Intake Assessments and Examinations Issues of Newly Arrived Inmate/Patients
California Correctional Health Care System (CCHCS) provides overall health care of inmates of inmates/patients housed in California Department of Corrections and Rehabilitation (CDCR) institutions. In 1995, a class action law suit was filed by the Prison Law Office at San Quintin, California (Plata, vs. Davis, 2003). The class action law suit was brought upon at the time CDCR for unconstitutional health care claiming the CDCR violated the 8
th
Amendment of the Constitution, Cruel and Unusual Punishment (Plata vs. Davis, 2003). CDCR was placed under a receiver in 2006 as it did not meet the expectations and the agreement of the Plata Case, and has been under Federal Receivership ever since (Plata ns Davis, 2003).
During my time in CDCR and CCHCS, I have worked in and supervised the Receiving and Release (R&R) clinic. The R &R clinic is responsible for screening all newly arrived inmates to the institution, and all inmates who transfer from institution to institution and all inmates who parole out of CDCR (CCHCS, 2019, pages 7-10). CDCR also has reception centers which accepts new inmates from jails and other non-California jails and prisons. I worked in a reception center in Tracy, California named Deuel Vocational Institute (DVI). At DVI, we received new inmates from county jails and at times non-California prisons. At my institution California City Correctional Facility (CAC) and DVI, we receive inmates from outside contracted prisons out of state. Regardless of what institution that I worked, we had inmates who were categorized low, medium, and high-risk inmates who required care appropriate for their medical conditions. At both institutions, we received inmates that were high risk that were inappropriate to house at either prison due to the complex of their medical diagnosis. Therefore, the medical department had to inform the prison administration that the inmate had to be transferred to another institution. However, this took time to transfer inmates resulting the receiving institution caring for these inmates.
The sending institution is required to do a transfer screening that prevents inmates going to institutions that are unable to provide the appropriate care for these inmates (CCHCS, 2019, pages 1-8). However, there are always are cracks in the system. An example of cracks in the system would be a county jail sending a complex patient to a CCHCS reception center. Additionally, I have experienced other CDCR institutions transfer inmates with complex medical needs in which the receiving institution was unable to care for this patient. Therefore, complex patients with medical conditions, what is the effect in effectively screening these inmates reducing the burden of the receiving unprepared institution compared to institutions that can appropriately handle these inmates, and to provide these inmates the access of care needed?
One of the responsibilities of a reception center is to conduct general screenings on all newly arrived inmates to CDCR (CCHCS, 2019, pages 1-8). In CDCR, we receive inmates of all ages. One of the challenges to CCHCS health providers are elderly inmates. In New South Wales, Australia, elderly inmates have more chronic diseases than younger inmates (Field and Archer, 2019). Many of our elderly inmates who are housed in CDCR either have chronic health problems develop while in prisons or have recycled back into the prison health care system due to committing new crimes in the community. These inmates are arriving with complex of chronic health conditions and are more prevalent in older inmates than in younger inmates (Greene, Ahalt and others, 2018). One problem that the R and R encounters is the newly arrived inmate arrives to the CDCR institution without medications. It is CCHCS policy to provide these medications after receiving the physician’s order or request a therapeutic change (CCHCS, 2019, pages 1-8). These inmates also arrive with multiple medications, which takes the nurse time to electronically enter these medications in the electronic health records system (EHRS) also known as CERNER. The sending jail is supposed to send a medication history, however, when the R & R nurse receives the paperwork, the paperwork is usually in a large mess and the nurse must search this information is time consuming and frustrating.
All newly arrived inmates to any CCHCS institution are screened for a medication history, and to verify if the medication is on person upon arrival. All outside CCHCS medications must be reordered, and the patient is expected to receive a dose when appropriate. All hand medications such as inhalants and nitroglycerin are to be on the inmate’s person. If not, the patient is to receive these medications immediately (CCHCS, 2019, pages 1-8). CAC does not accept inmates with nitroglycerin (NTG); therefore, when a patient arrives with NTG, the provider is notified, and custody is notified for transfer to another prison. Until transferred, the inmate is to receive the care he or she was receiving at their last institution of jail (CCHCS, 2019, pages 1-8).
In CDCR, we have women institutions named California Women’s Institution (CIW) and California Correctional Women’s Facility (CCWF). CIW is in Chino, California, and CCWF is in Chowchilla, California. Both CIW and CCWF are both reception centers. Female inmates have different needs than men. Unlike male inmates, female inmates have gynecological needs, and at times the female inmate would arrive at the institution pregnant (Mignon, 2016, page 2052). The R and R clinic nurse would have to relay on the female inmate’s personal history on the date of conception. Additionally, these inmates also may be victims of sexual abuse, possess mental health, substance abuse history and a possible history of trauma (Mignon. 2016, page 2052). The R and R clinic nurse would have to rely on the patient’s history as the sending county jail may have inadequate medical history on these types of inmate/patients. A complete health screening needs to be completed with these types of inmate/patients. Many incarcerated women do not have access to health care services prior to incarceration. This can be attributed to their low socioeconomic status and problems such as substance abuse, lack of good nutrition, and lack of preventive health care (Mignon, 2016, page 2053).
In CCHCS, we have protocols and power plans in the EHRS that provides orders that the higher licensed provider can order to assist the pregnant inmate. In Washington state, there was a study completed that focused on pregnant female inmates. An in-depth process analysis was completed which integrated in the Washington State Residential Parenting Program (Fean and Parker, 2004). CCHCS does it best to provide the pregnant inmate care to improve the pregnancy for both the mother and the new baby. The R and R clinic nurse orders an initial appointment for the pregnant inmate to the yard Registered Nurse (RN), so they can be receiving the education and further assistance needed.
CDCR also was sued by the prison law office for lack of mental health care. In 2014, CDCR settled the case with the Prison Law office named Coleman (2014). At CAC, our institution is a general population (GP) institution. CAC does not have a mental health program, therefore, a transferring inmate who is classified as a Mental Health Services Delivery Service (MHSDS) inmate is to be housed at an institution that possesses a MHSDS program. One problem that occurs at CAC is an inmate who has a mental health condition is accidentally transferred from an MHSDS institution to ours. In CCHCS, we have mental health classifications known as Clinical Case Management System (CCCMS), and the Enhanced Outpatient Program (EOP) throughout the state (O’Reilly, 2011). CCCMS inmates’ conditions are not serious and stable enough to meet a therapist every 90 days and may live in general population (GP) (O’Reilly, 2014), however, EOP inmate’s mental health conditions are serious enough that these types of inmates are special housing units (O’Reilly, 2014). The reception center prison is responsible in classifying these inmates and place inmates as GP, CCCMS, and EOP. The ERHS identifies these types of inmates upon arrival. However, at times, inmates that are CCCMS and EOP accidentally slip through the cracks. A mental health evaluation is ordered (CAC has only a psychologist and a social worker). If the inmate arrives with psychotropic medications, the R and R nurses contact the ordering provider and continues these medications. All patients arriving to all CCHCS prions are screened for mental health issues and history. If an inmate states he is suicidal, he or she is immediately referred for evaluation (CCHCS, 2019, pages 1-8). These inmates also are screened for new bad news (extension of sentence or new sentence). If these inmates receive bad news, they are referred for a mental health screening. Additionally, all inmates with new diagnosis of cancer or trauma are also screened, and if these inmates were just diagnosed with cancer or trauma, these inmates also are referred for a mental health evaluation (CCHCS 2019 pages 1-8).
The reception centers are responsible in screening all newly arrived inmates for infectious diseases like HIV, Hepatitis C (HCV), Varicella, Tuberculosis (TB), and sexually transmitted diseases (STD). Many of newly arrived inmates engaged in drug-related and sexual risk behaviors, and the transmission of HIV, hepatitis and sexually transmitted diseases (Hammet, 2006, page 974). A study was completed in which a group of Thai inmates were placed in two separate groups (Hammet, 2006, page 975). In the first group which contained the Thai inmates, logistic inmate’s regression techniques to attribute HIV acquisition leading to HIV being a major problem (Hamment, 2014, page 975).
Newly arrived inmates to CDCR are screened for HIV, HCV, and TB. However, at times, newly arrived inmates from the reception centers to CAC with shingles, scabies, and varicella. The reception R and R nurse is required to screen these inmates, however, there are inmates that again fall through the crack. One of the screening requirements at CAC is we ask inmates for any present type of rash or skin abnormality. The R and R nurse at CAC also checks the EHRS for a current varicella titer result. If there is no varicella titer result in the EHRS, the R and R nurses receives an order from the ordering provider in which this inmate is sent to our blood specimen collection unit. If this inmate refuses the blood test, the inmate signs a refusal of treatment and examination form then the provider may place this inmate in quarantine for approximate 14-21 days. Inmate/patients with shingles are placed also in quarantine for the same time as varicella as these two aliments are both caused by the varicella zoster virus (Gould, 2014). Even though varicella may not be an issue and a notifiable disease in the outside community (Gould, 2014, page 55), consequently, inmates are housed close to each other, and may spread the virus to another inmate. Therefore, custody is notified so appropriate housing is assigned and the institutional public health nurse is notified. The inmate is also ordered an anti-viral medication (acyclovir) and analgesics for pain. If the inmate is diagnosed with scabies, he again is appropriately housed and quarantined. CAC has a scabies protocol in which he is to use a scabicide cream (Permethrin) and Ivermectin which is a weight-based drug (Fawcett, 2003).
In CCHCS, we administer Ivermectin twice with a high fat snack, first thing the next morning, and in two to three weeks after the exposure (Fawcett, 2003). The inmate is also to place all clothing in a water-soluble bag, to disinfect the cell with a scabicide spray and receive a new set of clothing from custody the next following day.
The R and R nurse also screens inmates for all durable medical equipment (DME) upon arrival. If an inmate has a current DME and does not have it on himself or herself, the inmate either must search their property or is immediately issued a new DME free of charge (unless the DME is a special device such as orthopedic shoes, dentures or bridges, prosthetic limbs or prescriptive eyeglasses) which requires an appointment with the inmate’s new provider (CCHCS, 2019, pages 1-8). If the inmate has a dental problem, they are to submit a sick call request to the dental department. The dental department screens these sick call slips and sees all inmates with dental problems per their protocol.
If the R and R nurse does not effectively screen new inmates for changes of their mental, health or dental status, the inmate will not receive the care needed, all commutable diseases that would possibly spread throughout the institution, and the inmate may want to immediately harm his or herself. Therefore, R and R clinic is the footstone to all healthcare programs. If an inmate has a chronic disease such as diabetes, hypertension, possess a history of seizures or HCV, these inmates are scheduled to se the yard nurse, and the provider between seven (for the RN) and 30 days (all stable inmates). All high-risk inmates are scheduled to see their provider in their yard or assigned housing clinic within 14 days.
The Office of Inspector General (OIG) routinely audits all CCHCS institutions for compliance for all remedial plans assigned by the courts. The supervisors audit the care of documentation of the R and R nurse and other nurses who assist the R and R nurse who complete intake, transferring and parole screenings. If the R and R nurse feels that the patient is not fit to be housed, the supervisor will also audit the care provided by the Treatment and Triage Area (TTA) nurse for disposition (CCHCS, 2019, pages 1-8). If the inmate has a medical or psychiatric emergency, this inmate is immediately transferred to a higher level of care for further evaluation.
In Conclusion, CCHCS is mandated by the federal courts to provide constitutional health care. The federal courts have dictated what is constitutional health care, and how CCHCS is to administer this care. CCHCS administers this care and is audited by the OIG and other agencies. The R and R clinic is the gateway to the institution, and the access or care the inmate is to receive. Even though many obstacles may arise, the R and R clinic does it best to meet the expectations of CCHCS and the institution.
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