Custody Death Review"*

infirmary with nurses lacking adequate emergency medical skills and/or regularly scheduled skills maintenance training. Response: Disagree with the finding. The unit referred to by the Grand Jury as the jail infirmary is known as the Women's Observation Unit. On this unit, nursing staff observe inmates for signs of possible acute illnesses. Any inmate exhibiting signs of an acute illness is transferred to an appropriate higher level of care, such as a hospital. Health Care Agency (HCA) nurses working in Correctional Medical Services (CMS) are required to be certified in Cardiopulmonary Resuscitation (CPR) and must be recertified every two years. As part of the CPR training, nurses are trained on the use of the Automated External Defibrillator (AED). On several occasions since the year 2000, CMS personnel have successfully used AED's during jail medical emergencies. All CMS nurses are trained on CMS nursing procedures, including Procedure #113 - Medical Aid/Man-Down. These procedures and associated training are updated on a regular basis to ensure that nurses are aware of and prepared for medical and mental health emergencies that result in a Man-Down response. Annual in-service training for CMS nurses includes education on and hands-on demonstration of essential emergency response skills including cervical spine stabilization, initial assessment of patients including state of consciousness, CPR/AED review, use of oxygen equipment, and use of the Ambu bag and mask. This specific in-service training was first conducted in October 2006 and will be conducted again in October 2007.

Knowledge of Emergency Medical Equipment: The nurses appeared to demonstrate an inadequate knowledge of some emergency medical equipment. Response: Disagree with the finding. CMS medical and administrative representatives have reviewed the documentation and video available from the medical response to this event. Nurses responded promptly to the event, continued to assess the individual's condition and provided appropriate emergency response measures while paramedics were en-route to transport the individual to a hospital. Exhibit 2 Access to Emergency Medical Equipment: No AED was located in the Women's

Outpatient Housing. Response: Agree with the response. At the time of the event, the closest AED was located in the Dispensary area, about 40 feet away from the Women's Observation Unit. There are no locked doors between the Dispensary and the Unit, and nurses had unimpeded access to the equipment. Recordkeeping: There was a deficiency in accurate record keeping, as demonstrated by the

discrepancy between the number of shocks given as reported by the AED printout, the nurses and other witnesses. Response: Agree with the response. There were differences between participant statements and the AED record regarding the number of shocks delivered to the inmate. This did not affect the use and operation of the AED, an automated device that provides recommendations to responders regarding the delivery of additional shocks to the patient.

Planning: There was insufficient pre-planning for this type of incident. Response: Disagree with the finding. In the past year, CMS personnel have responded to over 200 medical emergencies in the jails, also known as Man-Down calls. CMS nurse orientation includes review of emergency response procedures, familiarization with equipment, and procedures for transfer of patients to acute care facilities. The CMS Medical Director and Assistant Medical Director review all in-custody deaths, with Registered Nurses, Nurse Practitioners and Staff Physicians participating in the review of in-custody deaths involving a Medical Aid/Man-Down response. This practice has resulted in recommendations for improvements in policies, procedures and training that have saved lives, improved response times, enhanced the quality of response and provided a better working relationship with Orange County emergency response personnel. Response to Recommendations R-1 through R-5