Roy Lee First District Laura Capps Board of Supervisors Second District, Chair County Administration Building Joan*

Because of the lack of an accurate and comprehensive master problem list in AAO's electronic health record, Wellpath medical staff did not make fully informed decisions regarding AAO's health needs and risks when he came to the Northern Branch Jail on August 29, 2024. The Board of Supervisors disagree partially with an explanation. A problem list is generated by a provider when a diagnosis is made, either when a patient self-reports and/or upon assessment by the provider. Here, a problem list was not generated because at intake the patient was not under the influence of alcohol, and did not self-report symptoms or history of chronic conditions; traumatic brain injury; recent, regular, and heavy alcohol use; or other risk factors as stated in the Department of Justice (DOJ) Guidelines for Managing Substance Withdrawals in Jails. If any of this information had been reported, it would have triggered a referral to a provider which could have generated a problem list. In prior incarcerations, a problem list was not generated because AAO was not seen by a physician as he did not report or exhibit chronic care symptoms, and he denied having a traumatic brain injury, substance use disorder, or other issues that would warrant a provider consult. During his March 2024 incarceration, AAO was involved in an altercation and required evaluation at the hospital because a jail medical provider was not on-site. There was no indication of a serious head injury at the time, and he was released from the hospital and did not return to jail. As such, a problem list was not generated as a result of this injury.

AAO's known medical history at the jail provided clear indicators for serious alcohol withdrawal risk, but no such identification occurred. The Board of Supervisors disagrees with an explanation. As reflected in the response to Finding 1, review of medical records from previous incarcerations indicated inconsistent self-reported alcohol use and withdrawal history. AAO's known medical history did not provide clear or consistent indicators of serious alcohol withdrawal risk. As per the DOJ guidelines, recent, regular, and heavy alcohol use or other indicators are prerequisites for withdrawal monitoring. AAO consistently denied heavy use and withdrawal symptoms in 12 of 15 prior bookings and showed no clinical signs of withdrawal in prior incarcerations. At intake, he reported infrequent alcohol use and no withdrawal history. Based on AAO's clinical presentation at the time of intake, automatic placement on withdrawal monitoring would not have been warranted.

Custody staff were not aware that AAO had an alcohol withdrawal alert or history because it was not communicated to them by medical staff or by means of an alert in the Jail Management System, though such communication would have been valuable. The Board of Supervisors disagrees partially with an explanation. The County recognizes the importance of timely and effective communication between medical and custody staff regarding persons at risk for alcohol withdrawal. The current practice is for the intake registered nurse to initiate a medical treatment order to indicate that a patient is on withdrawal monitoring and outline necessary precautions (e.g., lower bunk assignment, electrolyte monitoring). Specific to AAO, as with Findings 1 and 2, County Health's review indicates the treatment plan initiated from intake was based on the findings of the intake screening and the patient's presentation at that time. As stated earlier, based on AAO's clinical presentation at the time of intake, automatic placement on withdrawal monitoring would not have been warranted.