Man Down! ! ! Will He Get Up? Nursing Care at Orange County's Jail Facilities*

Quality Medical Services: The nursing and executive staffs of Correctional Medical Services interviewed are highly professional, competent and dedicated to providing a high level of medical service to the inmates housed in Orange County jail facilities. Agree with the Finding Response:

Staffing Levels: Staffing levels for Correctional Medical Services are inadequate, particularly at Senior Nurse levels, leading to low morale and complaints about lack of communication. Disagree partially with the finding Response: HCA does not agree with the blanket statement that all staffing levels are inadequate. Correctional Medical Services (CMS) is in the process of reviewing nurse staffing, which has been an area of particular concern. CMS is in the final stages of hiring a Director of Nursing, who will be directed to focus immediately on nurse staffing levels as a high priority. A report recently received from a nursing consultant will assist in this effort. Currently, all nine Senior Comprehensive Care Nurse positions are filled. Background Checks: Background checks for new nursing employees are over-

burdensome and take too long to complete, resulting in fewer applicants and a high drop- out rate for those who have applied. Disagree partially with the finding. Response: We do not agree with the statement that the background check process is "over- burdensome." The nature and extent of background checking is determined by the Sheriff-Coroner, who determines the requirements necessary to maintain security within فو Exhibit 2 the jail system. The length of time needed to conduct background checks, however, does result in some nurse candidates accepting other job offers that allow them to begin a new job sooner. This factor can have a significant impact on recruitment considering the competitive employment market for nurses. The Health Care Agency will continue to work with the Sheriff's Department toward the goal of reducing the current processing time.

Recruitment: Current outreach programs to recruit nurses focus primarily on local schools and fail to reach out to all nursing schools in Southern California; programs for student interns are inadequate and could be expanded to provide a deeper pool for future recruits. Disagree partially with the finding. Response: While we do not agree that the current internship programs are inadequate, we do agree that careful expansion would be desirable and that we will add more student nurses to the extent that we are able to integrate them effectively into the CMS nursing program. The nursing student intern program was only recently established, with the first students being accepted into the program in spring 2007. The program is already showing some initial success. CMS was recently able to hire the first nurse as a result of the program. There is a limit to the number of student interns that can be properly supervised while maintaining the quality of direct nursing care provided to inmates in the jails. Appropriate clinical supervision is not only necessary for quality medical care, it is also a requirement of all nursing programs placing interns. Accordingly, great care needs to be exercised in expanding the program.

Training: On-going training for nursing staff is insufficient; few hands-on drills or mock emergency scenarios are presently offered. Disagree wholly with the finding. Response: Correctional Medical Services hired a clinical nurse educator in February 2008 to develop and provide on-going training opportunities. The staging of regular emergency medical drills within each of the jails was initiated in the fall of 2007 and is ongoing. Correctional Medical Services has also conducted skills fairs to ensure staff competence in key skill areas and to provide additional avenues for training. Licensed health care professionals working for Correctional Medical Services have numerous other opportunities for training and development. Under the current County Healthcare Professional Unit Memorandum of Understanding (MOU), CMS staff members can request up to five paid professional conference days per fiscal year to use for attendance at job related professional conferences of their choice or to conduct professional study. In addition, healthcare professionals may request paid time off for up to 30 hours of continuing education every two years in order to earn Continuing Education Units (CEUs) necessary to maintain their professional standards. Exhibit 2

Computer Programs: Some computer programs are outdated or non-existent and new programs and training for nurses are needed. Agree with the finding. Response: The CMS electronic medical record system, referred to as "CHART," is 14 years old and needs to be replaced with a fully integrated system. This will be a multi-year project with the first step being securing a consultant to evaluate information technology needs within Correctional Medical Services. Due to the County's fiscal constraints, funds have not yet been allocated for the acquisition and implementation of a replacement system. Until a new, comprehensive system can be put in place, interim information technology improvements are being explored to deal with the most pressing needs. This will include evaluation of technology for the scanning of medical records.