doctor noted ascites with
cirrhosis and a mass on the liver and cellulitis of the right leg.

2/11/2016

BUN 34; sodium 134; CO2 19; creatinine 1.93; WBC 6; HGB
10.3; platelets 178; BNP 75 (<100).
The patient was incontinent of liquid stool.

2/13/2016

375

1, 2, 8, The failure to obtain records resulted in the doctor not
11, 14 knowing what occurred at the hospital. The patient
now appeared to have anasarca probably from his
cirrhosis. Diuretics were appropriate, but because the
doctor didn't know the diagnosis, higher level of careadmission to a hospital, was indicated. The doctor
should also have ordered stat BMP.

14

The patient had altered mental status and should have
been sent to a hospital as he could not be cared for at
the prison and he appeared to no be competent to
make his own decision.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 376 of 431 PageID #:12574
Patient #28
2/14/2016

2/15/2016
2/15/2016

2/15/2016

2/15/2016

When taking a shower, the patient was incontinent of stool,
which was bloody. This was noted on three separate notes,
and on one note a nurse noted that it was guaiac positive. A
doctor wasn't notified.
CK MB 4 (0-3.6); A1c 7.9; HGB 8.7; WBC 5; platelets 167; BUN
43; creatinine 2.2; albumin 1.8.
A doctor saw the patient and noted that the patient had some
abdominal pain and noted that the patient had blood in the
stool twice the day before but no gross blood in the stool now.
The doctor noted that the patient was DNR and wanted to die.
The doctor noted that the patient had wheezes, abdominal
tenderness and bruises on the abdominal wall, and a
distended abdomen. The doctor stopped IVs, ordered a CBC,
INR, BMP, and amylase. The doctor ordered a week follow up
even though it appeared that the patient was acutely ill.
At 4:35 pm a doctor saw the patient. The patient had left
pleuritic chest pain with hemoptysis but no shortness of
breath or hypoxia. The patient didn't want to go to the
hospital. The patient was sent to a hospital for a CT to assess
for a pulmonary embolism. The oxygen saturation was 97%
on room air.
Amylase 57 (25-125); BUN 38 (6-20); potassium 5.5 3.5-5.3);
CO2 17; creatinine 1.99; anion gap 12 (3-11); INR 1.3; WBC
4.7; HGB 10.5; platelets 183.

376

16

The nurses should have consulted a physician.

14

The patient was seriously ill and should have been sent
to a hospital. DNR status was not documented in any
progress note. We couldn't locate the document. But
this doctor did not appear to have read the recent
hospital report or understand all of the patient's
conditions. Under the circumstances as represented in
this note the doctor should have admitted the patient.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 377 of 431 PageID #:12575
Patient #28
2/22/2016

2/22/2016

2/22/2016

2/23/2016

2/23/2016
2/23/2016

There were patient discharge instructions stating that the
patient was hospitalized for hemoptysis, cirrhosis, chronic
hepatitis C, diabetes, HTN, urinary retention, chronic
indwelling Foley catheter, normochromic anemia, peripheral
vascular disease, stage 2 sacral pressure ulcer, acute blood
loss anemia, and liver mass. This was not a discharge
summary but a summary for the patient. There was no
discharge summary.
A doctor admitted the patient to the infirmary and noted that
the patient had diagnoses of liver cancer and upper GI bleed.
The patient was on DNR status. The admission note had
virtually no history and no physical examination. The
assessment was hepatitis C, cirrhosis, and hepatic cancer.
None of the patient's other problems was addressed.
A nurse noted that the patient had a 10 cm open area
between the gluteal folds and multiple open areas on the
buttock. The nurse noted that the scrotum was swollen and
irritated.
A nurse noted that the patient was back from the hospital and
wrote down the hospital diagnoses, which was the first time
these diagnoses were listed. They included: hemoptysis,
hepatitis C, cirrhosis, hepatic cancer, diabetes, hypertension,
decubitus ulcer of the foot, urinary retention, anemia,
peripheral vascular disease, acute blood loss post-GI bleed,
sacral pressure ulcer, hepatic cancer. The doctor ordered
comfort measures.
Inderal was started at 10 mg TID.
BUN 16; creatinine 1.17; total protein 5.5 (6-8); albumin 2; alk
phos 143; AST 59; ALT 34; WBC 4.9; HGB 9.6; platelets 56.

377

11

There was no hospital report, making it very difficult to
manage the patient.

11, 10, The doctor failed to review the hospital note and
1, 2, 3 therefore follow up was poor. The doctor did not
understand all of the patient's problems and the
therapeutic plan was there fore deficient. The patient
had an indwelling Foley catheter and open sacral
decubitus, for example, but there were no orders for
this.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 378 of 431 PageID #:12576
Patient #28
2/28/2016

Ativan 1 mg TID was started.

17

The doctor was starting palliative sedation but there
was no discussion with the patient documented in the
record that we could find. This is inappropriate, as this
action needed to be fully discussed with a cooperative
patient and family if needed.

2/28/2016

Fentanyl patch was started 12 mcg per hour.

17

The doctor was starting palliative sedation but there
was no discussion with the patient documented in the
record that we could find. This is inappropriate, as this
action needed to be fully discussed with a cooperative
patient and family if needed.

2/29/2016
3/1/2016
3/3/2016

A doctor added Aldactone, and stopped HCTZ.
Lisinopril, potassium, vitamin B12 were discontinued.
Aspirin, furosemide, Inderal, metformin, Zofran, insulin, and
Cardizem were held.
A doctor stopped Lasix and added Ativan IM for "restlessness."

17

Restlessness is not an indication for Ativan. The doctor
appeared to be using palliative sedation without a
discussion with the patient, which has significant ethical
concerns.

3/7/2016

3/8/2016
3/9/2016
3/11/2016
3/16/2016

Oxycontin 5 mg every four hours was started.
Fentanyl patch 50 mcg patch was started to be used every
third day with Ativan 1 mg every six hours.
The patient died.
Dr. Butler, the Medical Director, wrote a death summary
stating that the patient had known hepatitis C, DM, and
cellulitis. The doctor said that the patient developed
hematemesis and was sent to a hospital and had liver cancer
diagnosed. The doctor said the patient refused treatment and
was DNR.

378

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 379 of 431 PageID #:12577
Patient #28
3/18/2016

A death certificate documented that an autopsy was done and
showed hypertensive cardiovascular disease, severe stenosis
of the LAD, and thin renal cortices with pulmonary edema.
The death certificate made no mention of the patient's liver
mass or cirrhosis.

379

Patient #29

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 380 of 431 PageID #:12578

3/15/2013 An EKG had wandering baseline but showed NSSTT changes.
1/31/2014 The January 2014 MAR documents that the patient was on
only 10 mg simvastatin; 60 units NPH am and 30 units pm with
sliding scale insulin 5 mg Lisinopril, amlodipine; Xopenex,
furosemide 40 BID.
3/21/2014 Urine microalbumin 256; BUN 23; creatinine 1.76; A1c 10.4;
cholesterol 157; HDL 37; LDL 102.
7/22/2014 A1c 10.
11/5/2014 BUN 21; creatinine 1.64; A1c 10.4; Total cholesterol 170; HDL
39; LDL 111.
11/10/2014 An annual health visit documented BP 128/64; weight 236
with height of 5 foot 6 inches. The only problem listed was
diabetes even though the patient had high blood lipids, HTN,
nephropathy, and heart failure. The doctor noted that the
patient needed to lose weight and increased insulin to 64 am
34 pm NPH. The patient was 66 years old and was a smoker
and African American.
12/3/2014 Insulin was changed to 66 u NPH am and 34 units pm.
1/13/2015 A doctor referred the patient for a sleep study.
1/14/2015 The doctor noted the patient had approval at collegial review
for a sleep study.
1/15/2015 Asthma chronic clinic. The doctor noted that the age of onset
wasn't know except it was thought to be when he was an
adult. The patient had a prior history of smoking. The patient
had BP 155/85; PEFRs were 350/370/300. The patient was
described wheezing at times. The doctor took insufficient
history to determine the status, but diagnosed intermittent
asthma and stated, "difficult to judge SOB etiol - likely
multifactorial obesity? sleep apnea." The patient was
diagnosed with good control and the doctor said he would
refer for a sleep study. The patient did not have pulmonary
function testing.

380

17

Minimal increase of insulin but no follow up of diabetes
in significantly out of control patient. The patient's 10year risk of heart disease or stroke for a 66 year old
African American smoker with diabetes and
hypertension was 46%. He needed a high intensity
statin but was on a low intensity statin drug.

7

Given the patient's age, and long-standing hypertension,
the doctor could have considered heart failure. In any
case, the patient should have had pulmonary function
tests to clarify his diagnosis.

Patient #29

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 381 of 431 PageID #:12579

1/20/2015 Wexford approved a sleep study.
1/21/2015 BUN 21; creatinine 1.81; cholesterol 168; HDL 39; LDL 98.
1/27/2015 The sleep study result was very severe sleep disordered
breathing. The recommendations were to utilize a CPAP
device but to refer to ENT to reduce risk of mortality. The
patient had irregularity of the pulse rate and suggested "if
clinically appropriate, further cardiac evaluation is suggested."
1/28/2015 The sleep study was completed at the prison.
2/5/2015 A doctor referred the patient for a CPAP device.

6

The doctor failed to review labs which showed chronic
kidney disease and cholesterol levels consistent with a
46% 10-year risk of heart disease or stroke. The doctor
should have changed the statin to a high intensity statin.

2/18/2015
2/20/2015
2/25/2015
2/26/2015
3/4/2015

17

At this point based on recent labs, the patient had a 54%
10-year risk of heart disease and should have been on a
high intensity statin. This was not done. The patient
had chronic kidney disease and the doctor increased the
lisinopril. Caution should have been documented and
the creatinine and potassium should have been
monitored more closely when starting the increased
dose.

Wexford approved a CPAP machine.
Calcium 7.9; sodium 136; potassium 4.6. No LFTs done.
A CPAP unit was provided to the patient.
Creatinine 1.72; cholesterol 156; HDL 35; LDL 97.
HTN chronic clinic. The doctor documented that the patient
just started with a CPAP machine. The BP was 145/76. The
creatinine was documented as 1.72 and urinary protein was
noted. The doctor noted fair control and increased lisinopril
to 10 mg daily. The doctor did not mention blood lipids.

3/7/2015 Simvastatin was increased to 20 mg daily and lisinopril was
increased to 10 mg daily.

Simvastatin 20 mg is not a high intensity statin. It is not
even a moderate intensity statin.

381

Patient #29

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 382 of 431 PageID #:12580

3/17/2015 A doctor saw the patient for the annual HTN clinic. This was
only two weeks after the last HTN chronic clinic visit, both of
which were documented as annual visits. The doctor noted
that the patient was now on CPAP. The BP was 140/68. The
doctor took little history and noted that the blood pressure
was in good control when it was not good control for a
diabetic. The doctor noted that the patient was on 10 mg of
simvastatin but made no evaluation of lipids or changed the
dose to a proper dose for this patient. The creatinine was
noted to be 1.72 but the patient wasn't diagnosed with
nephropathy. Because of both diabetes and nephropathy the
blood pressure should have been lowered to 130/80.
4/9/2015 Urine microalbumin 678; creatinine 1.64; A1c 10.2; cholesterol
144; HDL 34; LDL 93.
4/15/2015 NPH increased to 68 am and 36 pm.
4/15/2015 A doctor saw the patient for annual diabetic clinic. The doctor
took no history with respect to diabetes. The BMI was 41.5.
The doctor did check the box that the patient had no
hypoglycemia episodes. The A1c was listed as 10.4; the
creatinine was listed as 1.64 which was elevated, the urine
microalbumin was 678. The lipids were listed as in good
control because the LDL was <100. The doctor diagnosed
poor control but added "control stable." The doctor made a
minor increase to insulin to 68 NPH am and 36 pm.
4/20/2015 The patient complained to a nurse of shortness of breath. The
nurse referred to a doctor.

382

3, 17

17

With diabetes, hypertension and nephropathy a blood
pressure of 130/80 is typically the goal. Being on
Lisinopril with nephropathy was a concern. The patient
should have been on a high intensity statin.

The doctor did not utilize a high intensity statin.

Patient #29

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 383 of 431 PageID #:12581

4/21/2015 A doctor saw the patient for shortness of breath. The blood
pressure was 148/75. The patient complained of three weeks
of shortness of breath making him stop and rest on his way to
the dining hall. He had no chest pain and was using his CPAP
regularly. The doctor diagnosed "CHF?" and ordered only a
CXR, EKG, BNP and increased Lasix to 40 BID with a follow up
in two weeks. The doctor did not order an echocardiogram.

7

The patient could have had angina or heart failure. An
echocardiogram should have been considered and
stress testing should have been considered given the
patient's risk profile and symptoms.

7

Given the patient's symptoms and chest film, a stress
echocardiogram and pulmonary function testing should
probably have been done as the doctor did not know
the diagnosis and apparently was working on hunches.

4/22/2015 BNP 139 (<100).
4/23/2015 A chest x-ray showed mild to moderate cardiomegaly.
4/27/2015 An EKG was done. The tracing was technically very poor and
should have been repeated. It showed NSSTT wave changes
indicating possible lateral ischemia.
4/29/2015 A nurse saw the patient using a "cold" protocol. The patient
had productive cough for 10 days with some shortness of
breath. The nurse auscultated wheezing and assessed a
complication of asthma and referred to a physician.
4/29/2015 A doctor saw the patient and noted that he had cough for nine
days. No additional history was taken beyond what the nurse
obtained. The doctor noted that the patient had a recent
chest x-ray and noted that there was cardiomegaly. The
doctor noted that the BNP was not significantly elevated. The
doctor started Augmentin for 10 days.
5/7/2015 A doctor saw the patient in follow up and the patient was
improved. No additional steps were taken.
5/7/2015 For unclear reasons the doctor discussed a "living will" with
the patient who told the doctor that his brother had power of
attorney and he wished a no code status. A DNR was filled
out.
5/15/2015 Alvesco was started for asthma added to Xopenex.

383

Patient #29

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5/15/2015 A doctor saw the patient. The BP was 153/78. The patient
had shortness of breath with exertion but no chest pain. The
patient was using Xopenex regularly. The patient had a history
of smoking. The doctor diagnosed dyspnea due to obesity and
deconditioning. The doctor ordered a BMP and added
Alvesco.
5/15/2015 Creatinine 1.62.
7/6/2015 A nurse saw the patient using a "cold" protocol. The nurse
documented cough and sore throat. The BP was 132/71;
oxygen saturation was 96%. The nurse gave the patient cold
tablets by protocol.
7/13/2015 Oral prednisone was started at a tapering schedule.
7/13/2015 A doctor saw the patient for asthma chronic clinic. The doctor
noted that the patient was on Alvesco and Xopenex and
described increased shortness of breath 2-3 days. The BP was
140/75. The breath sounds were decreased with wheezing.
The PEFRs were 275/150/150. The doctor diagnosed
moderate persistent asthma and added "deteriorating SOB but
not so sure is [secondary] asthma contributory." The doctor
ordered a chest x-ray and ordered a tapering prednisone dose.

7

The doctor should have ordered pulmonary function
testing and echocardiogram. Stress testing should have
ben considered.

7

The doctor should have ordered pulmonary function
testing and echocardiogram. Stress testing should have
ben considered. The doctor did not appear to know the
condition of the patient.

1, 7

The doctor took inadequate history about the shortness
of breath. He should have obtained pulmonary function
testing and echocardiogram as the doctor didn't appear
to understand the diagnosis of the patient. The doctor
diagnosed asthma but other evidence (CXR) was
consistent with heart failure. The history may have
helped but was not done.

7/20/2015 A chest x-ray showed enlarged heart and haziness in perihilar
regions possibly indicative of mild heart failure.
7/22/2015 A1c 9.4.
7/23/2015 A doctor saw the patient for follow up. BP was 145/78; PEFRs
were 300/285/250. The doctor had started prednisone and
mentioned that "prednisone helped." The patient was
"breathing heavy" and had shortness of breath. The patient
said it was seasonal. The doctor ordered prednisone every
other day for two weeks and increased the Alvesco dose.

8/8/2015 Lasix increased to 60 BID; atenolol started 25 mg daily.

384

Patient #29

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8/8/2015 The patient was admitted to the infirmary for shortness of
breath at rest and with exertion. The doctor thought he heard
an S3 heart sound and there were basilar crackles in the lungs.
There was 1+ bilateral pitting edema. The doctor diagnosed
heart failure and ordered Lasix increased to 60 mg BID but did
not order an echocardiogram, a basic diagnostic evaluation of
persons with heart failure. The BP was 136/74; pulse 90; R 20
and oxygen saturation 92%.
8/8/2015 A doctor saw the patient in diabetes clinic. The patient had
used insulin for 29 years. The doctor noted retinopathy,
nephropathy, and neuropathy. The BP was 136/74 and BMI
42.9. The doctor noted that the patient had a chest x-ray
showing cardiomegaly. The doctor examined the feet, noted
that the optometrist had seen the patient, noted an A1c of 9.4
and LDL of 93 and creatinine of 1.62 with urine protein of 678.
The doctor ordered an EKG, TSH, and admitted the patient to
the infirmary for heart failure and increased the Lasix to 60
BID. Remarkably, there was no history with respect to why
the doctor thought the patient had acute heart failure. The
doctor did not change the statin dose. The doctor noted that
the patient was in poor diabetic control but made no change
to therapy. The doctor documented good lipid control and fair
HTN control but did not change medication.

8/10/2015 An EKG was done. The tracing was poor quality and should
have been repeated. It showed NSSTT changes.
8/13/2015 Without seeing the patient on the infirmary, a doctor
discharged the patient on 8/13/15. The doctor documented
that the edema was decreased, ordered a BMP and told the
patient to stop using Ramen noodles.

385

7

The patient likely had heart failure but the doctor did
not order an echocardiogram a basic diagnostic test for
this condition.

Patient #29

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 386 of 431 PageID #:12584

8/13/2015 An EKG was done. The tracing was very poor and none of the
limb leads were present. The automated reading stated that
inferior infarct could not be ruled out.
8/13/2015 BUN 25; creatinine 1.97.
8/29/2015 A doctor saw the patient. The BP was 150/64. The doctor said
that the patient was doing better. The doctor assessed heart
failure, stopped Norvasc and started atenolol.
9/26/2015 A doctor saw the patient and the BP was 138/76.. The doctor
noted no chest pain. The doctor noted that the hypertension
was "controlled" and that the patient had no exercise
intolerance. No changes were made.
10/1/2015 BUN 21; creatinine 1.88; glucose 304.
10/14/2015 A doctor saw the patient for HTN clinic and noted that the
patient also had heart failure, DM, and sleep apnea. The
doctor noted that the patient had dyspnea on exertion and
shortness of breath. The blood pressure was 139/72. The
creatinine was 1.88; glucose 304 and cholesterol 144. The
patient was listed as in good hypertension control.
11/25/2015 A doctor saw the patient. The BP was 152/89. PEFRs were
200/175/150. Oxygen saturation was 94%. The patient had
shortness of breath and DOE. The patient wanted to change
back to Norvasc. The patient's DNR status was changed at his
desire to attempt resuscitation. The doctor stopped atenolol
and restarted Norvasc at 5 mg a day.
11/25/2015 A1c 8.4.
12/29/2015 A doctor saw the patient for diabetes chronic clinic annual.
There was virtually no history except to check a few of the
formatted boxes. The blood pressure was 136/76. The A1c
was listed as 8.4. The diabetes was documented as fair
control; lipids in good control and BP in good control. There
was no change in therapy.

386

7

The doctor should have referred the patient for
echocardiogram.

7, 17

The doctor failed to order echocardiogram, pulmonary
function tests and stress testing. The doctor did not
start a high intensity statin.

7

The doctor should have ordered echocardiogram and
PFT and stress testing.

17

The doctor should have started high intensity statin.

Patient #29

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 387 of 431 PageID #:12585

1/15/2016 Lisinopril was changed to 20 mg daily.
1/15/2016 A doctor saw the patient in asthma chronic clinic. The doctor
noted daytime symptoms but no night time symptoms. The
blood pressure was 138/78. PEFRs were 225/225/230. The
patient had bilateral ronchi. The doctor diagnosed moderate
persistent asthma.
1/28/2016 A doctor saw the patient for chest pain which occurred at
night when he was lying in bed. The blood pressure was
169/94 with pulse 100. The chest pain was described as right
sided without radiation, not pleuritis, without shortness of
breath, and without prior similar episodes. The patient had
previously told a nurse that exertion relieved the pain. The
doctor noted a prior family history of CAD. The patient had 1+
edema. The doctor documented review of an EKG and noted
"no acute changes." Remarkably, the doctor told the patient
that, "He will need a treadmill when discharged." Yet the
doctor did not discuss getting a treadmill currently for the
patient's acute symptoms. If the doctor thought that the
patient needed a treadmill he should have ordered it. The
doctor increased the Norvasc to 10 mg and recommended
decreasing salt.
1/28/2016 An EKG on this date was a poor tracing and should have been
repeated. It showed NSSTT changes but the limb leads were
technically poorly traced and unreadable and this study should
have been repeated. V1 and V2 showed ST elevation on one
portion. This should have been repeated but should otherwise
have been considered consistent with possible ischemia.

387

7, 14

The patient was very high risk for heart disease and had
a questionable history of angina. The doctor should
have ordered stress testing and echocardiogram. He
was 66 years old, smoker, diabetic, with hypertension
and abnormal lipids. This panel of conditions is very
high risk for heart disease. The EKG supported ischemia
sufficient to warrant evaluation. The doctor should
have considered sending the patient to a hospital for
evaluation. To tell the patient to get a treadmill test on
discharge was indifferent.

Patient #29

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 388 of 431 PageID #:12586

3/6/2016 At 3:10 am a nurse saw the patient for "sudden" shortness of
breath. The patient had 2+ edema. The nurse did not take BP
but the pulse was 107 and the pulse oximeter reading was
85%. The nurse called a doctor. Oxygen was started. The
doctor ordered IM Lasix by phone. The oxygen saturation
decreased to the 60s and the doctor ordered the nurse to
send the patient to a hospital. The ambulance arrived at 3:40
am. As ambulance personnel were transferring the patient he
experienced cardiac arrest and CPR was initiated but the
patient was pronounced dead at the hospital.
3/7/2016 A Wexford death summary documented a brief death
summary without any critical evaluation. The doctor noted
that "The last time I saw the patient 12/28/15 and his ECG was
normal." No problems were identified.
3/24/2016 A coroner concluded that the patient died from coronary
atherosclerosis contributed to by hypertensive cardiovascular
disease and diabetes mellitus. There was "marked" edema in
the lungs. Cross sections of coronary arteries showed 75100% stenosis of the RCA with mid segment plaque and focal
acute rupture and hemorrhage. The "left sided coronary
arteries show between 75-85% stenosis with atherosclerotic
plaque." Cardiomegaly with hypertrophy were diagnosed and
sclerosis of the kidneys consistent with hypertensive
cardiovascular disease. Pulmonary edema was noted.

388

It was not accurate that the EKG was normal. The
tracing was poor but showed STT wave changes that
could be interpreted as acute ischemia.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 389 of 431 PageID #:12587
Patient #30
7/10/2012 The problem list was updated indicating seizure with VP shunt; DVT, CVA.
10/15/2012 An annual physical documented that the patient had DVT, hemiparesis, seizure
disorder, and hydrocephalus with VP shunt in 1993. It didn't document why
the patient had a VP shunt or hemiparesis. The patient was documented as
DNR.
9/25/2014 The patient was evaluated for seizure and general medicine clinics at Menard. 1, 3, 17
The doctor documented two seizures and documented that the INR was 1.8.
There was virtually no history. The doctor listed hyperthyroidism and DVT as
problems. The TSH was listed as 2.16. There was no change to medication.

There was no history so it couldn't be
determined what was wrong with the patient.
The patient had history of DVT but the INR
was subtherapeutic, yet the doctor made no
attempt to modify medication. The patient
had two seizures which is not good control,
yet the doctor did not modify medication.
The patient was on both aspirin and coumadin
yet had repeated seizures. There was no
documented clinical reason for being on
aspirin. It placed the patient at significant
risk, especially since he had a VP shunt.

10/22/2014 An annual physical exam listed seizures, history of DVT on anticoagulation, and
VP shunt for unspecified reasons.
11/30/2014 A NP saw the patient for general medicine chronic clinic. There was no history, 1, 2, 3, There was no history or examination and
no physical examination, and the only relevant data was documentation of a
17
therefore the anticoagulation, VP shunt, and
TSH of 2.16.
prior CVA were inadequately addressed and
therefore, the therapeutic plan was
inadequate. The NP failed to address why the
patient was on aspirin and coumadin. There
was no clinical indication for both drugs. It
placed the patient at risk.

389

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 390 of 431 PageID #:12588
Patient #30
1/8/2015 CT scan showed left sided VP shunt with no evidence of ventricular dilation
and no cerebral edema.
1/8/2015 The patient was sent to Chester Memorial Hospital for a seizure. The hospital
noted that he had a VP shunt and was on multiple seizure medications and had
uncontrolled seizures. A CT scan did not reveal unusual problems. Laboratory
studies were "unremarkable." The patient did have a hemoglobin of 9. He was
admitted for observation and discharged on 1/9/15.
1/8/2015 A nurse noted that the patient had seizure. The patient was sent to Chester
hospital from Menard.
1/15/2015 Hemoglobin 9; MCV 70.7 (80-99); platelets 321; Keppra 26 (12-46).
1/15/2015 A nurse noted that the patient had repetitive seizures, apparently witnessed,
called a doctor. The doctor ordered Ativan, Tegretol, Keppra, and
phenobarbital levels in the morning and send-out to Chester hospital. The
nurse noted that the patient had a subclavian port-a-cath but it wasn't clearly
stated why the patient had the central line catheter. There was no mention of
this in progress notes.
1/16/2015 Carbamazepine 8.6 (4-12); phenobarbital 18.4 (15-40); phenytoin <2.5 (10-20).

390

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 391 of 431 PageID #:12589
Patient #30
1/16/2015 The inmate told a nurse he had a seizure. A doctor saw the patient later and
there was no history and the only examination was "neuro intact." No action
was taken.

1/18/2015 The patient had an unwitnessed seizure and was admitted to the infirmary for
observation.
1/19/2015 A doctor wrote an admission note but took no history. The only neurological
exam was "neuro intact." No new actions taken. The same day the doctor
discharged the patient without follow up. Later on the same day a doctor
noted microcytic hypochromic anemia and the only plan was to order iron and
stool for fecal occult blood x 3.

391

1, 2, 12, The history and physical examination were
17
inadequate. The patient had repetitive
seizures and had a VP shunt. The patient
should have been referred to a neurologist
because the facility physician was unable to
get the seizures under control and the patient
had a complicated case, having a VP shunt.
The patient had a microcytic anemia yet the
doctor took no history of whether there was
blood loss and did not initiate a work up for
this. The doctor should have noted why the
aspirin was indicated, as in combination with
coumadin placed the patient at significant risk
with respect to his seizures.

1, 2, 6, The doctor took no history and the
8, 17 examination was inadequate. The doctor
should have ordered iron laboratory studies
but did not. Obtaining fecal occult blood tests
was appropriate and starting iron was
reasonable. But the doctor needed further
work up for the anemia. The doctor also
failed to assess prior therapeutic drug levels.
The doctor also failed to indicate why the
patient was on both aspirin and coumadin.
Since the patient had seizures, this placed him
at significant risk.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 392 of 431 PageID #:12590
Patient #30
1/22/2015 INR 3; carbamazepine 8.7 (4-12); Keppra 24 (12-46).
2/2/2015 A doctor noted that the patient had no seizures. Aside from stating no seizures 1, 2, 3, 6 The doctor took no history and performed no
there was no history and no physical examination. The doctor ordered an INR.
examination. The doctor made no
assessments or plan. The doctor noted that
The doctor made a comment that seizure med levels were "OK."
the seizure medication levels were OK.
Recent labs from 1/22/15 were normal but
labs from 1/16/15 showed a subtherapeutic
dilantin level which was unnoticed.
2/21/2015 A doctor saw the patient for seizure disorder. The doctor noted that the
1, 7, 17
patient had >6 seizures since the previous clinic and noted normal drug levels.
There was virtually no history. The doctor diagnosed the patient as having
"stable" disease. Despite normal drug levels and multiple breakthrough
seizures, a prior history of significant brain injury and a VP shunt, the patient
was not referred to a neurologist. There was no change in therapy despite the
breakthrough seizures.

3/22/2015 A nurse documented that the patient had a seizure. The nurse took an order
from the doctor to leave the inmate in his cell.
3/23/2015 INR 2.8.
4/24/2015 INR 2.3; hemoglobin 12.9; MCV 83; MCH 25.8 (26-35); MCHC 31 (32-37).

392

The doctor took inadequate history. Since the
patient had a complicated seizure problem
and the facility doctor (who was a surgeon)
couldn't control the inmate's seizures, the
doctor should have referred to a neurologist.
The doctor should have noted why the aspirin
was indicated as in combination with
coumadin placed the patient at significant risk
with respect to his seizures.

T

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 393 of 431 PageID #:12591
Patient #30
6/7/2015 The patient was evaluated apparently in general medicine clinic. There was no 1, 2, 3,
history, no examination, and the only documentation was that the TSH was
17
3.29. The patient was listed as stable and in good control but his condition was
not documented, although presumably he was being seen for hypothyroidism.

6/17/2015 INR 2.3.
7/7/2015 INR 2.2; phenobarbital 19.6 (15-40); Keppra 27 (12-46).
7/17/2015 A nurse saw the patient for a seizure. The nurse tried to call a doctor 3xs but
was unsuccessful and admitted the patient to the infirmary.
7/18/2015 The doctor noted that the patient's last seizure was four months ago. The
doctor did not order therapeutic drug levels. A doctor wrote that the patient
could return to the housing unit. The doctor didn't take an adequate history
and there was no change of plan.

7/23/2015 Hemoglobin 14 (13.2-18); MCHC 31.8 (32-37).
8/5/2015 INR 2.9.

393

There was no history, physical examination or
assessment of the patient's multiple problems
including epilepsy, VP shunt or
anticoagulation. The patient still had anemia
which had not been worked up appropriately.
The doctor should have noted why the aspirin
was indicated as in combination with
coumadin placed the patient at significant risk
with respect to his seizures.

1, 8, 17 The doctor took inadequate history and
should have ordered therapeutic drug levels.
The doctor should have noted why the aspirin
was indicated as in combination with
coumadin placed the patient at significant risk
with respect to his seizures.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 394 of 431 PageID #:12592
Patient #30
9/8/2015 A NP saw the patient for seizure chronic clinic. The last documented seizure
was two months ago. The patient was documented as having no signs of
bleeding and was documented as on coumadin. The Keppra and phenobarbital
levels were documented. The only medications documented were Keppra and
Tegretol. The patient was on aspirin and coumadin which in combination,
particularly because of the seizures, was potentially dangerous. The INR
wasn't mentioned. There was insufficient information in this note to give a
sense of the current management or the future therapeutic plan for the
patient.
9/10/2015 INR 3.3.
10/1/2015 INR 1.5.
10/1/2015 A nurse documented that the patient had dizziness, blurred vision and
lethargy. The nurse noted that the patient still had a subclavian catheter and
that it was accessed for a blood draw.
10/17/2015 A nurse noted that an officer witnessed the patient having a seizure. The
nurse called a doctor who ordered drug levels in the morning. The nurse
documented that cellies and officers witnessed the event.
10/19/2015 A nurse noted that the subclavian catheter flushed but could not be aspirated.
The next day the nurse was able to obtain blood from the port.
10/20/2015 INR 3.9; carbamazepine 10.4 (4-12); Keppra 25 (12-46).

6, 17

The NP failed to check the INR and did not
note that the patient was on both coumadin
and aspirin which, given his seizure disorder,
placed the patient at risk.

15

The doctor failed to see the patient or follow
up after a seizure.

The medication renewal process didn't work
and the patient's medication stopped in mid
December and wasn't started again until
1/8/17, about 3-4 weeks later.

394

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 395 of 431 PageID #:12593
Patient #30
10/22/2015 Dr. Trost saw the patient and noted that the INR was 3.9. There was no
history, no examination, and no assessment. The coumadin was held for seven
days and then resumed at 4 mg daily.

17

The doctor did not indicate why the patient
was receiving aspirin. The doctor should have
noted why the aspirin was indicated, as in
combination with coumadin, placed the
patient at significant risk with respect to his
seizures.

10/25/2015 The NP noted a supratherapeutic INR but did not adjust medication and did
not note that the patient was on both coumadin and aspirin which, given his
seizure disorder, placed the patient at risk. The history was inadequate for
seizure disorder and anticoagulation and the NP asked no questions about the
VP shunt.

1, 17

The NP noted a supratherapeutic INR but did
not adjust medication and did not note that
the patient was on both coumadin and aspirin
which, given his seizure disorder, placed the
patient at risk. The history was inadequate for
seizure disorder and anticoagulation and the
NP asked no questions about the VP shunt.

10/30/2015 A nurse noted that the patient had a reported seizure and was brought to the
health unit in a wheelchair. The patient had headache. The nurse called Dr.
Trost, who sent the patient back to his cell with follow up as needed with
nurses.
11/3/2015 A nurse noted that the patient had seizure. Dr. Trost gave a phone order for
the patient to return to his cell.
11/20/2015 INR 2.4.
11/22/2015 A nurse saw the patient for an unwitnessed seizure. The nurse documented
calling a doctor but did not document what the doctor ordered. The patient
was sent back to his cell. Later that day a doctor saw the patient. The doctor
documented an episode of convulsion for four minutes. The doctor
documented no abnormalities on exam and sent the patient back to his cell.

15

The doctor should have seen the patient and
should have ordered follow up as a seizure is a
significant event.

15

This was indifferent. The doctor should have
evaluated the patient.

11/29/2015 A nurse saw the patient for a seizure. The patient was returned to his cell.
12/14/2015 INR 2.

395

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 396 of 431 PageID #:12594
Patient #30
12/17/2015 The patient transferred to Hill from Menard. The transfer summary
documented seizures and VP shunt as problems. The reason for either of
these was not mentioned.
12/17/2015 Shortly after the patient transferred to Hill he had a seizure. A nurse witnessed
the seizure for an hour. The nurse called Dr. Sood, and Ativan was repeatedly
given. Dr. Sood wrote an order to give Ativan 2 mg IM stat for "continuous
seizure activity" the "send out if unresponsive to therapy and continuous
seizures." After multiple injections of Ativan the patient was sent to a hospital.
The patient went to Cottage ER. From the local hospital the patient was
transferred to OSF St. Francis Hospital in Peoria.
12/22/2015 The patient returned to the Hill facility and a doctor saw the patient. The
doctor did not document what occurred at the hospital. The doctor reviewed
the patient instructions. The doctor noted that the patient had history of
ataxia [presumably from the hospital] but documented no ataxia. The doctor
initiated the patient's seizure meds (Depakote and phenobarbital) and
apparently sent back to his cell.
12/22/2015 At 6:29 pm a nurse documented that the inmate's cell mate noted that the
inmate was having a seizure. Dr. Sood ordered IM Ativan 2 mg. The nurse
noted two further seizures, after which Dr. Sood ordered IM Ativan. After the
fourth seizure the patient was sent to a hospital.
12/22/2015 At 10:56 pm a nurse documented that the hospital stated that the inmate was
having non-epileptic convulsions, was not having seizures and would return to
Hill.
12/22/2015 The patient was admitted to a local hospital and transferred to a regional
hospital in Peoria. He transferred from the local hospital intubated but was
extubated the same day. He had EEG leads in the ICU and while having
"seizures" there was no EEG activity and ultimately was determined to have
pseudoseizure activity. The INR was 2. The hospital noted that at the local
hospital a CT scan showed no acute bleed.

396

11

The lack of review of reports is a serious
problem. The physician did not know what
occurred at the hospital or the basis of the
therapeutic plan.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 397 of 431 PageID #:12595
Patient #30
12/23/2015 A nurse noted drawing blood from the central IV port which was in for the past
year without clear indication.
12/23/2015 The patient was admitted to the infirmary post hospitalization. The reason for
admission was frequent seizures and ataxia. The nurse documented that the
patient had ataxic gait.
12/23/2015 An NP performed an infirmary admission note. The NP documented that the 2, 14, 17
patient fell twice on the infirmary on 12/23/15 due to ataxic gait. The NP
noted that the left pupil was larger that the right and that the patient had
delayed speech and repeated himself. The NP did not examine for ataxia. The
NP noted that the patient had a VP shunt and that the epilepsy was not well
controlled and that the patient had ataxia with falls. The NP ordered to have
the mattress placed on the floor, neuro checks every shift, and for Dr. Sood to
evaluate the patient.

12/23/2015 At 4:30 pm a nurse documented that the patient was incontinent of urine. The
nurse documented that the hospital would fax the neurology report and
discharge note.
12/23/2015 At 7:30 am a nurse documented that the patient fell twice. The nurse noted
that the patient's Lt pupil was larger than the right. On a later note at 3:00 pm,
a nurse documented that the patient fell twice today.

12/24/2015 INR 3.1.
12/24/2015 At 6:20 pm the patient rang the emergency call light. When the nurse arrived
the patient was off the floor mattress and was incontinent of urine. The nurse
presumed that the patient had a seizure. The nurse apparently called a doctor
but there were no orders documented.

397

The patient was said to have ataxia but there
was no examination for this. Ataxia and
unequal pupils in a person with VP shunt
requires immediate hospitalization for brain
imaging. To merely place a mattress on the
floor was grossly and flagrantly unacceptable
care. Also the staff did not assess why the
patient was on aspirin as the combination of
aspirin and coumadin placed the patient at
risk of significant harm.

16

16

These were all red-flag type symptoms and
signs and the patient should have been
referred to a physician immediately. Care was
grossly and flagrantly unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 398 of 431 PageID #:12596
Patient #30
12/24/2015 Dr. Sood saw the patient on rounds and noted that the staff said the patient
had incontinence of urine. The doctor documented good eye contact, that the
patient was sitting on the mattress. The doctor did not perform an adequate
neurological examination. The assessment was intractable seizures. The
doctor did not assess why the patient had incontinence. The doctor did not
assess the unequal pupils or ataxia. The patient was to continue the same
management.

398

1, 2, 4, The doctor's history failed to determine why
17
the patient was incontinent or whether he
had a seizure. There was inadequate
neurological examination. The doctor did not
assess the pupils; apparently the patient still
had unequal pupils. The doctor did not assess
the ataxia. The doctor had no plan for the
incontinence, ataxia, unequal pupils, or
abnormal behavior. The doctor did not assess
why the patient was on both aspirin and
coumadin. Care was grossly and flagrantly
unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 399 of 431 PageID #:12597
Patient #30
12/24/2015 A nurse documented that the inmate was attempting to stand but needed
assistance. The nurse described the inmate as able to swallow water and
making intermittent eye contact but was not otherwise interacting in
conversation and was uncooperative with the neuro examination. No action
was taken. On a later note at 4:00 pm, a nurse documented that the patient
was attempting to sit up without assistance. His pulse was 122. The patient
was not responsive to commands but was responsive to painful stimuli. The
nurse documented unequal pupils. The patient was staring out without being
responsive. The nurse applied oxygen but it wasn't sure there was an order for
this. The nurse noted that the patient had urinated on the bedsheets. Three
people were required to assist the patient in getting up. The nurse applied
diapers. The nurse documented that the patient had a seizure but it appeared
that the patient was continuously disorganized, lethargic, and confused. The
nurse didn't document consulting a doctor. Later at 5:00 pm, the patient's
cellie called the nurse back to the room because the inmate was trying to get
up again. This was not normal behavior and should have been immediately
evaluated. The patient should have been sent to a hospital. The nurse
diagnosed post-ictal status. But the behavior had been ongoing for two hours.
The nurse documented that the patient was still not responding to commands
and since he wasn't drinking water, she held his oral medication. At 7:00 pm,
the patient was in a reclining chair and earlier had drinking some water but the
nurse noted that he hadn't eaten. At 8:00 pm, the patient took his meds with
some pudding. At midnight with assistance of two inmates the patient was
placed on the floor and was noted to be incontinent.

399

16

Nursing assessments without referral were
grossly and flagrantly unacceptable. The
patient should have had a better history, a
thorough examination, and should have been
sent to a hospital. The nurse needed to
consult a physician.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 400 of 431 PageID #:12598
Patient #30
12/25/2015 The patient wasn't responsive, barely moving legs and opening his eyes just a
14, 15
slit. He wasn't answering questions. The nurse noted that the left pupil was
larger than the right. The assessment was post ictal. At 9:30 am the patient
was incontinent. The patient needed assistance to get off the mattress and
was unable to drink with a straw. Later a nurse reported to Dr. Sood and was
instructed to continue to observe the patient. At 4:15 pm a nurse noted that
the inmate responded to tissue being moved across his eyes. The nurse
documented that Dr. Sood was made aware of the patient's condition. Later at
8:30 pm the patient was incontinent.

The patient showed several red-flag signs of
significant life-threatening illness including
unequal pupil, altered mental status, and lack
of responsiveness. The doctor should have
sent the patient immediately to a hospital and
immediately evaluate the patient.

12/26/2015 At midnight the patient was still unresponsive and was incontinent. The nurse
described the patient as "post-ictal like state." The patient was not drinking.
By 8:00 pm the patient was responding verbally to questions and his speech
was sluggish but intelligible. The patient ate some food. Nurses continued to
document unequal pupils.
12/27/2015 At 3:00 am the inmate was trying to get up out of bed but was unsteady. He
was incontinent of urine. At 5:20 am the inmate was found on the floor and
placed back in bed. At 6:00 am the patient was found with his chair on top of
him. The patient was now eating. At 4:30 pm a nurse documented that there
was bruising on both elbows and the left elbow with a 3 by 3 cm purple area
that was pliable. Since the patient was on coumadin the patient should have
been promptly evaluated for bleeding problems and there was concern for a
CNS bleed. A stat INR should have been obtained. At 8:00 pm a nurse noted
that the patient ate 100% of his dinner.

16

The patient had red-flag signs of significant lifethreatening illness. The nurse should have
consulted a physician.

12/28/2015 A nurse noted that the patient was incontinent and the bedding was saturated
with urine. At 7:15 am the patient was noted to be responding to commands
but slow to follow orders.

16

400

16

The patient had red-flag signs of significant lifethreatening illness. The nurse should have
consulted a physician.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 401 of 431 PageID #:12599
Patient #30
12/28/2015 Dr Sood saw the patient. The only history was that the patient was responding 1, 2, 8, The doctor failed to take an adequate history.
to commands. Dr. Sood noted that the patient was sitting on the floor and
14, 17 The doctor failed to note bruising identified by
that according to staff he had eaten yesterday and took all of his medication.
nurses earlier. The doctor failed to document
The doctor didn't assess for ataxia, didn't assess the unequal pupils, and
a neurologic examination despite being called
performed no neurological examination. The doctor assessed seizure
several times for altered mental status. The
recurrence. There was no plan.
doctor failed to assess why the patient was on
aspirin and coumadin or check an INR despite
bruising. Altered mental status and bruising in
someone with a VP shunt and on Coumadin
and aspirin should have resulted in
hospitalization for immediate brain imaging.
The lack of history and examination was
indifferent and grossly and flagrantly
unacceptable care. The doctor did not
address why the patient was on aspirin
despite the bruising.

12/28/2015 A nurse noted that the patient had constipation. The patient was still
incontinent of urine.
12/29/2015 Dr. Sood saw the patient. The doctor noted that the patient was sleeping on
the mattress. Dr. Sood noted that the patient's bloody elbows were resolving
with decreased swelling. The doctor changed the patient's status to chronic.
The doctor had yet to examine the patient's eyes, perform a neurologic
examination, or evaluate the patient for problems with anticoagulation in light
of the patients severe altered mental status and recent bruising. The doctor
made no changes except to lower the acuity status of the patient.

401

1, 2, 8, The doctor again failed to take adequate
14, 17 history or try to discover how the patient
developed bloody elbows. The doctor failed
to adequately examine the patient or order an
INR to assess anticoagulation despite the
patient having a bruising problem. The doctor
failed to ask why the patient was on aspirin
and coumadin. There was no clinical
indication for the aspirin. The patient should
have been sent to a hospital.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 402 of 431 PageID #:12600
Patient #30
12/29/2015 A nurse noted that the patient was climbing up and down out of the reclining
chair. He ate some food. He was answering yes and no questions. At 11:00
pm the patient was incontinent of stool and was again unresponsive to verbal
stimuli.
12/30/2015 Carbamazepine 4.8 (4-12); phenobarbital 34.7 (15-40); valproic acid 38.1 (50100).
12/30/2015 The patient was incontinent of stool at 6:45 am. At 3:30 pm a nurse noted
that the patient had bruising on his right arm and was on blood thinners. No
action was taken.

16

The patient had red-flag signs of significant lifethreatening illness. The nurse should have
consulted a physician.

16

The patient had red-flag signs of significant lifethreatening illness. The nurse should have
consulted a physician.

12/31/2015 The patient was still incontinent. At 2:00 pm a nurse noted bruising on both
elbows and to bilateral knees, and lower back. There was no evaluation for
supratherapeutic INR or excess anticoagulation. The inmate did ask to use the
commode but did not have a bowel movement.

16

The patient had red-flag signs of significant lifethreatening illness. The nurse should have
consulted a physician.

1/1/2016 The patient was incontinent of urine. At 8:30 pm a nurse noted that he was
sometimes responsive and sometimes unresponsive. The nurse noted
persistent bruising on various areas of the body including the elbows.

16

The patient had red-flag signs of significant lifethreatening illness. The nurse should have
consulted a physician.

16

The patient had red-flag signs of significant lifethreatening illness. The nurse should have
consulted a physician.

16

The patient appeared to manifest altered
mental status and the nurse should have
consulted a physician.

1/1/2016 Notably the patient was on 4 mg of coumadin and 81 mg of aspirin throughout
his stay at Menard and Hill without any indication of why he needed aspirin or
why he was on coumadin when he had an IVC filter. The IVC filter was
apparently not known to staff.
1/2/2016 The patient knew that he was in prison. The nurse noted large ecchymoses on
his arms and thighs. Yet there was no evaluation of INR level.
1/3/2016 At 4:30 am the nurse responded to an emergency call light and the patient was
standing naked in the middle of the cell saying he had to go to the bathroom.
The nurse assisted him to the toilet with a gait belt. At 5:30 am the nurse
responded to the call light and the inmate was sitting on the floor saying he
was hungry.

402

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 403 of 431 PageID #:12601
Patient #30
1/4/2016 At 6:05 am a nurse noted that the patient was sitting naked in the chair with
his diaper on the floor. There was urine on the floor. The nurse noted that the
inmate was confused as to the source of the liquid.

16

The patient had red-flag signs of significant lifethreatening illness. The nurse should have
consulted a physician.

1/4/2016 Dr Sood saw the patient. He noted that the inmate was sitting in the chair. Dr. 2, 8, 14,
Sood noted that the patient made "good eye contact" but didn't evaluate the
17
pupils which were described previously as unequal. Dr. Sood noted that the
patient was responding to commands. He performed no neurological
examination except to note that the patient was responding to commands. He
did note examine the bruises or initiate evaluation for excessive
anticoagulation or evaluate the obvious altered mental status of this patient.
No labs or diagnostic tests were ordered.

The doctor's physical examination was
inadequate and he failed to note obvious
abnormalities identified by nurses, especially
the bruising and altered mental status. An
INR should have been immediately done. The
doctor should have identified why the patient
was on aspirin and coumadin; the bruising
was life-threatening and unrecognized by the
doctor. The patient should have been sent to
a hospital. Care was grossly and flagrantly
unacceptable.

1/4/2016 At 1:30 pm the patient was incontinent of stool. The patient was walked in the
hall and had unsteady gait. At 6:40 pm a nurse saw the patient standing in his
cell door with blood on his nose and in front of his gown. The inmate didn't
know what happened but blood was on the wall and beside the toilet at head
height. The inmate had a 2.5 cm laceration to the bridge of his nose. The INR
wasn't checked. Dr. Sood was notified that it was hard to get the bleeding
stopped. He did not order an INR. Later a nurse noted that the pupils were
still unequal. The nurse noted bruising to the right buttock about 8 cm in
diameter, on the lower back and noted "assorted bruising in various stages of
healing to bilateral arms and legs." The nurse also noted unequal hand grips.

The patient had significant bruising and
difficult to control bleeding with altered
mental status and the doctor should have
immediately transferred the patient to a
hospital. Care was grossly and flagrantly
unacceptable.

403

14

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 404 of 431 PageID #:12602
Patient #30
1/5/2016 At 6:50 am a nurse documented giving a report to the MD nurse regarding
1, 2, 8, The doctor failed to take adequate history and
seepage of blood from the wound and red-tinged urine and bruising to back.
14, 17 failed to perform an adequate examination
Dr Sood saw the patient at 8:00 am. The only history was that he was seeing
particularly a neurological examination. The
the patient because a nurse documented seeing the patient bleeding. There
doctor failed to assess an INR despite
was no other history. His examination was poor. He noted that the patient
numerous bruises and difficult to control
was sitting in a chair responding to commands with conversation. He noted
bleeding. The patient had altered mental
status and there was no evaluation. The
that there was active bleeding and ecchymosis on the buttock, lower back, and
bilateral arms. The doctor sutured the nasal laceration but remarkably did not
doctor failed to assess why the patient was on
check an INR level to assess for potential for bleeding. The doctor made no
aspirin and coumadin. The patient should
evaluation of the altered mental status and performed no neurological
have been sent to a hospital. Care was grossly
examination but did order nasal bone x-rays.
and flagrantly unacceptable.
1/5/2016 At 7:30 am a nurse noted that the patient still had unequal pupils. Notably Dr.
15
Sood never evaluated this once. A nurse noted blood in the stool. At 7:02 pm
a nurse noted moderate amount of blood in the toilet. The nurse called Dr.
Sood and was awaiting a call back.
1/6/2016 X-ray showed no evidence of nasal fracture.
1/6/2016 A nurse showed Dr. Sood the urinal where the nurse noted "gross blood." Dr. 4, 14, 17
Sood did not check the INR but ordered ciprofloxacin for five days and ordered
a repeat dipstick urine. Later a nurse noted unsteady gait.

1/6/2016 UA showed 3+ blood.
1/7/2016 The inmate was able to feed himself with minimal assistance and complained
he had been up all night and had "a lot of migraines."

404

A physician should have seen the patient.

The patient was on coumadin and aspirin and
had gross blood in his urine yet the doctor
treated the patient with antibiotics for a
presumed urine infection without checking an
INR. The doctor failed to associate the
coumadin and aspirin with bloody urine. This
was incompetent and grossly and flagrantly
unacceptable care. The patient should have
been sent to a hospital.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 405 of 431 PageID #:12603
Patient #30
1/7/2016 Dr. Sood saw the patient and noted he was watching TV but took no history. It 1, 2, 8, The doctor failed to take adequate history and
was difficult to read the note due to legibility but it did not appear that the
14, 17 failed to perform an adequate examination
doctor performed a neurologic examination. The assessment was
particularly a neurological examination. The
pseudoseizure and DVT. Even though assessing DVT, Dr. Sood did not order an
doctor failed to assess an INR despite
INR to evaluate for excess anticoagulation despite bruising, bleeding in his
numerous bruises and difficult to control
urine and in his BM. He took no action.
bleeding. The patient had altered mental
status yet was not evaluated for this. The
doctor failed to assess why the patient had
bleeding while on coumadin and aspirin. The
doctor failed to address why the patient was
on aspirin. The patient should have been sent
to a hospital. Care was grossly and flagrantly
unacceptable.
1/7/2016 At 4:30 pm a nurse noted a moderate amount of blood in his urine. No action
was taken.

16

1/8/2016 At 9:30 am a nurse noted that the patient had bruises in both eyes. There was
blood in his urine and he had bruises in various stages of healing. At 3:40 pm a
nurse obtained urine for a UA and gross hematuria was observed. At 7:00 pm
the patient had a BM and there was blood in the toilet.

16

1/8/2016 At 11:50 pm a nurse noted that the inmate was standing at the door yelling
"can you help me" and when asked what help he needed he said "I don't need
any help." The nurse noted "some confusion." No action was taken.

16

1/8/2016 UA showed 3+ blood.

405

The patient had red-flag signs of significant lifethreatening illness. The nurse should have
consulted a physician.
The patient had red-flag signs of significant lifethreatening illness. The nurse should have
consulted a physician.

The patient had red-flag signs of significant lifethreatening illness. The nurse should have
consulted a physician.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 406 of 431 PageID #:12604
Patient #30
1/9/2016 At 7:15 am the inmate was making sounds but didn't understand and needed
assistance with gait. There was a new purple bruise on his right hip and the
top of his head had dried blood. Dr. Sood was called and said to monitor the
patient. At 11:00 am Dr. Sood ordered the patient sent to a hospital in
another hour if there was no change. At 2:00 pm there was no change in the
patient's condition. His pupils were fixed bilaterally based on a nurse
evaluation. There was no response to sternal rub. An EKG was done and an
ambulance took the patient off to the hospital at 2:15 pm.
1/10/2016 The patient died.
1/10/2016 A hospital record documented that the patient arrived at the hospital
unresponsive. He had an INR of 10 and the CT scan showed a massive
herniation and massive right sided subdural hematoma with a 16 mm shift of
the brain across midline. Pupils were fixed and dilated. At the hospital they
noted that it wasn't certain why he was on anticoagulation. On examination
the patient had fixed dilated pupils, a contusion and laceration on top of the
head. The WBC was 17.9; hemoglobin 9.3; INR 10; potassium 3.4. The
diagnosis was hypercoagulable state secondary to coumadin with large
subdural hematoma with brain herniation. The patient was not recoverable
under admitting conditions. A CT scan of the abdomen and pelvis showed a
possible contusion/hematoma overlying the right greater trochanter without
fracture. Notably the hospital noted that the patient had a right central
venous line in place with an implantable port. It was not clear why the patient
had this device as he was not on chemotherapy.

406

14, 15 The patient had further bruising, was
confused, and needed assistance to walk. The
doctor should have immediately sent the
patient to a hospital. Care was grossly and
flagrantly unacceptable.

The patient had a brain bleed due to over
anticoagulation while on both coumadin and
aspirin. The patient had repeated
manifestations of excessive anticoagulation
and repeated manifestations of altered brain
function yet was not appropriately evaluated.
Care was grossly and flagrantly unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 407 of 431 PageID #:12605
Patient #30
1/12/2016 Dr. Sood wrote a death summary stating that he was transferred from Menard
to Hill on 12/17/15 with a history of seizure disorder secondary to a
craniotomy in 1996. The patient had multiple DVTs and PE in the past and had
LV shunt placement in 1996 secondary to hydrocephalus. The patient
developed bacterial meningitis in 2001. In 2005 the patient had an IVC placed
for unclear reasons. Dr. Sood said that the patient had a chronic left subdural
hematoma in 2001.

407

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 408 of 431 PageID #:12606
Patient #31
6/24/2013 Problem list documents DM, HTN, substance abuse, umbilical
hernia,
8/1/2013 The patient was transferred from NRC to Taylorville.
8/13/2013 HTN and DM clinics documented BP 135/68 with weight of
300 pounds. The patient also had diabetes and therefore the
blood pressure was not at recommended goal yet the patient
was listed as "in control." The patient had 1-2+ edema. The
doctor noted that the patient had diabetes and added aspirin
and simvastatin. The patient was also on metformin, lisinopril,
and HCTZ.
11/15/2013 A nurse saw the patient at the request of the Warden who
asked to evaluate a large growth on his left ear that was
bleeding.
11/19/2013 A doctor noted that the patient had a left ear growth. The
doctor referred the patient to an ENT consultant.
11/19/2013 A doctor referred the patient for removal of a growth.
11/30/2013 The ENT referral was denied; instead the patient was sent to
plastic surgery.

1/7/2014 A nurse saw the patient. The BP was 153/79. The patient was
off for a medical writ but the nurse didn't document what
occurred.
1/7/2014 An ENT doctor recommended removal of the ear and cheek
growths and correction of the ectropion.
1/17/2014 CMP and CBC normal.
1/31/2014 An annual examination was done. The BP was 151/81.
2/6/2014 A doctor noted that the patient was scheduled for an
outpatient surgery appointment on 2/10/14.

408

Of note, there is not much difference in referral to a
plastic surgeon vs an ENT surgeon for this condition. It
merely depends on access in the community.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 409 of 431 PageID #:12607
Patient #31
2/10/2014 The patient had outpatient surgery to remove the ear mass
apparently. The return note did not document what occurred.
2/10/2014 A biopsy of the left ear was a basal cell carcinoma. The
surgical margins were negative for tumor.
2/17/2014 A doctor saw the patient and noted that the growth had been
removed. The doctor did not document what the pathological
diagnosis was. A PRN follow up was ordered. The blood
pressure was 144/81.
8/29/2014 CMP normal; cholesterol 171; TG 158; HDL 33; LDL 106.
9/3/2014 A progress note documented that the patient was seen in HTN
and diabetic clinic but there was no note.
11/18/2014 A1c 5.8.
12/9/2014 A progress note documented that the patient was seen in
diabetic clinic but there was no note.
2/18/2015 CMP normal; cholesterol 122; TG 121; HDL 33; LDL 65.
4/10/2015 CMP normal; cholesterol 131; TG 117; HDL 35; LDL 73.
4/29/2015 A doctor saw the patient for follow up of blood pressure. The
blood pressure was 169/77 but the doctor made no changes.
The doctor noted that the patient recently started Festeritic.
5/8/2015 BUN 21; glucose 126; cholesterol 127; TG 155; HDL 34; LDL 62.
5/14/2015 An annual examination was done. The BP was 156/76. The
weight was 315. Aside from diabetes and HTN no other
problems were mentioned. Apparently, a doctor re-did the
blood pressure, which was 138/80.
5/22/2015 CMP normal; CBC normal.

409

11

We could not locate a note.

11

We could not locate a note.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 410 of 431 PageID #:12608
Patient #31
5/27/2015 A doctor saw the patient. The blood pressure was 130/80.
The weight was 310. The only examination was to record the
blood pressure. There was no history except that the patient
felt OK and had decreased caloric intake, was tolerating the
ace inhibitor, had no chest pain and no dyspnea. That was the
last note until the patient was diagnosed with squamous cell
cancer.
6/5/2015 A discharge medical summary was written from Taylorville.
There were no further notes and it wasn't clear where the
patient went. It appeared that the patient was transferred to
an adult transition center. The patient didn't come back to the
prison until after a hospitalization where cancer was
diagnosed. It is not clear what care the patient received in the
adult transition center.
9/20/2016 An OSF Health care note. A CT scan was done. The history
was that the patient had a right tongue mass for the past 2-3
months with right ear pain. The CT scan showed an ulcerated
mass in the right anterior oral tongue measuring 4.7 cm with
multiple abnormal lymph nodes and a left orbital intraconal
mass between the lateral rectus muscle and the optic nerve
sheath.
10/3/2016 An MRI showed an oral cavity squamous cell carcinoma on the
right side of the tongue with multiple lymph nodes suspicious
for metastatic adenopathy. A PET scan was recommended.
10/5/2016 A PET scan showed large malignancy of the right tongue with
multiple lymph nodes. There were multiple pulmonary
nodules suspicious for malignancy.

410

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 411 of 431 PageID #:12609
Patient #31
10/28/2016 An oncologist saw the patient and noted stage IV squamous
cell cancer of the tongue. Radiation therapy was not an
option. The oncologist recommended palliative
chemotherapy. The patient had hyperkalemia. The patient
weighed 242 pounds.
11/10/2016 A doctor admitted the patient to the infirmary for a history of
oral squamous cell cancer with metastases. The doctor did
not document a history of the patient's recent treatment.
11/17/2016 Glucose 167; T protein 5.7 (6-8); albumin 2.5 (3.4-5); WBC
18.6; hemoglobin 11.7 (13.2-18); platelets 561.
12/2/2016 The patient died while in hospice care at the facility.

411

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 412 of 431 PageID #:12610
Patient #32
12/6/2016 The patient was admitted to NRC. The medications on entry
were not listed and there was no evidence of what the patient
said he was taking. A PA did an initial physical examination
and documented asthma, HTN, heart failure, COPD, diabetes,
and ITP. There was no history of the ITP except that the
patient had prior splenectomy. A blood glucose was 154. The
patient's medication was listed as insulin NPH38 am and 20
pm with sliding scale regular insulin. Lisinopril, Coreg, Lasix,
Zocor, and Flomax. Two other drugs were prescribed but the
names were illegible.
12/6/2016 A transfer summary from the Lake County Jail documented
that the patient was on NPH insulin, olanzapine, gabapentin,
regular insulin QID, albuterol inhaler, carvedilol, ciclesonide
inhaler, danacrine 600 BID, Lasix 40 Bid, ipratropium inhaler,
lisinopril, tamsulosin, atorvastatin. Danocrine is danazol.
12/6/2016 BUN 23; glucose 157; creatinine 1.87 (0.5-1.5); albumin 2.9.
12/7/2016 A1c 9.4; cholesterol 136; HDL 29; LDL 96; WBC 14.6; platelets
60.
12/14/2016 Creatinine 1.36 (0.5-1.5).
12/28/2016 A nurse saw the patient for constant hip pain radiating to his
back. The nurse plan was not clearly documented.
1/4/2017 The patient was transferred from NRC to Pinckneyville. It does
not appear that blood tests had been done at NRC. The
transfer form listed HTN, diabetes, asthma, and
thrombocytopenia with prior splenectomy as problems. A
blood sugar wasn't done on transfer.

412

1

ITP is a serious medical illness. The history of this
condition was inadequate with respect to medication
and current status and treatment. Old records should
have been obtained.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 413 of 431 PageID #:12611
Patient #32
1/6/2017 A doctor did a chart review to review medications. The doctor
stopped Atrovent, danazol, ciclesonide, Zocor; increased
ellipta, kept the patient on Neurontin and ordered chronic
clinic as needed. The doctor also renewed insulin. Notably, it
did not appear that the patient had a chronic clinic visit to
date.
1/6/2017 Danazol was discontinued.
1/9/2017 An LPN wrote that the patient complained of not getting his
medication and said that he hadn't seen a doctor yet and said
that his hematologist had ordered his medication. The patient
was upset that his medications were discontinued without
having spoken with a doctor. The nurse noted that old records
were needed. The nurse referred to a doctor.

3

The doctor stopped a medication being used for ITP
without documenting a therapeutic plan for the ITP.
Old records should have been requested.

1/17/2017 A doctor saw the patient who was concerned about not
receiving Danazol, a drug he was previously prescribed. The
doctor said the patient was taking this drug for low platelets
in the past and that the last platelet count was 60 on 12/8/16.
The doctor couldn't find a reference source that this drug was
indicated for the patient's condition. The doctor documented
that he would start the danazol and request old records.
Danazol was started at 300mg BID for six months. This drug
has an FDA box warning for thromboembolism, thrombotic,
and thrombophlebitic events including life threatening or fatal
strokes. The manufacturer also warns to use with caution in
persons with diabetes as insulin requirements may increase.
They recommend careful monitoring. Liver and renal function
and hematologica and lipids are recommended to be
monitored.

12

The doctor was using a medication without clear
knowledge of use of the drug. The medication had
multiple side effects. The doctor should have referred
the patient promptly to a hematologist for management
because the patient's condition was beyond the
management ability of the physician.

413

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 414 of 431 PageID #:12612
Patient #32
1/18/2017 Danazol was re-started.

12, 17 The patient had elevated renal function in the past.
Danazol is contraindicated in persons with markedly
impaired renal function, so it needed to be monitored.
The patient was on a fairly high dose of Danazol which
had a black box warning for thromboembolism,
thrombotic and thrombophlebitic events, and lifethreatening or fatal strokes have been reported. The
doctor should have referred the patient to a
hematologist.

1/18/2017 Urine 300 mg/DL protein; microalbumin 1303 (0-30).
1/25/2017 A doctor saw the patient in hypertension chronic clinic. The
blood pressure was 131/68. Renal function was not noted.
The doctor stopped lisinopril, started Cozaar, and continued
Pravachol, Lasix, and Coreg. The only problem noted was
hypertension. There was no history related to chronic kidney
disease or heart failure or the patient's other medical
conditions except that dyslipidemia was noted. There was
also a diabetic chronic clinic for this date. The patient was
documented as having prior hyper and hypo glycemia without
being more specific. The doctor noted that the patient had
diabetic neuropathy but did not mention the nephropathy.
The blood sugar wasn't checked and the A1c wasn't
documented. The doctor continued the same diabetes
medication. The doctor also saw the patient for "asthma"
documenting on a separate note for this. The doctor
documented daytime and nighttime symptoms. The PEFRs
were 225/200/200. The doctor noted that the patient was on
Xopenex and increased Ellipta.

414

1, 12

The doctor did not monitor all of the patient's medical
conditions. The doctor should have referred the patient
to a hematologist because the ITP wasn't being
monitored by someone who knew how to manage this
disease.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 415 of 431 PageID #:12613
Patient #32
2/7/2017 A doctor wrote a brief note without seeing the patient. He
documented that the platelets were 50 and therefore he was
going to start prednisone, which he started at 60 mg daily
tapering over a month and stopping at 10 mg.
2/14/2017 BUN 29; sodium 133; glucose 548; creatinine 2.05; albumin
2.7; A1c 9.4; WBC 17; platelets 10.
2/16/2017 A doctor documented discussing the problems with low
platelets with a hematologist, who recommended giving the
patient IVIG. The doctor sent the patient to a hospital in
Carbondale who agreed to give the patient IVIG in the ER. The
doctor referred to the ER. The patient should have been
referred to a hematologist for evaluation. The doctor did not
discuss the Danazol.
2/17/2017 The doctor documented that the patient went to the ER and
that platelets were 10 and that repeat platelets were 34. The
doctor noted that no treatment "per hematology." The
doctor's plan was to continue present therapy and returned
the patient to general population. The doctor did not
document whether hematology saw the patient.
2/17/2017 The patient was seen at SIU Hospital ER. The WBC was 21, and
platelets were 34 K. The albumin was 2.9; glucose 351; BUN
27; creatinine 1.5 (1.3). The ER note documented that the ER
doctor consulted the hematologist who didn't see the patient.
The doctor noted that the hematologist would see the patient
in his office.

415

12

The doctor should have referred the patient to a
hematologist to manage the ITP. The doctor should also
have attempted to obtain old records for this patient.

6, 12

The doctor failed to note recent extremely high blood
glucose and other lab abnormalities. The doctor should
have referred the patient to a hematologist instead of
attempting to manage a disease he was uncertain
about.

10, 11 Apparently, when the patient went to the ER, the ER
doctor called a hematologist, but the IDOC physician
failed to review what the hematologist said because
there was no record. There was no follow up.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 416 of 431 PageID #:12614
Patient #32
2/20/2017 The doctor at Pinckneyville wrote an undated note to Steve,
presumably the Wexford Regional Medical Director. The note
stated that the patient had a history of thrombocytopenia
"(?ITP)" and that he was transferred to Pinckneyville and was
off medication for weeks which were resumed on arrival. The
doctor noted that the patient was on Danazol. The doctor
noted that the last platelet count was 10K and the "release
date 2/20/17." The doctor asked, "What should we do?"
2/20/2017 WBC 17.5; platelets 60.
3/17/2017 A doctor apparently in chart review wrote "dental caries [with]
thrombocytopenia." The doctor ordered a visit the following
week with a blood count.
3/22/2017 Urine microalbumin 615 (0-30); BUN 22; glucose 348;
creatinine 1.72 (0.5-1.5); albumin 2.3; A1c 13.9; platelets 6;
WBC 11.8. The platelets of 6 were noted by the lab to be a
critical level.
3/23/2017 At 8:00 am the patient told a nurse "I'm going to die." The
nurse documented that the patient was brought to the health
care unit for a platelet count of 6. The nurse consulted a
doctor, who ordered the patient to be sent to the hospital.
3/23/2017 The patient was sent to Memorial Hospital in Carbondale. He
was discharged from the ER on 50 mg prednisone twice a day
with instructions to follow up with a hematologist with a
diagnosis of chronic ITP.
3/23/2017 At noon a nurse documented that the patient just returned to
the facility from a furlough and was placed on 23 hour
observation. A doctor ordered prednisone 50 mg BID "x 30
tabs" with follow up in the morning with a doctor and for
collegial and infirmary discharge.

416

12

6

The doctor clearly didn't know how to manage the
patient and should have referred the patient promptly
to a hematologist.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 417 of 431 PageID #:12615
Patient #32
3/23/2017 BUN 22; glucose 348; creatinine 1.72; calcium 8.3; albumin
2.3; T protein 5 (6-8); WBC 11.8; platelets 6.
3/24/2017 A doctor admitted the patient to the infirmary as an acute
admission. The doctor noted that the platelets were recently
6 and that prednisone was started. The patient was still on
300 mg Danazol BID. The assessment was very low platelets.
There was no documented plan to see a hematologist.
3/24/2017 A doctor referred the patient to a hematologist for follow up.
This was a routine appointment. But the Wexford UM
documented the request as urgent.
3/25/2017 Lisinopril was restarted.
3/28/2017 A clerk wrote that the patient had an appointment with a
hematologist on 3/30/17.
3/30/2017 A hematologist saw the patient. The consultant wrote
comments on the referral form that the patient had ITP with
splenectomy and now with relapse and without active
bleeding. The consultant recommended continuing
prednisone 100 mg with return in two weeks with a blood
count. The hematologist did not document that the patient
was on Danazol.
3/30/2017 A doctor referred the patient for hematology follow up on
3/30/17 for a two week follow up.
3/31/2017 A doctor documented that a hematology consultation was
approved at collegial review.
3/31/2017 A nurse wrote that the patient had a high glucose but didn't
document the value.

417

11

There was no report so it was unclear what transpired
with the hematologist.

16

The nurse should have referred the patient to a
physician.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 418 of 431 PageID #:12616
Patient #32
4/1/2017 A doctor saw the patient. The note was partly illegible but
appeared to state that the patient saw a hematologist without
stating what occurred. The assessment was
thrombocytopenia and the plan was to continue the current
plan and that the patient was waiting to see a hematologist.

10

The doctor did not have a report and therefore didn't
appear to know what transpired at the hematologist
consultation and what the therapeutic plan was.

4/3/2017 The patient had a blood sugar of "hi" and the nurse
administered 15 u regular insulin apparently as sliding scale.
The patient didn't want vital signs.
4/5/2017 A nurse documented a blood sugar of 347. This was the first
blood sugar documented on infirmary progress notes. The
nurse took no action.
4/5/2017 Wexford UM approved follow up hematology.
4/5/2017 WBC 23.2; platelets 10.
4/6/2017 A nurse documented that the patient had pain in his "waist."
The nurse noted that the patient was refusing insulin because
he wanted to leave the infirmary. The nurse referred to a
doctor ASAP. A doctor didn't see the patient. Vital signs and
glucose values were not documented.

16

The nurse should have referred the patient to a
physician.

418

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 419 of 431 PageID #:12617
Patient #32
4/7/2017 Pinckneyville Comm Hosp EKG showed recent anterolateral
infarct with ST elevation V4-5. This hospital found that the
patient had air fluid levels in the bowel with findings
suspicious for enterocolitis. There was no free air on plain film
but a CT scan showed free air indicating perforated viscus with
findings reflecting ischemic bowel. The creatinine was 3.52
with GFR of 17.6; BUN 93; potassium 6.1 and glucose 357.
Platelets were 29; WBC 18. The patient was transferred to
Barnes Hospital and discharged 4/13/17. The patient had
ischemic bowel with perforation. The patient was not a
surgical candidate due to comorbidities, high dose steroids
and severe malnutrition. The patient wanted to stop
treatment and was sent back to the prison.
4/7/2017 At 5:00 am a nurse documented that the patient had stomach
pain and was grimacing. The abdomen was distended. The
patient said his last bowel movement was two days ago and
that he hadn't been eating. The patient refused vital signs due
to pain. The nurse noted that the patient was to see a doctor
that day.
4/7/2017 At 8:23 am a doctor saw the patient. The doctor noted that
the patient complained of abdominal distention over the past
three days with vomiting and watery diarrhea. The patient
had shortness of breath with difficulty taking a deep breath.
The patient was only able to eat a little breakfast. The patient
had no bleeding and was unable to speak full sentences. On
examination the abdomen was markedly distended with a
fluid wave. The doctor referred the patient to a local hospital.

419

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 420 of 431 PageID #:12618
Patient #32
4/13/2017 At noon a nurse documented that the patient returned from
the hospital and had a Texas condom catheter in place.
4/14/2017 A nurse documented that the patient was incontinent and that
his clothes were changed. The patient was incontinent three
more times during the day.
4/14/2017 At 9:10 am doctor wrote a note that the patient returned from
the hospital with diagnosis of perforated bowel which was
ischemic. The doctor documented that the patient was
without significant abdominal pain. But it wasn't clear what
the patient's pain status was. The patient agreed to sign a
DNR. The doctor continued insulin and ordered a tapering
prednisone dose and continued the Danazol. The patient was
on plain Tylenol for pain.
4/14/2017 At 9:15 am a nurse saw the patient immediately after the
doctor saw the patient and asked if he could have something
for pain. The nurse gave the patient the plain Tylenol that was
ordered for him.
4/15/2017 At 11:30 pm a nurse noted that the patient said, "I hurt bad."
The nurse noted that she would call the doctor about the pain.
The nurse then took a phone order for Tylenol #3 1-2 tablets
every four hours for pain.
4/16/2017 At 8:00 am the patient complained of pain. A nurse gave the
patient Tylenol #3.
4/18/2017 Custody cancelled a medical furlough to Carbondale to
apparently the hematologist because the ADA van was
unavailable. The appointment was rescheduled for 4/27/17.
4/19/2017 A nurse assisted the patient to sit up and he became
unresponsive and died.

420

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 421 of 431 PageID #:12619
Patient #33
8/21/2015 The patient transferred from Graham to Robinson CC. The BP
was 147/81 and weight was 236. No problems were noted
except knee pains. Despite the elevated blood pressure the
patient wasn't referred.
8/27/2015 A nurse saw the patient for knee pain and blood per rectum.
The blood pressure was 143/82 but there was no referral. The
nurse on a "hemorrhoid" protocol noted that the patient had
blood on toilet paper and had occasional rectal pain. The
nurse noted no protrusion of a hemorrhoid yet presumed that
the patient had hemorrhoids. The nurse referred to a
physician. Since the patient was 58, he should have had
colonoscopy.
8/31/2015 A doctor saw the patient for hernia, knee pain, and
1, 2, 3,7,
hemorrhoids. The blood pressure was 154/74. The only
8, 17
history regarding hemorrhoids was that the patient
complained of hemorrhoids. The doctor noted knee pain for
five years but took no other history of the knee pain. The
doctor noted crepitance. The doctor did not perform a rectal
examination or perform guaiac testing; did not order a blood
count and did not refer for colorectal screening. The doctor
ordered ibuprofen and hemorrhoid pads without having taken
a history or performed an examination. The doctor didn't
treat the elevated blood pressure even though the patient had
elevated blood pressure at least three times. The doctor
prescribed 600 TID of ibuprofen.

9/1/2015 The patient was on ibuprofen 600 TID for the month.
10/1/2015 The patient was on ibuprofen 600 TID for the month.
11/1/2015 The patient was on ibuprofen 600 TID for the month.

Page 421

421

The patient had elevated blood pressure that was not
treated. The doctor presumed that the patient had
hemorrhoids for a patient complaint of blood per
rectum without examination. The doctor took
inadequate history and performed inadequate physical
examination. The treatment plan failed to include
treatment of blood pressure and diagnostic studies
(blood count, fecal occult blood testing, colonoscopy)
which were indicated for his complaint. Use of a NSAID
in someone with possible rectal bleeding without
evaluating the source is inappropriate since NSAID can
increase bleeding risk. Also the patient had high blood
pressure and NSAID should be used with caution in
persons with hypertension. The dose of the NSAID was
also quite high.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 422 of 431 PageID #:12620
Patient #33
1/28/2016 A doctor saw the patient who was still complaining of rectal
1, 2, 3,7,
bleeding. The doctor noted that the patient had rectal
17
bleeding for over two years. The doctor did not examine the
rectum, did not order a blood count or refer the patient for
colonoscopy. The blood pressure was 166/91, but the doctor
did not start antihypertensive medication. The doctor noted
that the patient had a torn knee cartilage and had prior
surgery, and reviewed an x-ray which he documented showed
osteoarthritis.
2/1/2016 The patient was on ibuprofen 600 daily for a month.
2/3/2016 A nurse saw the patient for knee pain. The blood pressure was
16
167/91. The nurse gave the patient ibuprofen by protocol but
did not refer the patient for hypertension.

The patient still had rectal bleeding but there was
inadequate history, inadequate physical examination,
and no diagnostic studies ordered. The doctor failed to
treat hypertension. Colonoscopy should have been
ordered. The patient was 58 years old with history of
blood per rectum. The patient was on NSAID and had GI
bleeding but the doctor failed to adjust medication or
evaluate the bleeding.

2/5/2016 A doctor saw the patient to renew ibuprofen. The blood
pressure was 145/94. The doctor took no history and
recommended reduction of salt, exercise, and weight loss but
did not start blood pressure medication. The doctor also
ordered ibuprofen.
2/22/2016 A doctor saw the patient for a refill of ibuprofen. The blood
pressure was 150/80 but the doctor did not start
antihypertensive medication. The doctor did renew ibuprofen.

3, 17

The doctor failed to treat the high blood pressure and
ordered long-term NSAID that should be used with
caution in persons with high blood pressure because
long term NSAID can result in renal damage.

3, 17

The doctor failed to treat hypertension and failed to
assess renal function when prescribing a NSAID to a
person with hypertension.

2/26/2016 A doctor saw the patient for follow up of knee x-rays. The
blood pressure was 155/98 but it was unrecognized and not
treated. The doctor started Mobic 7.5 mg daily for six months.

3

3/1/2016 Ibuprofen was discontinued on 3/8/16 and Mobic 7.5 mg daily
was started for six months.

Page 422

422

The blood pressure was elevated but the nurse didn't
consult a physician.

The doctor failed to treat the hypertension.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 423 of 431 PageID #:12621
Patient #33
3/7/2016 A doctor saw the patient for follow up of a knee x-ray. The
blood pressure was 155/98. The doctor noted that the x-ray
showed osteoarthritis. The doctor prescribed Mobic but failed
to address the high blood pressure.
3/10/2016 The patient had a periodic examination.
3/11/2016 Cholesterol 238; HDL 39; LDL 166.

3, 17

3/16/2016 At 5:03 pm an EKG showed atrial fibrillation with rapid
ventricular response (rate 142) and marked ST depression
with subendocardial injury. The automated read which was
accurate, recommended "immediate clinical assessment of
this individual is strongly advised." This was signed as
reviewed.

Page 423

423

The doctor failed to treat hypertension and continued
NSAID without having evaluated the patient's history of
GI bleeding.

This patient had a 10-year risk of heart disease or stroke
of 23% (BP 155/98 untreated, lipids as given, age 58 in a
smoker) and should have been started on a moderate to
high intensity statin and aspirin. Notably, the NSAID he
was using was a cardiovascular risk for serious adverse
cardiovascular thrombotic events including MI and
stroke.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 424 of 431 PageID #:12622
Patient #33
3/16/2016 A nurse saw the patient for chest pain at about 6:00 pm. The 7, 12, 14
patient had dyspnea and nausea and increased pain with
movement. The blood pressure was 200/118 and the pulse
was 129. The nurse documented that the patient had chest
pain since 5:50 pm but an EKG done at 5:03 pm showed
marked ST depression consistent with subendocardial injury.
The automated reading stated, "immediate clinical assessment
of this individual is strongly recommended." The nurse called
Dr. Vipin Shah who gave a phone order for Inderal 20 mg and
clonidine 0.1 mg stat and recheck the blood pressure in 30
minutes and to call back if the pressure was elevated. The
nurse placed the patient on the infirmary for 23 hour
observation. The nurse did not discuss the EKG. A doctor
signed the EKG as reviewed but the date wasn't legible.

3/16/2016 At 7:10 pm a nurse noted that the pulse was irregular and the
blood pressure was 152/78. The nurse called the doctor, who
ordered to recheck the BP every four hours. At 11:16 pm the
blood pressure was 133/80 and at 3:30 am the blood pressure
was 110/74.

Page 424

424

The EKG showed evidence of acute ischemia and new
onset atrial fibrillation with unstable vital signs. The
patient should have immediately been transferred to a
hospital. Care was grossly and flagrantly unacceptable.
Failure to send the patient to a hospital, refer to a
cardiologist or refer for cardiac catheterization placed
the patient at risk of death. The treatment only with
stat doses of clonidine and Inderal was grossly and
flagrantly incompetent. This patient had atrial
fibrillation with probable acute coronary syndrome and
should have been anticoagulated and should have been
hospitalized for testing including echocardiogram and
cardiac catheterization.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 425 of 431 PageID #:12623
Patient #33
3/17/2016 At 7:30 am Dr. Shah saw the patient and noted that the
6, 7, 14,
patient had chest pain the prior evening. He noted that the
15
patient had pain when he walked and that it occurred with
nausea and shortness of breath. The pain was described as
squeezing in the upper chest. He noted no history of heart
problems and said that the patient was not on BP or
cholesterol medication. He noted that the patient was a
smoker. The blood pressure was 126/65. The doctor
reviewed an EKG done at 6:25 am and noted RBBB. The
doctor did not review the EKG from the evening before. The
assessment was chest pain and the doctor started Zocor and
aspirin but no antianginal drug and did not refer for cardiac
catheterization. Beta-blocker was not started. The doctor did
not stop the NSAID. The doctor enrolled the patient in cardiac
clinic.

3/17/2016 At 6:25 am an EKG showed sinus bradycardia with incomplete
RBBB. There appeared to be some flattening of the ST
segment of V4-6 but not specific. The rate was normal sinus
rhythm. This was signed as reviewed.
3/17/2016 At 12:30 pm a nurse documented that the patient had BP of
162/87 and documented that the doctor noted the results and
started lisinopril. At 2:15 pm the inmate was sent back to his
housing unit from the infirmary.

Page 425

425

The doctor failed to review the EKG from the previous
day. The patient described symptoms of typical angina,
which given the prior day's EKG, should have resulted in
prompt cardiac catheterization and referral to a hospital
and/or referral to a cardiologist promptly. The doctor
did start a statin and aspirin but did not start antianginal medication. The doctor did not stop the NSAID
despite the manufacturer's black box warning about
cardiovascular thrombotic events resulting in possible
MI or stroke. The patient had recent atrial fibrillation.
Though the CHAD score was 1, the patient had recent
acute coronary syndrome and should have been
anticoagulated. Anticoagulation wasn't even
considered. Care was grossly and flagrantly
unacceptable. The doctor clearly did not know how to
manage this patient's condition. The patient was placed
at risk of myocardial infarction and/or stroke.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 426 of 431 PageID #:12624
Patient #33
3/24/2016 A doctor saw the patient in follow up of chest pain and
requested pain medication. The doctor noted that the patient
had a "code 3" on 3/16/16 but had no more chest pain. The
BP was somewhat illegible but appeared to be 180/101. The
doctor started Mobic, a NSAID and increased lisinopril. The
patient was still not on an antianginal drug. Mobic has a black
box warning for cardiac events.

17

The doctor started a NSAID (which has a black box
warning regarding risk for cardiovascular thrombotic
events including MI and stroke) in a patient with angina
and ischemic heart disease.

3/31/2016 The HCUA received a call from the family stating that the
patient was having pain when walking and because of having
pain when walking was not going to the dining hall. A
counselor also called and stated that the inmate couldn't walk
to these and was "having heart issues." The HCUA wrote that
the patient was "not in any distress but complains he is unable
to walk to dietary." The HCUA placed the patient on the
doctor line on 4/4/16 to evaluate cardiac related issues.

5, 16

The patient had continued chest pain sufficient that his
family called. Since the complaint was serious (angina)
and placed the patient at risk of death, the patient
should have been referred immediately to a physician.

Page 426

426

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 427 of 431 PageID #:12625
Patient #33
4/4/2016 Vipin Shah saw the patient for baseline hypertension clinic. He 4, 7, 15,
documented angina but failed to include the recent history of
17
ischemia. The blood pressure was 194/84 and 185/106. The
assessment was fair stable control. This was presumably of
HTN but it wasn't clear. The doctor added Norvasc. Lipids
were not discussed. The doctor ordered a wheelchair for long
distance (gym and chow).

4/5/2016 At 9:35 am a nurse evaluated the patient for chest pain while
walking which improved while sitting then began again when
he walked to the health care unit. The blood pressure was
174/82. The nurse noted a "normal" EKG. The nurse noted 1+
leg edema. The patient said his chest just hurt but there was
no tightness, squeezing, pressure or shortness of breath. The
nurse referred emergently to a doctor.

Page 427

427

The patient had angina. The doctor did not start
antianginal medication; instead offered the patient a
wheelchair. Presumably, wheeling himself would likely
constitute exertional strain similar to walking. The
patient had angina and elevated blood pressure. The
doctor started Norvasc. This drug carries a warning the
increased angina or myocardial infarction have occurred
with initiation of this drug in patients with obstructive
coronary disease especially when beta blockers are not
used. The doctor was treating the patient with
potentially harmful drugs without realizing it. This was
incompetent management. The patient should have
had prompt catheterization. Care was grossly and
flagrantly unacceptable.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 428 of 431 PageID #:12626
Patient #33
4/5/2016 The patient went to radiology. There were a few brief lines on 14, 17
the referral form. A two month follow up was recommended.
A procedure was recommended in 45 days. They
recommended a CMP. There was a oncology note in the
record that summarized the patient care. It said that HCC was
found January 11, 2016, found on ultrasound screening. A CT
scan was done on 2/26/16 noting cirrhosis and 3 cm
hypodense lesion in the lateral lobe; an MRI 3/23/16 showing
a large infiltrative mass of the L lobe; in April 2016 the AFP
was elevated; and a CT guided biopsy was done not until
5/24/16 and a PET scan was done 5/26/16. The patient wasn't
seen at UIC until 8/4/16 and the patient didn't have treatment
of the HCC until 9/12/16. The note documented that the CT
guided biopsy results from 5/24/16 were requested multiple
times but not received.
4/6/2016 An EKG showed normal sinus rhythm. This was signed as
reviewed.
4/13/2016 Wexford denied request for wheelchair. This had been
requested because of severe osteoarthritis and new cardiac
diagnosis with elevated cholesterol needing the wheelchair for
long distance travel.
4/15/2016 An EKG showed ST depression of the lateral leads suggesting
anterolateral ischemia. Clinical correlation was advised. This
was signed as reviewed.

Page 428

428

The patient had prior acute coronary syndrome and had
recurrent angina. The doctor diagnosed chest wall pain
but started NTG and Norvasc. The patient should have
been placed on a beta blocker. Norvasc carries a
warning of myocardial infarction in patients with
obstructive coronary disease. The patient was not
referred to a cardiologist or for cardiac catheterization.

Wheelchairs are not appropriate therapy for angina in
the absence of appropriate medical therapy.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 429 of 431 PageID #:12627
Patient #33
4/15/2016 At 2:50 pm a nurse saw the patient for chest pain on an
5, 6, 14
emergency basis. The patient had pain for about 10-20
minutes and occurred while working in the laundry. The
patient had diaphoresis with the chest pain. The patient took
a nitroglycerin and it helped "a lot." The pulse was 102 and BP
151/77. The nurse called Dr. Shah, who ordered 23 hour
observation but no further orders were given. An EKG was
done and showed "moderate ST depression rule out
anterolateral ischemia." Clinical correlation was advised. The
ST depression was in the anterolateral leads V3-6. The nurse
didn't specifically document review of the EKG but under heart
rhythm wrote "normal sinus regular." The nurse advised the
patient that if he has difficulty walking to chow or working he
should try to get a different assignment to avoid precipitating
chest pain.
4/15/2016 At 11:20 pm a nurse saw the patient on the infirmary. The
blood pressure was 154/82.
4/16/2016 At 8:00 am the patient said he had no pain and was ready to
leave. The blood pressure was 157/82. The nurse contacted a
doctor who discharged the patient without seeing him.

9

4/19/2016 A doctor referred the patient for a routine stress test because
of frequent chest pain and shortness of breath. The doctor
wrote that the patient had a history of heart disease and a
new diagnosis of high blood cholesterol. The doctor also
noted that the EKG was normal, which it was not.

Page 429

429

The patient had chest pain with EKG findings of acute
ischemia consistent with acute coronary syndrome. He
should have been immediately referred to a hospital for
cardiac catheterization. Instead the doctor only ordered
23 hour observation and the nurse advised the patient
to get a different job. Care was grossly and flagrantly
unacceptable. Care was also indifferent.

The patient had unrecognized acute coronary syndrome
and without a doctor evaluating the patient, the doctor
discharged the patient from the infirmary.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 430 of 431 PageID #:12628
Patient #33
4/19/2016 A doctor saw the patient for follow up of the code 3. The
doctor noted that the patient had chest pain 2-3 times a day
and was using the nitroglycerin. The pain was substernal with
diaphoresis. The blood pressure was 143/70. The doctor
documented that the 4/15/16 EKG was normal. The doctor
referred the patient to cardiology for a stress test. The doctor
did not address the elevated blood pressure.

4

4/25/2016 The doctor documented that the patient was approved in
collegial for a cardiology appointment.
5/24/2016 A cardiologist saw the patient and recommended adding
Imdur and to arrange for a cardiac catheterization at Carlisle
Hospital in Urbana.
5/24/2016 A cardiologist saw the patient. His report documents the
progressive angina. His report also reviewed EKGs showing
atrial fibrillation with ST segment depression on 3/16/16; the
EKG of 4/15/16 showing ST segment depression in V3-6. The
consultant assessed worsening chest pain suggestive of
progressive angina and recommended adding Imdur and a
cardiac catheter "in the near future."
5/31/2016 A doctor (Vipin Shah) referred the patient for cardiac
catheterization on an urgent basis.
5/31/2016 A doctor saw the patient post cardiology visit and noted that
the cardiologist wanted to do "some tests." The assessment
was "cardiac." The plan was illegible as was much of the note.
6/1/2016 Wexford approved cardiac catheterization.
6/7/2016 The doctor noted that the cardiac catheterization was
approved in collegial the day before.

Page 430

430

The patient had two episodes of acute coronary
syndrome, one with atrial fibrillation, yet the doctor
referred the patient for a routine stress test. The
patient should have been referred promptly for cardiac
catheterization, as the patient still had ongoing chest
pain. Beta blockers were not prescribed. The treatment
plan was not competently carried out.

Case: 1:10-cv-04603 Document #: 767-7 Filed: 11/14/18 Page 431 of 431 PageID #:12629
Patient #33
6/10/2016 An EKG showed atrial fibrillation with incomplete RBBB.
Although the automated reading did not indicated it, there
appeared to be ST depression in several lateral leads.
6/10/2016 At 1:30 pm a nurse evaluated the patient for chest pain. The
5, 6, 14
nurse appears to have seen the patient earlier, as an EKG was
done just after noon. The pulse was 98 and the BP 129/89.
The nurse documented that an EKG showed "A fib same as
previous." The patient noted the pain while working in the
laundry. There were no associated symptoms. The nurse
called Dr. Shah, who recommended 23 hour observation and
an EKG the following morning. At 3:05 pm the patient was
without complaints but the nurse did not perform vital signs.
At 5:00 pm the BP was 143/74 and pulse 57 and the nurse
noted that the patient "feels fine." At 7:25 pm the patient was
found laying face down on the floor by his bunk with a small
amount of vomit and small amount of blood on the forehead.
The patient had no pulse or respirations. CPR was started until
an ambulance removed the patient to a hospital.

The patient had return of atrial fibrillation with chest
pain. The patient had prior ischemic changes and acute
coronary syndrome and should have been immediately
referred to a hospital, anticoagulated, and had a cardiac
catheterization. To place the patient on 23 observation
was incompetent as the doctor did not appropriately
evaluate the change in status. Care was grossly and
flagrantly unacceptable and likely resulted in the
patient's death.

6/19/2016 Vipin Shah completed the death summary. The death
summary was inaccurate, as it did not state that the EKG on
3/16/16 showed anterolateral ischemia but did state that the
patient had atrial fibrillation. He documented that the EKG on
4/15/16 showed ST depression and that cardiology was
requested. Apparently an autopsy was not done. The cause
of death was listed as atherosclerotic heart disease and
temporal lobe infarction. It was not clear if an autopsy was
done.

Either the doctor failed to recognize an EKG finding of
acute ischemia or was not being accurate. This
physician should not have reviewed a death in which he
was the treating physician.

Page 431

431

Case: 1:10-cv-04603 Document #: 767-8 Filed: 11/14/18 Page 1 of 2 PageID #:12630

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION
DON LIPPERT, et al.,

)
)
)
)
)
)
)
)

Plaintiffs,
v.
JOHN BALDWIN, et al.,
Defendants.

No. 10-cv-4603
Judge Jorge L. Alonso
Magistrate Judge Susan E. Cox

NOTICE OF FILING
To:

All counsel of record.

PLEASE TAKE NOTICE that on November 14, 2018, the Report of the Second CourtAppointed Expert was filed with the Clerk of the United States District Court for the Northern
District of Illinois, Eastern Division, at the U.S. Courthouse, 219 S. Dearborn St., Chicago, IL
60604.

DATED: November 14, 2018

Respectfully submitted,
By: /s/ Camille E. Bennett
One of Plaintiffs’ attorneys

Alan Mills
Uptown People’s Law Center
4413 North Sheridan
Chicago, IL 60640

Benjamin S. Wolf
Camille E. Bennett
Lindsay S. Miller
Roger Baldwin Foundation of ACLU, Inc.
150 N. Michigan Ave., Ste. 600
Chicago, IL 60601

Harold C. Hirshman
Dentons US LLP
233 S. Wacker Drive, Ste. 5900
Chicago, IL 60606

1

Case: 1:10-cv-04603 Document #: 767-8 Filed: 11/14/18 Page 2 of 2 PageID #:12631

CERTIFICATE OF SERVICE
The undersigned, an attorney, certifies that on November 14, 2018, she caused a copy of
the above and foregoing Report of the Second Court-Appointed Expert to be served on all
counsel of record via the Court’s electronic filing system (CM/ECF):

/s/ Camille E. Bennett

2