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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:

Tobacco Use in Adolescents (1.0 contact hours) This course will review how adolescents are more susceptible to the marketing of tobacco products, and the health consequences of nicotine addiction, and will provide techniques for encouraging a tobacco-free lifestyle.

Patient Education for Poor Readers (0.5 contact hours) This course provides information to help nurses present information in a manner that helps their patients understand vital healthcare instructions.