0BCHAPTER 15 F 1BI. POLICY The California Department of Corrections and Rehabilitation (CDCR) shall maintain s (CTC) to house inmate-patients who do not require general acute care level of services but are in need of professionally supervised health care that cannot be provided on an outpatient basis. 2BII. PURPOSE To provide inmate-patients with inpatient services consistent with their health care needs that are necessary to protect life, prevent or treat significant illness or disability, and to alleviate significant pain. III. RESPONSIBILITY The Medical Director is the Chief Medical Officer (CMO) or Chief Physician and Surgeon (CP&S) and is a licensed physician responsible for the daily administration and clinical management of the CTC. The Facility/Correctional Captain, in coordination with the Associate Warden, Health Care Operations, shall be responsible for ensuring that security is maintained in the CTC. Each institution shall contract with a community hospital(s) for the provision of health care service beyond the capability of the CTC. The CTC is governed and regulated by California Code of Regulations, Title 22, Chapter 12,. IV. STAFFING A Physician on Call (POC) shall be available twenty-four (24) hours a day, seven (7) days a week. The POC shall be contacted through the Registered Nurse (RN) when health care assistance is required. An RN shall be on duty in the CTC twenty-four (24) hours a day, seven (7) days a week. V. 3BPLACEMENT IN THE CTC Medical conditions appropriate for placement in a CTC may include, but are not limited to, the following: 1. Continuous IV therapy 2. Pick line 3. IV antibiotics 4. Complicated wound care 5. Decubitus care 6. Continuous Oxygen 7. Inmate-patient requiring skilled nursing care 8. Quadriplegia The Skilled Nursing Facility at Central California Women s Facility is subject to the CTC policy auditing tool. January 2006 DIVISION OF CORRECTIONAL HEALTH CARE SERVICES 4-15-1
Inmate-patients whose level of care or medical needs include any of the following shall not be housed in the CTC and shall be transferred to a general acute care hospital: 1. Cardiac monitoring 2. Chest tube 3. Total parenteral nutrition 4. Hyperbaric oxygen 5. Major surgery 6. Intensive care 7. Ventilator care 8. Central venous pressure monitoring The above list is not exhaustive; other medical conditions may require transfer from a CTC, as specified by a physician. VI. GENERAL INSTRUCTIONS A. Admission 1. The admitting member of the medical staff shall write admission orders to the CTC on the CDCR Form 7221, Physician s Order, documenting admission diagnosis, allergies, diet, condition, level of activity, orders for vital signs (including frequency), lab and x- ray orders, and medications with stop dates, as appropriate, on the day of admission. 2. On the day of admission, the admitting physician shall complete an admission note on the CDCR Form. 3. The inmate-patient s condition and diagnosis shall be written on the physician order sheet and progress note within twenty-four (24) hours of admission to the CTC by the admitting member of the medical staff. 4. The attending physician shall complete a progress note at least every three days or more often as the inmate-patient s condition requires. Each visit by a physician shall be documented. 5. The physician shall also complete a CDCR Form 7342, Request for Services, documenting the medical necessity for any requested service(s). The CDCR Form 7342 shall be forwarded to the UM Nurse after completion for review and tracking purposes. 6. Within twenty-four (24) hours after admission, a physician shall conduct an evaluation, including an admission history, physical examination, assessment, and treatment plan on every inmate-patient. 7. A complete written history and physical examination shall be performed by a physician and documented in the Unit Health Record (UHR) within seventy-two (72) hours unless completed within five (5) days prior to admission. 8. The CDCR Form 7202, Nursing Admission Initial Assessment, shall commence at the time of admission. Nursing staff shall complete both sides of the CDCR Form 7202. 9. Inmate-patients shall be admitted, discharged, or transferred only on a written order of the attending physician or the alternate physician in place of the attending physician. Should an inmate-patient refuse medical treatment against the advice of the attending physician, a notation of the refusal shall be made in the inmate-patient s UHR and a signed CDCR Form 7225, Refusal of Examination and/or Treatment, shall be obtained from the inmate-patient and filed in the UHR. A physician may require an inmate-patient January 2006 DIVISION OF CORRECTIONAL HEALTH CARE SERVICES 4-15-2
to be housed in the CTC even if the inmate-patient refuses all treatment. Admission to a CTC is a housing assignment and thus not subject to inmate-patient refusal. 10. Each inmate-patient returned to the CTC for observation following discharge from any health care facility shall have an interval history and physical examination by an advanced level provider within 24 hours, per Title 22 requirements. B. Discharge 1. At the time of discharge from the CTC, the attending physician or physician designee shall ensure that a final diagnosis and discharge summary is written or dictated prior to or at the time of the inmate-patient s discharge. 2. The discharge summary shall include the final diagnosis, clinical summary, and discharge orders. The final diagnosis shall be recorded in full without the use of symbols. 3. An inmate-patient shall be discharged from the CTC only with a written order of the attending physician or physician designee. At the time of release, the attending physician shall ensure the record is complete and must sign the discharge summary. 4. The discharge summary shall provide the principal diagnosis, and secondary diagnoses if any, and clinical summary. The final diagnosis shall be recorded in full without the use of symbols. The discharge summary shall include the significant findings and events of the inpatient stay, including the treatment, important diagnostic studies, recommendations and arrangements for further treatment, including prescribed medications, aftercare plans, and condition at the time of discharge. In the event of an inmate-patient s death, a summation statement of the circumstances leading to the death shall be added to the discharge summary. 5. Discharge orders shall be written by the attending physician, or physician designee, and shall include discharge diagnosis, medications, treatment, aftercare instructions, housing needs, other accommodations needed, if any, follow up appointments, and CDCR Form 128-C Chronos. 6. The RN Discharge Planning Summary shall include, but is not limited to, inmate-patient education regarding a specific health problem, medication, or follow-up care appointment. 7. The inpatient medical record must be placed in the inpatient section of the inmate s UHR within two business days of discharge. 4BC. General Operations 1. Verbal orders shall be signed by the nurse to whom the order was given with the name of the physician clearly documented. All verbal orders shall be signed by the prescriber within 48 hours, excluding weekends and holidays. 2. All inpatient orders for medication shall specify the length of time they are in effect and shall not exceed 30 days. 3. Inmate-patients admitted to the CTC for podiatry, dental, or mental health care shall be given the same basic medical evaluation as those inmate-patients admitted for other services and are the dual responsibility of the non-physician member and the physician member of the medical staff. 4. Non-Physician Responsibilities (Dentist, Podiatrist, or Psychologist): A detailed dental/podiatric/mental health history justifying admission Detailed description of the examination and diagnosis January 2006 DIVISION OF CORRECTIONAL HEALTH CARE SERVICES 4-15-3
An operative report Progress notes 5. Physician Responsibilities: Medical history A physical examination Supervision of the inmate-patient s medical status while an inpatient in the CTC, with documentation on a Progress Note at least every three days or more frequently, based on inmate-patient s acuity level Discharge summary 6. When an inmate-patient is transferred to a non-cdcr health care facility, the physician shall document in the transfer summary the following: treatment plan; diagnosis; treatment course; dietary requirements; allergies; emergency medical services record; history and physical examination; adequate documentation of the inmate-patient's present status including lab, x-ray, and current medication as well as the specific service being requested. All transfers to/from another licensed facility require a physician-to-physician contact and acceptance. 7. The Inpatient Medical Record shall be used to document all inpatient medications ordered by a physician. 8. The CDCR Form 7211, Graphic Record, shall be used for every inmate-patient admitted to the CTC, and shall include the documentation of vital signs, height and weight. Weight shall be documented for all inmate-patients on admission and as the inmatepatient s condition warrants but no less than weekly. Where ordered, the nurse responsible for charting on the inpatient record shall be responsible for totaling the inmate-patient s intake and output under the eight-hour total section. The 24-hour totals shall also be recorded on the intake and output record. Graphic sheets shall be used for a total of five days, and then a new graphic sheet shall be started. 9. The CDCR Form 7212A, Nursing Care Record, shall be used for all inmate-patients admitted to the CTC. The CDCR Form 7212A shall reflect any remarks or observations made by the RN and shall note the time and date of the observation. The CDCR Form 7212A shall be used for every 24-hour period and shall reflect nursing care performed at eight-hour intervals. On each watch, the nurse responsible for the care of the inmatepatient shall complete a systems assessment, document the time of the assessment, and shall sign the assessment form. Activity, physical care, elimination, equipment, restraint, and teaching status shall be documented for every watch, opposite the observation. 10. Nursing assessment of decubitus ulcers shall be performed at the first sign of skin breakdown on an inmate-patient and every watch for inmate-patients with a decreased level of consciousness. The documentation on the CDCR Form 7299, Skin Profile, shall reflect any change in wound, treatment, and effectiveness of treatment. 11. The CDCR Form 7305, Intravenous Profile shall be utilized for any inmate-patient receiving intravenous (IV) therapy. The date, time, and type of solution started shall be documented. The condition of the IV site shall be observed and documented in the adjacent column. Other solutions or additives shall be documented in the Other Solution/Additive column. 12. All inmate-patients admitted to the CTC shall have a Patient Care Plan initiated by the admitting RN within 72 hours of admission. The Patient Care Plan shall be January 2006 DIVISION OF CORRECTIONAL HEALTH CARE SERVICES 4-15-4
interdisciplinary and document inmate-patient problems, goals, interventions, discipline responsibilities, and dates to be met. The Patient Care Plan shall be reviewed, evaluated and updated as necessary by the RN involved in the care of the inmate-patient (i.e., at least monthly and more often as the inmate-patient s condition warrants. 13. After the initial admission assessment has been completed, the admitting RN shall initiate the Patient Care Plan. The date section of the form shall be completed followed by the inmate-patient s problem or need, the anticipated goal of the nursing staff, the date by which the goal is to be met, the initials of the admitting RN and the staff member who is responsible for providing that element of care. The next adjacent section shall contain the intervention that a staff member has taken, the date of the intervention, and the initials of the intervening staff. The inmate-patient s full name, CDCR number, physician and room number in the top or bottom right corner shall be documented on all Patient Care Plans. Additionally, at the bottom of the page, the signature and initials of any nursing staff member documenting on the Patient Care Plan shall be included. 14. As a final step in completing the Patient Care Plan, the discharge planning section shall be completed as part of the admission process. Discharge planning shall include, but is not limited to, inmate-patient education regarding a specific health problem, medication, and follow-up care or appointments. 15. Inmate-patients admitted for a medical diagnosis shall be offered showers every other day, unless otherwise indicated by a physician s order. 16. All inmate-patients returning from medical facilities for admission to the CTC shall be processed through the Triage and Treatment Area and logged in. All paperwork and records shall be obtained at this time. The inmate-patient s vital signs and assessment shall be taken and documented. A physician shall be contacted and given a report on the status of the inmate-patient. The physician shall make the determination for placement. If the inmate-patient is released to the general population, follow-up instructions for care shall be given to the inmate-patient and clinic health care staff that will provide any follow-up care. When an inmate-patient is discharged from the CTC by written or verbal physician s order, the CDCR Form 7221 shall be completed by the physician or RN on duty at the time of the discharge. The form shall be completed as follows: Date of discharge Full name CDCR Number Special Instructions Document any special instructions that the inmate-patient needs to continue after discharge such as checking wound for bleeding or reporting chills or fever after surgery. Also, any equipment needs should be noted. Medications The discharging physician shall order any discharge medications. If the discharging physician is unable to sign these discharge orders, as in the case of a telephone order or after-hours discharge, the RN shall document and sign indicating that the discharge medication was a verbal order. The physician shall sign the order within 48 hours. Activity As ordered by the physician and documented on a CDCR Form 7410 (e.g., no lifting, no running, or normal activity). Diet As ordered by the physician. Nursing staff shall instruct the inmate-patient on any dietary restrictions and request a dietitian s consultation as needed. January 2006 DIVISION OF CORRECTIONAL HEALTH CARE SERVICES 4-15-5
Follow-Up Document the time frames of any follow-up appointments and notify schedulers as indicated. Special Treatments Document any follow-up treatments such as dressing changes and wound checks. Medical Staff Signatures Physician signature with date and time shall indicate that the instructions are completed. A physician or a RN may sign as long as discharge instructions are concurrent with a written discharge order from the physician. 17. All CTC inmate-patients released on parole to the community on maintenance medication shall receive a 30-day supply of these medications unless contraindicated (Refer to Volume 4, Medication Management). 18. The Supervising Registered Nurse or designee shall maintain a CTC Tracking System to document each CTC admission and discharge. 19. The CTC RN shall review CTC placements upon admission and daily for appropriate placement. The Utilization Management Nurse shall assess and document per UM guidelines, each new medical CTC placement weekly and then every 30 days thereafter to determine if the inmate-patient is in the appropriate health care setting and to report his/her findings to the CMO or CP&S or designee. 20. The CMO or CP&S shall conduct weekly rounds or chart reviews for each medical CTC inmate-patient to ensure appropriate health care placement and treatment of the inmatepatient. 21. Inmate-patients housed in the CTC as long-term care patients shall have their level of care assessment completed by the institution UM Nurse. The institution UM nurse shall use the level of care assessment tool approved by the DCHCS. When the UM Nurse identifies a patient whose need exceeds the CTC criteria, the UM Nurse and physician shall discuss an appropriate strategy and document in the UHR. A copy of the assessment shall be placed in the inmate-patient s UHR and a copy forwarded to the DCHCS UM staff. As the inmate-patient s condition changes or at 30-day intervals, the institution UM Nurse shall complete another level of care assessment tool and forward a copy to the DCHCS UM staff. CTC Cleanliness 22. The CTC shall be maintained in a clean and sanitary manner at all times. The CTC shall be cleaned on a daily basis or more often as necessary to maintain a sanitary environment. It is the responsibility of the Associate Warden Health Care Services and the RN on each watch to ensure that the CTC is maintained in a clean and sanitary manner. This includes common areas, inmate-patient rooms, staff office space, storage areas and treatment areas. January 2006 DIVISION OF CORRECTIONAL HEALTH CARE SERVICES 4-15-6