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Case study examines challenges of correctional nursing

Correctional nursing is a unique and demanding area of nursing practice.

The following case illustrates what correctional nursing, and correctional care generally, should not be.

Inmate challenges lack of care for injury

A male inmate was injured during a prison basketball game in 2010. The injury occurred to his right hand and consisted of a “torn ligament, dislocation of his thumb, tissue damage and a gaping wound between his thumb and right index finger,” as detailed in the case Perez v. Fenoglio, 792 F. 3d 768 (2015).

Since no physician was on duty at the time of the injury, a nurse saw the injured inmate. She wrapped his hand with gauze and told him she could not administer pain medication or stitch his wound because only a physician could do so.

The next day, the inmate was seen by a physician at the prison. The physician prescribed antibiotics, but did not stitch the wound. Because of the severity of the injury, the physician told the inmate he would need to go to the “outside” hospital the prison used to have a hand surgeon provide the needed care.

Such a referral needed to be approved by the prison’s healthcare administrator. This took several days while the inmate was in severe pain and tried to manage his open, bleeding wound as best he could.

Four days after the injury occurred, the inmate filed a grievance with the prison. The basis of his grievance was that the open wound and severe pain and discomfort he was experiencing was not being treated because of “retribution” for a prior grievance he filed when there was a delay in administering prescription medication for depression.

Six days after the wound occurred, a physician’s assistant at the “outside” hospital saw the inmate. The physician’s assistant determined the wound was very serious but he could not suture it because of the length of time from the date of the injury to being seen at the hospital.

The physician’s assistant also concluded a “surgical revision” or “secondary intention” was needed. The physician’s assistant did order twice-daily dressing changes and cleanings with hydrogen peroxide and suggested possible splinting for the thumb injury.

A “wound check” appointment was scheduled at the hospital within the next week.

Did prison staff follow care recommendations?

correctional nursingPrison staff failed to follow the physician assistant’s orders and did not take the inmate to his wound check appointment.

The inmate filed another grievance and requested he be seen again at the hospital. At this time, he also learned his initial grievance after the hand injury was denied.

The inmate appealed the denial, but it was upheld by prison administration, stating “the issue was appropriately addressed” by the administration.

Seven months after the inmate’s initial visit, prison staff brought him back to the hospital.

He was seen by a physician who concluded the injury could be treated by either a surgical procedure (a right thumb metacarpophalangeal fusion) or he could “live with it” and have a Thermoplast Spica splint custom made for his hand, although the latter might not be acceptable in a prison setting.

Even so, if the splint was the inmate’s choice, another appointment would be needed.

These recommendations were sent to the prison physician who initially saw the inmate. He wrapped the inmate’s hand in an Ace bandage and told him, “that’s [your] thumb-spica splint.”

After filing another grievance, the inmate had the required surgery 10 months later but with residual, “irreparable” damage to his hand.

Inmate takes legal action

The inmate filed a “pro se” (on his own) 42 U.S.C. Section 1983 complaint against various prison staff, including the nurse, alleging cruel and unusual punishment in violation of the Eighth Amendment to the U.S. Constitution.

He asserted that prison officials were “deliberately indifferent to his severe hand injury, delaying the receipt of medically necessary surgery for 10 months.” The result of this delay was needless and unnecessary pain and suffering and left him with permanent loss of hand function.

He also requested a pro bono attorney (a volunteer lawyer who does not charge a fee).

The federal district court denied his request for a pro bono attorney and dismissed his suit on its own accord (sua sponte), with prejudice, for failure to state a cause of action.

The inmate appealed that decision to the U.S. Court of Appeals, 7th Circuit.

Analysis of correctional nursing conduct

correctional nursingOf particular importance to this blog is the court’s analysis of the prison staff nurse, who allegedly acted with deliberate indifference to the inmate’s injury. The defendants contended the nurse acted appropriately by making an appointment with the physician and that she lacked the authority to provide additional care to the inmate.

Citing applicable case law, the court opined that a “nurse may not unthinkingly defer to physicians and ignore obvious risks to an inmate’s health.”

The court continued that a nurse “has a professional obligation to the patient to ‘take appropriate action,’ whether by discussing the nurse’s concerns with the treating physician or by contacting a responsible administrator or higher authority.”

As a result, the inmate’s allegations against the nurse did state a claim against her for deliberate indifference. Whether or not the nurse had the authority to stitch wounds or administer pain medication are issues that need further discovery, the court continued, as does the question of whether or not she did more to ensure the inmate would get adequate care required by the U.S. Constitution.

Final order of the court

The court carefully scrutinized the other allegations and held that the dismissal by the district court was “premature,” and that the inmate’s pro se complaint, liberally construed, states a valid Eighth Amendment claim against the prison medical staff and various grievance officials.

The case was reversed and remanded to the district court for further proceedings consistent with this opinion.

I touched on this topic more in the blog post, “Correctional Nurses Face Challenges When Treating Inmates with HIV,” for further reading.

 


Take these courses on correctional nursing:

Control and Management of Infectious Diseases in the Correctional Setting
(1 contact hr)
The number of inmates in state and federal prisons is nearly 1.6 million, making the U.S. the world leader of incarcerated citizens. The prevalence of infectious diseases in the correctional setting is four to 10 times than in the general U.S. population and is also linked to greater risk of communicable diseases, such as HIV, tuberculosis, hepatitis B and C, and sexually transmitted diseases. With more than 600,000 people released each year from state and federal prisons, correctional healthcare providers have a window of opportunity to identify and treat communicable diseases, directly affecting the health of people in surrounding communities.

Mental Health Nursing in the Correctional Setting
(1 contact hr)
A survey of state correctional facilities indicates that there are three times more mentally ill people in jails and prisons than in hospitals, making the correctional setting the de facto mental hospitals of our time. About 25% of jail and prison inmates have co-occurring addiction and mental health disorders. The psychiatric nurse’s role in a correctional setting is unique. The nurse may work as a staff nurse on an inpatient unit providing psychiatric nursing care to inmates or act as an outpatient nurse, providing evaluations, counseling or crisis intervention to inmates in the general population. The assessment techniques and interventions appropriate to psychiatric care of patients in the correctional setting are addressed.

Legal Issues and Origins Behind Correctional Nursing
(1 contact hr)
Regardless of your primary practice setting, you may come in contact with inmates requiring healthcare services. Do you know when you are allowed to disclose protected health information to law enforcement? This module will describe laws, ethics, and issues of correctional nursing key to the nurse’s role in the evolution of healthcare in adult correctional facilities.

By | 2019-04-04T21:27:34+00:00 April 3rd, 2019|Categories: Nursing careers and jobs|4 Comments

About the Author:

Nancy J. Brent, MS, JD, RN
Our legal information columnist Nancy J. Brent, MS, JD, RN, received her Juris Doctor from Loyola University Chicago School of Law and concentrates her solo law practice in health law and legal representation, consultation and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent has conducted many seminars on legal issues in nursing and healthcare delivery across the country and has published extensively in the area of law and nursing practice. She brings more than 30 years of experience to her role of legal information columnist. Her posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.

4 Comments

  1. Avatar
    Paul Price April 8, 2019 at 6:17 am - Reply

    Ok so what should the Nurse done to protect the patient? It looks to me like the Physician and the Administrator both were at fault due to negligence and shoved the blame onto the Nurse. It is obvious that the nurse did not have the authority to prescribe pain medication or to stitch a wound. The rest was just pure neglect on the part of those that run that facility.

  2. Avatar
    Nancy J. Brent May 13, 2019 at 7:19 pm - Reply

    Yes, all involved with this inmate did not provide the care that he needed.

  3. Avatar
    Belinda June 7, 2019 at 11:40 pm - Reply

    In my opinion the nurse obviously had poor assessment skills. The patient should have been sent to the hospital. Document document document.

  4. Avatar
    Kent Krueger July 10, 2019 at 9:05 am - Reply

    I believe this is one of the more extreme cases of indifference concerning an inmares medical care. Unfortunately it’s not that unusual. This kind of neglect exists in all levels in the correctional setting. From the local city and county level all the way into the federal level. It exists because those in charge allow it to happen. They don’t call for medical rescue because then a paper trail would exist documenting the lack of care or deliberate mistreatment. I believe that often the medical staff administers there own form of punishment against inmates, whether in retaliation for a previous complaint or simply because they don’t like the inmate because of what he or she has been accused of. And they do it because they know no-one will believe an inmate’s accusations. This can range anywhere from improper treatment for an injury to withholding an inmates maintenance medications. I personally fall into the latter category. I was falsely accused of domestic violence and arrested. I’m also on maintenance medications for a Cardiac condition. My medications came with me to the county jail. Understand, I was a first time offender and I was arrested without any physical evidence that I had done anything wrong. I cooperated fully with the Sheriff’s Deputies. I went with them peacefully and offered no resistance. This was in the evening. The deputies were informed I was a cardiac patient and that I had scheduled maintenance medications that I must take. The intake officers were also informed of this. Yet the very next day my maintenance medications were withheld from me, until I passed out from extreme high blood pressure. The excuse was, “You’re going to be going before a judge this afternoon and you will be bonded out of here before you’ll ever need to take your medications. You can take them then yourself. But I’ll talk to the nurse.”. To make the story short, my bond hearing was delayed a day, the additional stress and anxiety pushed my blood pressure to dangerously high levels, to the point that my heart could no longer push enough blood through my blood vessels and I passed out, falling onto the concrete floor. The impact with the floor fractured one of my sternum wires. Finally the nurse was called. She acted like I was pulling a fast one until she took my vital signs. My pulse was racing, over 200 beats per minute. My systolic blood pressure was greater than 240. My diastolic pressure was over 160. These readings are considered to be a life threatening emergency. Yet rescue was not called (paper trail). The United States Supreme Court has ruled this kind of mistreatment is a violation of the 8th and 14th Amendments to the United States Constitution. But jails and prisons get by with this because the general public doesn’t believe this happens or they are indifferent or just maybe they think the inmates deserve it. Keep in mind, I was never convicted of any criminal wrong doing. I had never had more than a traffic ticket before. I did not and do not have a criminal record, yet this is how I was treated by the Justice system. I did file a complaint with the State D.O.J., the complaint was ignored. Jail officials broke several laws, possibly even committed felonies, yet received no retribution for their actions. I spent time in jail for doing absolutely nothing wrong and had 11 weeks of uncertainty hanging over my head. It also turned out my mistreatment caused permanent damage to me. I have become a fall risk and must walk with the assist of a cane. I have become virtually unemployable from my previous cardiac condition, my new acquired disability and that bladted arrest record. You ever wonder why some people don’t like law enforcement, just ask anybody who has ever been mistreated by the justice system and you will know why. Law Enforcement can get away with doing things to private citizens they arrest that would send normal people to prison with lengthy sentences. And remember, they sometimes manage to kill inmates who were arrested for relatively minor offenses. Some of those arrested never did anything wrong.

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