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IL Prisons - Medical Investigation Team - Statewide Summary Report, Including Review of Statewide Leadership and Overview of Major Services, 2018

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Case: 1:10-cv-04603 Document #: 767 Filed: 11/14/18 Page 1 of 153 PageID #:11432

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
timely.

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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.
Urgent/Emergent Patient #3.

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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
65

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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
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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
40

Patient #8 Hospitalization and Specialty Care.

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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
42

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•

Another patient with diabetes and hypertension arrived on 7/19/17.47 There is no July or
A