External Consultant Review

External Consultant Review Date of Review Inmate Name/Number DOD - AGE COD FACILITY/RGN Consultant's Sig Medications: Docusate Sodium 100 MG Cap, Take one capsule (100 MG) by mouth twice daily for 30 days Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML, shake well take 10ml by mouth twice daily AS NEEDED methylPREDNISolone 4 MG Tab ( 21 count Pack), Take the tablet by mouth as directed Omega 3 (Vascepa) 1 GM Capsule, Take two capsules (2 GM) twice daily by mouth with food Insulin Reg (10 ML) 100 UNITS/ML lnj, Inject regular insulin subcutaneously per sliding scale: each morning 9/19/2019 Epstein, Jeffrey #76318-054 8/10/2019 66 Hanging/Suicide MCC New York/NER Consultant Comments: Although there were no medical issues that contributed to this patient's death. The following is offered to strengthen and improve our medical processes: 1. Review Tracking system for diagnostic and screening tests when ordered. An FORT and ECG were ordered for this patient on 7/6/19, date of admission to the institution. However, there is no documentation of results and no follow-up noted addressing lack thereof even though this patient was seen on 7/9/19 (History and Physical) and 7/14/19 (Chronic Care clinic). 2. Review roles and responsibilities of staff responsible for inspecting, testing and maintaining your AED at all institutions. This is considered life support equipment requiring implementation of a process that assures that the AED is available and accessible on the event of a life threatening emergency. The suicide reconstruction review report noted that documentation of AED inspections in the institution was often incomplete. 3. Page 9 of the Suicide Reconstruction Report inaccurately reported that the patient's History and Physical was performed outside the required BOP policy. The BOP policy requires this to be done within 14 days of admission. This patient's History and Physical was conducted on 7/9/19. He entered the institution on 7/6/19. Unless the institution has a more stringent policy, the History and Physical was completed in compliance of policy. 4. Approximately 3 years ago, I recommended that a Health Services staff be added to the group/committee that meet to conduct the Psychological Reconstruction Review. A Health Services staff addition can provide clarification, but more importantly, strengthen our knowledge as part of the team providing comprehensive care for our patients. EFTA00040925 External Review Epstein, Jeffrey #76318-054 Continued 9/19/19 Were there findings from the medication mortality review? No Recommendations: None. Please submit the above stated recommendations (i.e., RCA, Corrective Action Tool, training presentations, and/or training rosters) to the HSD/Quality Managemenr@bop.gov mailbox and carbon-copying the respective Regional Director, RHSA, and RIOP within 45 days of the Warden's receipt of this notification. Findings Category: Unexpected Death within 30 days of hospital discharge Delay in Care: Untimely evaluation of symptoms/signs including red flags Untimely completion of diagnostics/consultations Untimely review of diagnostic or consultation reports Medical Hold not applied appropriately Untimely rendering of final diagnosis Communication Errors (Check all that apply) During Diagnosis During Treatment Improper Care (Check all that apply): Incorrect/missed diagnosis Failure to detect or address abnormal VS Medication mismanagement Incorrect treatment provided Treatment/condition not monitored properly Treatment not properly supervised CPG not followed (BOP or other) Treatment not provided EFTA00040926