

#inmate – NL evaluation 01/28/13 for eye exam with visual acuity >20/40, no referral to
optometry documented (provider signed off nurse note 03/01/13)
 #inmate – ICS response “passed out” 02/13/13, documents inmate “hit head”, no C-spine
precautions utilized (provider signed off nurse note 03/01/13)
 #inmate – NL evaluation 02/06/13 for c/o back pain, no NAP utilized
o Medication Room –
 Tools/sharps inventory log not consistently completed beginning/end of shift
 Refrigerator temperature log not completed daily
 Insulin opened and not dated (Humulin R, Lantus, Novolin R)
 21 outdated medications found in KOP bins, #inmate Doxycycline (antibiotic)
 1 outdated medication found in DOT bin currently being administered by nursing
 Multiple MARs found with med errors noted, 3 copied demonstrate:
• Missing initials/blank dates (doses not administered)
• Nurse initials on MAR do not have corresponding signature
March 19, 2013 –
- Reviewed charts @ ASPC Perryville Brent Lumley unit
o Chronic Care –
 16 charts were reviewed, 7 were found to be non-compliant with f/u appointments
(#inmate , #inmate , #inmate , #inmate , #inmate , #inmate , #inmate )
- Staffing –
o No desk nurse onsite, the scheduled nurse was pulled to San Carlos and not replaced
o One med nurse onsite, the am med pass had not been started at 1100 hours
o The assigned supervisor picks up the unit mail at Complex each morning for delivery to the unit,
at 1130 the paperwork had not been received on the unit
- Medication Room –
o Temperature log not documented daily
o 5 cards of outdated meds found, med nurse notified
o MARs incomplete as follows:
 missing diagnosis (#inmate , #inmate , #inmate , #inmate , #inmate , #inmate )
 9 MARs from 28 yd documented “N/A” for medications ordered
• #inmate – 03/06/13, 03/07/13, 03/08/13
• #inmate – 03/17/13, 03/18/13
• #inmate – 03/14/13 thru 03/19/13
• #inmate – 03/14/13 thru 03/19/13
• #inmate – 03/18/13, 03/19/13
• #inmate – 03/11/13, 03/12/13
• #inmate – 03/12/13 thru 03/18/13
• #inmate – 03/14/13 thru 03/18/13
• #inmate – 03/14/13, 03/15/13
 No doses documented since ordered 03/15/13 - #inmate
 1 MAR documented “No show” (#inmate ) 03/07/13
 15 MARs from 30 yd documented “N/A” for medications ordered
 2 MARs from 30 yd missing documentation of medications delivered (#inmate ,
#inmate )
- QA & Inventory –
o OB Bag inventory check has not been documented since February 14, 2013; documentation prior

PRR ADC00291

-

o #inmate - a note written by the provider indicates he prescribed medication last week but the
inmate has not received the medication
HNRs –
o #inmate – HNR triage date 03/28/13; c/o being out of medications – pharmacy profile indicates
meds refilled 03/25/13
o #inmate – HNR triage date 03/28/13; c/o being out of medications – pharmacy profile indicates
meds have not been refilled, submitted for refill 03/29/13
o #inmate – HNR triage date 03/28/13; c/o being out of medications – pharmacy profile indicates
one was filled 03/23/13, remaining medications submitted for refills 03/29/13
o #inmate – HNR triage date 03/26/13; c/o being out of medications – pharmacy profile indicates
some filled 03/08/13, 03/23/13, & 03/25/13. Remaining 3 medications submitted for refill
03/27/13

PRR ADC00295