SACRAMENTO — A flagship California prison medical facility built to improve the state’s substandard care is itself providing poor treatment including botched diagnoses and haphazard distribution of medications, California’s inspector general reported Thursday.

Corrections Department Inspector General Roy Wesley on Thursday gave an “inadequate” rating to the Correctional Health Care Facility in Stockton, south of Sacramento.
The state spent $820 million to build the 6-year-old facility, which holds about 2,670 inmates needing medical and mental health care. It most recently had a fatal outbreak of Legionnaires’ disease. The prison was built to centralize treatment of sick and mentally ill inmates in part to lower the high cost of outside treatment, and about four of every 10 inmates at the prison are considered to be at high medical risk.
Yet inspectors gave the facility failing grades on eight of 10 indicators, largely based on inspections in 2017 and a follow-up visit in October.
“The report documents that it had severe problems in providing adequate care,” said attorney Steve Fama, who represents ill inmates with the nonprofit Prison Law Office and toured the facility last week. “The prison holds the sickest — by which I mean the most complex — medical patients and it ought to score as proficient or better in delivering medical care.”
The federal receiver who controls prison medical care and pushed to build the prison, J. Clark Kelso, did not immediately comment.

Report Referenced Multiple Lapses in Care

Inspectors reported that doctors’ care “regressed significantly” since earlier reviews and “repeatedly failed to make sound assessments and accurate diagnoses.”
They did not sufficiently review diagnostic or laboratory reports and often delayed follow-up appointments or getting inmates care they needed from medical specialists.
The report partly blamed understaffing, although Fama said staffing shortages have significantly improved in recent months.
In an extreme case, a doctor ordered an emergency abdominal X-ray for an inmate with a bloated abdomen. But the doctor never told the on-call physician to check the X-ray, which revealed an obstructed bowel.
The inmate died five hours later, a death inspectors said may have been prevented had prison doctors promptly sent the inmate to an outside hospital.
In another case, doctors neglected for three weeks to review a wound culture report for an inmate with an aggressive bacterial infection in his right leg. That’s when they discovered the bacteria was resistant to multiple antibiotics, including the drug he’d been receiving.

Nurses Improperly Administered Blood Pressure Medication

In a third case, doctors took five weeks to follow up with an inmate whose heart monitoring showed he was having “a possible cardiac event.”
Nursing care also deteriorated, inspectors found, and “patients often did not receive medications either timely or correctly.”

They cited multiple examples where nurses improperly administered blood pressure medication, insulin and blood thinning medication.
The inspector general’s office reviews treatment at all state prisons as a federal judge considers whether to eventually return control of prison medical care to state officials. Yet ratings for six of the state’s 35 adult prisons — including the Stockton medical facility — regressed during the most recent round of inspections, though scores improved at another five prisons.
A federal judge seized control in 2005 after finding that poor care was killing an average of one inmate a week. He appointed Kelso, who had the Stockton medical center constructed as part of an effort to improve treatment.
Prison officials announced this week that they are using chlorine to disinfect the water system at the medical facility and two neighboring youth prisons after two inmates tested positive for the bacteria that causes Legionnaires’ disease and one died last month. They also brought in bottled water and mobile shower trailers and ordered 110 shower-head filters to help prevent more cases of what is considered a severe form of pneumonia.