Endorsed Filed*

R1

Clinical performance of the involved LVN should be evaluated by RN supervisors on a regular basis and reported to the JNM. The JNM and the AD should then review oversight and performance of the LVN to determine if the LVN meets minimum nursing standards.

R2

When present during an emergency situation the JNM should assume full responsibility as the lead RN to ensure professional quality medical care. The JNM should be more accessible when asked for guidance by jail nursing staff regarding inmate care and be more available to assist as needed.

R3

The JNM must ensure all JMS staff is thoroughly familiar with the new JMS Policy #16-506, which outlines parameters for abnormal vital signs and required actions.

R4

The AD should evaluate and make changes to ensure the person in the position of JNM is capable of fulfilling all job responsibilities. This could entail periodic feedback from the nursing staff, more direct observation, and frequent evaluations of the JNM's leadership abilities.

R5

Every effort should be made by the JNM, AD, and HO to finalize and implement all P&P's and make them available on the intranet. Thereafter, all P&P's should be reviewed and updated annually.

R6

The JNM should encourage and foster a learning environment for the nursing staff. They should have opportunities to attend continuing education courses and arrangements should be made for in-house training relating to direct patient care, i.e. man down, suicide prevention, etc.

R7

After a death or poor outcome at the jail clinic, the HO should conduct M&M-like conferences with the AD and all JMS staff present. The JNM, AD, and HO share the responsibility to schedule these discussions.

R8

JMS should implement all NCCHC recommendations. RESPONDENTS Director of Health and Human Services, Tom Sherry Assistant Director of Health and Human Services, Amerjit Bhattal County Medical Officer, Dr. Cummings Jail Nurse Program Manager, Brent Garbett

R9

Directs the recording of vital statistics.

R10

Acts as medical director of the county jail medical facility; reviews and approves all examination and treatment records initiated by practitioners.

R10-19

crawling on or under your skin?"

R11

Approves all prescriptions dispensed by health department.

R12

20 13 Pursuant tell and Code Scotlan 933 (a), the Providing Judge mikes the findings liet the foregoil, report is in compliance with the Tiste 4. Chapter 3 of the Fend Chee. ("Power and Duties of the Grend July") demonstrating designed Character Prestaing Judge Superior Court of California, County of Suiter County 3330 SUTTER COUNTY JAIL DEATH SUMMARY The 2011-2012 Sutter County Grand Jury (SCGJ) received a citizen's complaint on the Sutter County Jail alleging improper and denial of medical care resulting in an inmate's death. The SCGJ conducted an investigation into the inmate's time in custody and specifically the quality of medical treatment he received while at the jail. The SCGJ conducted interviews of all Jail Medical Services (JMS) personnel in management positions, jail clinic staff members, Rideout Hospital Emergency Room (ER) physicians, the ambulance emergency medical team (EMT) personnel, and family members of the deceased. The SCGJ found the medical treatment of the inmate, just prior to his final transport to Rideout Hospital ER, to have been below the standard of care. This can indirectly be traced to a myriad of problems with the jail clinic program. Recommendations from the SCGJ are to make changes at the jail medical clinic to improve oversight and supervision. Responsibility should be taken by those in management positions to complete and maintain policies and procedures, provide training to nurses, and conduct Morbidity and Mortality (M&M) discussions in order to prevent recurrence of adverse outcomes. BACKGROUND The Sutter County JMS provides necessary emergency and basic health care services to individuals who are in custody from booking until time of release. Medical Staff is comprised of the Health Officer (HO), Jail Nurse Manager (JNM), Nurse Practitioner (NP), two (2) Supervising Registered Nurses (RN), four (4) Licensed Vocational Nurses (LVN), and on-call LVN's as needed. A sick call request form must be filled out if an inmate wants to be seen at the jail medical clinic. These forms are collected by a JMS staff member during medication pass, then reviewed and triaged by an RN for follow-up. In a medical emergency, the nurse on duty, either using his/her own judgment or by consulting with a physician, NP or RN, can determine if an inmate needs to be seen at Rideout Hospital ER. Management As part of the investigation, the SCGJ reviewed job descriptions of those in authority at the jail clinic to ascertain their respective roles and responsibilities (see Appendix A). This included the JNM, the HO, and Assistant Director of Human Services-Health Division (AD). HE ARE JUST VERY DUCKNING TO AND MARK Para Carl 2012, ander Condy Grand Jury (SCOI) received a 61 mai a conceptant to the Patter county fair about improper and denial of medical care resulting in an immate's death. The SCCP conducted at investigation into the innuters time in custody and specifically the quality of nedical it calment he received white at the fail- mediseasum al execute (21 vil) activité souvres la destination de la la communication de la la communication de positivos, ballelinio uno Emphors, Ridebut Hospita Emergency Hacon 1991, nyslatensą Ae and hance of theory to a call cam (PVI) personnet and family ment on all her localised The SUD bound to medical assument of the inmate just prior to be set as easiest to blocout to privile is it, to have been below the standard or care. This can indice the consequency provided an problems with the self-chair programs. Secommonwhite or from the SCGI meto make changes at the jail medical clinic to legal the overskipt ood surete island. Koennakhilit v shirakit bureten by theet in pageagengapt pedillera to and make and manustropolicies and procedures, provide indicing so mustly and construct dadadib ana beridik (M22) disensiona in stip ta prevent recurrance di nduces appronue DATE OF STREET i le Sutic Courty Més provides neversary emergancy and basic health are services a each ideals were are in costody from booking until that of relative Medical Lord george models the Health Collect (HC); Jeff Manager (MM); Sees Preprinted (MF); Sees (NF) is transcent Augustated Vincent (EUS), four (EUS), include Vincent Constituted Number (EUS), perfect of the contract of babon sees NIV. I alia kating kating ada a nesa salat samen se ing ang an it sa kating a sama mati waka in salat sa kating a mul bbesstoris, and collected by a bits staff bloomer, strepy archiemien pass, then researed and in the enterior follower pulled in condinate environments on due, sides using purior owiejodyn ent er by compilieg with a hityslephol iff ar lith, cantiletemilye if an amaw áciliste No interest become an arrive of ness a period of As pair afitic of configuration, the Steel or lewel and descriptions of three conditions to and the studie broining from the exploration of the confidence (see Applicable 1.). This makes the the Rule and Assistant Director of Human Services Realth District Or Dr. Health Officer The HO is a physician who acts as medical director of the Sutter County jail and is responsible for oversight of the quality of health care provided to inmates and making final decisions on all clinical matters. The HO is responsible for the development and annual review of medical policies and procedures, including nursing assessment protocols. Even though the HO reports directly to the Board of Supervisors, this position coordinates with the AD in support of the JMS. The current HO has been in the position since 2010. Assistant Director of Human Services-Health Division According to the job description, the AD "...has the primary authority and responsibility for directing for a functional area of services within the Human Services Department..." including jail health services. Having oversight of the jail clinic, the AD is responsible for its efficient operation and delivery of quality medical care in a timely manner. The AD directly supervises the JNM. The current AD has been in this position since 2007. Jail Nurse Manager According to the job description, the JNM has the responsibility "...to plan, organize, coordinate and manage jail medical services; to supervise nursing staff; to oversee quality assurance and legal compliance issues; and to perform related work as required." This includes development of "...policies, procedures and standards to ensure quality of care", directing staff in the delivery of health services to inmates, responding to emergency inmate care, and providing "...professional nursing care as needed." The JNM is also responsible for "...handling employee concerns and problems" and "...directing employee training and development". The current JNM has been in this position since 2009. Policies and Procedures The 2010-2011 SCGJ wrote a report addressing a complaint of the Sutter County Jail Nurses Program which alleged, among other things, out of compliant policies/procedures. The complaint alleged the Jail Nurses Program was out of compliance with the California State correctional code - Title 15 sec 1206, which states that Policy and Procedures (P&P) are to be reviewed and updated annually. Also, Standardized Nursing Procedures had not been reviewed or updated since 1995 and had been changed with pencil marks. The 2010-2011 SCGJ recommended that "The County Medical Officer and the Jail Nurse Program Manager with oversight from the Assistant Director of Health and Human Services should ensure that Jail Nursing Program P&P's are reviewed, rewritten, and made current so they can be used and referred to by the jail staff." This was to be completed by December 31, 2011. Nurse Training The 2010-2011 SCGJ also addressed a complaint of lack of staff training at the Sutter County Jail and recommended the JNM, along with the HO, "...develop a training program to ensure adequate on-site training be made available to the nursing staff on a regular basis". The AD "...should provide oversight to ensure this training program is implemented." Entrated & Marketine ... to III it is a physician adapted on modical director of the Sottes County and and reversionable De so prefizieth had a sistem lam existem at behivang gave dibest to gitting off to the energy of libited unwested. The IPC is responsible for the development and mannel as the set of seed per policied and procedures, including numbry assessment protocols. Even though the UO objecto enth with the purpose of the orthogorasis inhance mathematical state property to be of self-of effective The chrest LC lasters to the position discretely and the Comment of Manager of Manager School and the Company of the Comment of the Comment of the Comment of the Comment of the Comment of the Comment of the Comment of the Comment of the Comment of the Comment of the Comm We difficulty to the fob-field injection, the AD "... Jane by extinctly a colourly to the following plant dazerbi, itu e familiteti itali etak aftaruasa widdin dipu bligaga. Sek looj filo jeran e ji filologian jell brait anvecte. Having oversign of the jelt clinic, the A.D sarespensible for its all along upo principal del dell'est de l'estable de la company de la company de la company de la company de la company d the Police primary by and the police of the posterior since 1997. CONTRACTOR STATE According scales for description the 1870 bas the corporabilities . . . . . . . . . . . . . . . . . . . line kraecijani voltera i premovo ovuštata gotenim primovu ot prokona tradicija in interiorijanim tradicije i o maga pale valo patast og skill i Stanbundove, danskabalaren modbarren brin fram et kan framskala i skill ski and the collision and abandants of mount gradity of antificial liquet of all the collisions of kanalah karan darah mendipakan periodah pendiri pendiri bahan dagah berpadah dalam darah darah beradah mendiri den afronce condition godhern. East ad kitariar a drek WK af E. Sodard e a chiadrina problems” and “… prestag amployco caining and sievelopende ”… The commit 14 Milling ac Juliji i samir na Nasay sitir m entities and Personal artists accin with all years a regular prints on large and a granwan talk larger is affined LDCFR to 95% to 12 of the rakport be bell norej ano kjerskilag sje, kpana kultur og nist mjate jaron „kaaditalikule stangari trada karen .................................... ran of anna ar afart (194), shi Nobey and Policy and Problem (194), states on the constant and pilated actually, of our Standard Mexical Phening Passed Local for being consecutives and u. U kabija e je se 10 0km 1954 titik se E sviene Germatik Vezarata e od boj om 254 kabija in i da Caratra de Caratra de Caratra de Caratra de Caratra de Caratra de Caratra de Caratra de Caratra de Caratr aheneri na na starit biganden tasakgat ganifikila disektira - afi natasisi y a san kara banda sa sakara a jada a ahumpa biban kahada a a dagara-sa sa sa antici a comi seri a comi seri a probita e si pia a makala mangangan matakantakantakan basaka da a si kacil ka กล้องการเพลงเหตุ รูปที่ และวิทฤติโรยเลก - และการสมที่ป่า และประปัติโรยเล้ม ประชา โดย ในได้ โดยไ the still the estimate for a few best-control of the other still as the still as the still of the still of the still of the still of the still of the still of the still of the still of the still of the still of the still o temperation of the most spirit at ensure first page, at an activation of the content to scale. Complaint Based on the serious nature of the complaint, the SCGJ agreed to investigate the allegation of an inmate not receiving proper medical care during his eight days of incarceration. Furthermore, there seemed to be a lack of urgency by JMS management to implement changes in order to avoid a similar adverse outcome. The SCGJ was concerned past inadequate staff training and incomplete JMS policies and procedures could have been contributing factors in the inmate's death. APPROACH Interviews were conducted with the Director of Human Services, Assistant Director of Human Services-Health Division, the Health Officer, the Jail Nurse Manager, several jail nursing staff members, Rideout Hospital ER physicians, the ambulance EMT personnel, several correctional officers, and family members of the deceased. Medical and jail records and reports associated with the case were obtained and studied. Copies of treatment protocols and the updated Policies and Procedures were requested. Several SCGJ members participated in a tour of the Sutter County Jail, including the jail clinic, the Medical Cell (formerly Sick Bay), and the office of the JNM. DISCUSSION The inmate had been complaining of pain in his leg/foot since sometime after his arrest on January 21, 2011. On January 24, 2011, he requested sick call, and was seen at the jail clinic on January 25, 2011. The inmate was scheduled for sick call again on January 26, 2011, because of increasing leg pain. The jail nurse on duty requested he be transported to Rideout Hospital ER. After evaluation and negative findings by ER physicians, he was returned to the jail. Since the inmate continued to complain of leg pain that night, he was prescribed medication and seen again at the jail clinic on Thursday morning, January 27, 2011. During late evening Thursday/early Friday morning his condition severely and rapidly deteriorated. He was escorted by the Correctional Officer on duty to the nurses' station on January 28, 2011, at 4:39 AM. Abnormal vital signs and appearance, together with reporting of coughing up blood, indicated the inmate to be in serious distress. His vitals were: Blood Pressure (BP) 64/44, Pulse (P) 120, Respirations (R) 24, Temperature (T) 97.6 and Oxygen Saturation 93. The LVN on duty failed to recognize the urgency of the medical situation to seek immediate help. The LVN did not consult with the on call physician or call for an ambulance. At 5:25 AM, the LVN made the determination to place the inmate in the Medical Cell, located across from the jail clinic, requesting 30 minute visual checks by custody officers. THE PROPERTY. and the confidence actives a fittle commentation of the commentation in organization and profite and profiter aapuu 1991 1999 kun geberror anadical carb daring big siglad kes saling seringan ja baring anaring saling seri raderno di peggaria nomalerale, memografian 27 % valvariane tabil al 2 m di banco attifici per primar Trape of probabilities in accomptions (C). If all the constitutions is the refirming blower and the DMS policy and the contract private the contribution of the contribution of the contribution of the contribution of the contribution of the contribution of the contribution of the contribution of the contribution o Mis-h 11 A 00 annul i Tagusa. Chana an Aseriya (mamrii ta naban(bad) diin bata (aga at be at dista Part I december 1 to the Health Officer, the Unit Niper 1 transported by the Control of the Investor I was the tang tipa, sa terore sajangan ng 1971) tinah sambadi jangdag ng 1991 bilinah Saleshia ta Malaysia. because with a madernia recent but the little esigal 3) queture lum is entre da desas estas estrablica batajo destribada que fore abrotar bair barrilari las on terbinarie contració distinta upto all Pallicies sind Papas duas were reconser o Marcella ISC ce da dipol kuji ji Svet kuji ekrenilia pol jipi, jeje zabi patok rekita zapio njika izpoli azpemba er l filikli aylı ilm applitmişti. Hasa atevi i ili da kazısımını bilikli il i ka judude ka kuzutudan kandan kan da san da ka ku ku Madilo kabada samaran da ku a ra a raca da na austijs in stima se at anviller ditegera kondupis, stijt i 10 20 venni siji. Siis - Cisporari remenska i 1917, 30 yozunet ar gilago bezirta errobiblik energiaren barrok 30 (1991), eripera errob ATT Labings in the chile of the lightest in the best purpose in the set entire light refer in its president on the and addition of the public of the contract of the public of the contract of the contract of the contract of the contract of the contract of the contract of the contract of the contract of the contract of the contract of th ninga paja. Peru galikat kan ingli akang asarayi, filaka kalikang ya Du makanisa sa Luke daka satanat gfuskterdamat i spil rot statil seftytti. I 190 A.C. gastarett gestermagisteretti on mid ibe klif hit besterit l rational de constituir de la constituir de constituir de constituir de france de la constituir de la constituir to record (1 - 1817 - 1917) for a cold CDE hydroll plan of the Colored and their period Colored Colored (1817) garana da mengaja, gelagijagah mategarangga mateklijan g e gipe - 12 com a Magaziff at Prett for Tama a wat Califold on accordable at the size of a pairson got or al legical tea con collimina lando carette mente carette de manocare antenario, accordi ballar state no 100 at bill ad 🖰 til 1968 did sed i prodiktor the prodikterebilder og det til 1968 fra de ver eka bezerin 1505 garbatik ap, genasailaidi jaan, ekabilaga reproblektikan 1500 a.a., Dipa uanovišky visitanov gri palominiu uzbanovniko dali kraliza rozni za Airi i dali i rivi s At 8:00 AM, the inmate was brought back to the clinic and his vital signs were retaken by the LVN: BP unobtainable, P 142, R 40 with significant shortness of breath, and T 94.2. The JNM arrived and was briefed by the LVN on the inmates' condition and he did not review the medical chart or examine the inmate. The NP arrived at 8:05 AM and noted very loud respirations from the inmate. Vital signs were taken, and the NP immediately requested an ambulance to transport him to Rideout Hospital. His condition further deteriorated and the inmate died in the ICU later that afternoon. According to several Rideout Hospital physicians, it is unknown and probably unlikely that an earlier transport to the hospital would have changed this outcome. However, this does not absolve the actions of the nurse on duty, who failed to recognize the emergency and confined the seriously ill inmate in the Medical Cell for over three hours while she attended to other routine duties. There was never any formal discussion or meeting held for the jail nursing staff to review the inmate's case. Morbidity and Mortality conferences are considered to be invaluable learning tools with the goal to discuss and gain insight when there is an unexpected death or poor outcome. As the medical director of JMS, the HO is the most likely person to moderate these M&M's. However, it was discovered that M&M-like discussions were not held and in fact the HO did not allow any discussion among medical staff about the inmate's case. The P&P's were not current at the time the JNM was hired four years ago and no progress was made until the 2010-2011 SCGJ made its recommendations for them to be updated. It has been an ongoing process for both the HO and JNM to write and implement them. Approximately half of the P&P's are completed except for most of the nursing assessment protocols which are pending HO approval. On the day the inmate was placed in the Medical Cell, the Sutter County Sick Bay Policy #56, dated October 8, 2001, was in place. It was one page and stated in general terms that only jail medical staff could place inmates with medical problems in Sick Bay; it did not offer any guidance. According to the October 12, 2011, revised JMS Policy #16-501, only the JNM, RN Supervisor or NP can determine if an inmate meets the criteria to be placed in the Medical Cell. It is not to be used for an inmate with an unstable condition that requires frequent observation. An LVN must have verbal orders to move an inmate into the Medical Cell. Almost one year after the inmate's death, a priority still had not been made to write a protocol to help guide nursing staff should an inmate present with similar vital signs and symptoms. There seemed to be no urgency in developing P&P's to ensure inmates receive critical medical attention in a timely manner. Finally, Vital Signs Monitoring JMS Policy #16-506, dated January 9, 2012, includes parameters for normal and abnormal vital signs and required actions. The need to consult with a NP or physician in case of any concerns or questions regarding inmate health is stressed numerous times in the policy. The JNM has provided the SCGJ with documentation of mandatory training for the JMS completed last year, including CPR, blood borne pathogens, HIPAA, and jail safety. However, he has not provided documentation of any in-house training related to direct patient care or staff meeting minutes showing patient care discussions or training. and the countries was brought brack to the climic and talk plant agence one of the agence. PACE 187 cooling mobile, P. 142, R.-G. With Significant Shortness of breath, and J. 1922, 202, 2020. on ved and vess briefed by the LVE on the immitted consistent and held or section to the first of ment of classic and fine per all mentions at 2.12 A.24. 2015 to be missing only only only on the fact lic infrace. 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Per 10° de las explojas de ili ne vierenangal pasingap esricar lithere isticaprar on diberotethri surtiti biratriki brotini iti titute i grading day Mary Brook on Burgang an eventral adapting the box grant some DIM at a Ac en bouchen wurde die der einem zicht der die der Beitregelfetag er damb zichte der die Gebeut der die Gebeut d opidi) – or plous boson posos areadoris meso rigare atrancimos bitas, i são a creciom diasipajada ni ka 1 jibo satan wali ni mana alio ka 1971 galipitasika kalenda da 1971 (balitak an with your and the increase of the control of the little control of the control of the control of the control of the control of the control of the control of the control of the control of the control of the control of th g to the production of the production of the production of the production of the production of the production of the production of the production of the production of the production of the production of the production of t jednoj jeleni zagrip zamomne kazadia nuddimi je end g 1920 - garan ing terminanan Narawani mengalah sa 1926 silihabaway a 1921 - sa er jalat 1975 gift fra 1981 sagert løg frags pri 1897 gift fra 1996 gift fra 1986 gift fra 1986 fra 1986 fra 19 and the second of the contract of the second of the second of the second of the second of the second of the second of promise to a supplying the answers entracted and in the Committee Throughout all of the interviews conducted by the SCGJ, not one JMS staff member felt that the JNM provides effective leadership nor are they confident about consulting him regarding patient care. When asked, several of their responses about the JNM's participation in the clinic indicated he's either never there or always in his office, which is located around the corner from the clinic. Sutter County Health Department requested the National Commission on Correctional Health Care (NCCHC) to assess and propose solutions to improve its health care management and costs. This organization is the leader in setting standards for correctional facilities. A facility can request an assessment by NCCHC for the purpose of reviewing and comparing their health care services against national standards. In November 2011, NCCHC conducted an on-site review of the JMS (see Appendix B). The chief finding of NCCHC for the JMS was their "...policies, procedures, and guidelines have not been vetted, nor has staff been trained. Although training is planned, the lack of strategic planning, developed policies and procedures and consistent leadership in the application of those policies and procedures have greatly hampered the delivery of health services at the Sutter County Jail." In addition, "...there has been no effective process that studies the quality of health care provided in the jail. A registered nurse reviews charts, but the data from these reviews is limited to documentation issues and does not evaluate the clinical care. The chart reviews include no information regarding the quality of care provided." Although the NCCHC commended the jail medical staff efforts to provide health care with their limited resources, they made several recommendations to improve the quality of care. The NCCHC recommendations include: completing the policies and procedure manual implementing "...nursing protocols as soon as possible and ensure that nursing staff is . properly trained" improvement on the health record format and contents to facilitate monitoring of the quality of health care delivery of the light expected that 2441, the result of estimates builded a september of the attended section. en la pje ibnore e signa ingrana mara Lobitnos yodi san van qidaadhad e dhebb abbuna jakki. cate is later and association in the responses about the Jaka's management in the glade incheste de la communicación de la compacta de la compacta de la compacta de la compacta de la compacta de la c entropie bandpromise se reason in the company of the teamer promise published to see the control to the control to the control to the control to the control to the control to the control to the control to the control to th atau ing kanggalangan saga dalaman mengang kepadehatan nggang lumi sebahat 1989, 199 km i us for example in the contraction for the contraction of the contraction of the contraction of the contraction of the contraction of the contraction of the contraction of the contraction of the contraction of the contracti r Characterist a received base palvolish to skearing adfabit OFFF to a monstree in stance of an arayka een a geerre geerre ja ka kii bii kii jak alkari erak ah qiiqa'an a karainaa kariinga kwee wax - Brango, N. soeh 27 West saut alfa mas, ha e somis ana paledon, — dada asv. 200, kili ad 1775 — com calimbidancia d ang kara-tatan arti a magatagi kada magagapati A . Nakifish tatah tersa arti satu tari sa milid tatah mengagapa year tij kyay ya wa e yeliye i rija iya iyali yali bali adiba da astani da astani bala e ka e ki e e este e ta the production of the contract of the second of the contract of the contract of the contract of the contract of the contract of the contract of the contract of the contract of the contract of the contract of the contract o ef colorespect to a gald file of the construction of each or a contract that the file of the contract of the contract of the contract of the contract of the contract of the contract of the contract of the contract of the c pro More de analogado por entre se empresa de confermación de la Maria de las como establación de la Maria de la Maria de la Maria de la Maria de la Maria de la Maria de la Maria de la Maria de la Maria de la Maria de la M ti on a septembre and standered for upode fill, alongs, in differencembed in the fill of deep division. ter, and he it is gifting all didition and in material of the landom is a is pod – graviti sa skorpej or godje Top (topomi 157 godinjaranem. Di boddom de bildzi of the programme of the contribution of the contribution of the contribution of the contribution of the contribution of the contribution of the contribution of the contribution of the contribution of the contribution of th regulatori resoluti artegorum de 1900 il por jas – studė ito ir lėjo sergifes, eddigadam truoj – s sharpasa le era muarril er disanag je rubijas samera, bruksati adal no esperante en autilitario pregnate o l'imperante del l'appropriété pol nell'en resolution de l'imperant ymalitate according to a different according FINDINGS F1. The involved LVN, by failing to recognize the medical emergency and by not calling for an ambulance, acted inadequately in the treatment of the inmate. F2. The JNM did not take any interest or immediate action responding to the inmate's medical emergency which is inconsistent with RN training and not in compliance with the job description to provide professional nursing care. F3. Although the 2010-2011 SCGJ recommended a December 31, 2011 completion date, only about half of the P&P's have been finalized and made available on the intranet. There was no priority after the inmate death to immediately implement a policy that included vital sign parameters indicating when to call for an ambulance. F4. According to the job description, the AD has direct involvement with JMS, not only for oversight of the JNM's performance, but for the purpose of recognizing and improving employee problems. With the discontent amongst the JMS staff with the JNM, the AD is not attune to the problems at the jail medical clinic and/or not taking appropriate, decisive steps to resolve them. F5. The AD violated the conditions of the job description by enabling the JNM to be negligent of duties and responsibilities throughout the JNM's entire tenure. This includes continuous noncompliance by not reviewing and updating P&P's annually (Title 15 sec 1206 CA code), no in-clinic training program to assure standardized treatment procedures, and reluctance to act in the capacity of an RN. F6. There is no in-house training provided to JMS staff that is specific to their job. F7. All JMS Management (JNM, AD, and HO) abrogated their responsibility by not conducting an M&M-like conference following the death of the inmate. M&M-like conferences have not been held after adverse incidents at the JMS clinic. F8. These discussions have been discouraged by the HO. M&M-like conferences are of great value as a teaching tool for patient management. Stifling any discussions of these cases is a detriment to the JMS since it deprives the nursing staff team an outlet to reflect upon and review poor or avoidable outcomes. Both the NCCHC visit and SCGJ investigation independently came to many of the same F9. conclusions concerning issues with the JNP. 5 7 3 1 7 5 5 For everyod IVN by Priling to recognize the medical enterior acceptably set office at a . Moreovice and the College fraction of the College for the College for the College for the College for the College for the College for the College for the College for the College for the College for the College para nga matatang pamagkat bada kembah sana ang Kanalas ya terbahan at tidih 1974 kaki -11 and for energency. 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The JNM must ensure all JMS staff is thoroughly familiar with the new JMS Policy #16-506, which outlines parameters for abnormal vital signs and required actions. R4. The AD should evaluate and make changes to ensure the person in the position of JNM is capable of fulfilling all job responsibilities. This could entail periodic feedback from the nursing staff, more direct observation, and frequent evaluations of the JNM's leadership abilities. R5. Every effort should be made by the JNM, AD, and HO to finalize and implement all P&P's and make them available on the intranet. Thereafter, all P&P's should be reviewed and updated annually. R6. The JNM should encourage and foster a learning environment for the nursing staff. They should have opportunities to attend continuing education courses and arrangements should be made for in-house training relating to direct patient care, i.e. man down, suicide prevention, etc. R7. After a death or poor outcome at the jail clinic, the HO should conduct M&M-like conferences with the AD and all JMS staff present. The JNM, AD, and HO share the responsibility to schedule these discussions. R8. JMS should implement all NCCHC recommendations. RESPONDENTS Director of Health and Human Services, Tom Sherry Assistant Director of Health and Human Services, Amerjit Bhattal County Medical Officer, Dr. Cummings Jail Nurse Program Manager, Brent Garbett