MEDICATION PASS G-105 01-27-22 FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: MEDICATION PASS NO: G-105
FILE: MEDICATION PASS
EFFECTIVE DATE: 07-25-17 REVISED:
AUTHORITY: Sheriff M. Mims APPROVED BY: Assistant Sheriff T. Gattie
REFERENCE: California Code of Regulations, Title 15, Sections 1206, 1214, and
1216; Hall v. County of Fresno, E.D. Cal. No. 1:11-CV-02047-LJO-BAM
(2015); 45 CFR 164.512(k)(5); Fresno County Administrative Officer's
Management Directives, Subject 112.3; and General Health Services Policy
and Procedure J-D-02.00.
PURPOSE:
The purpose of this policy is to establish guidelines for security and control during
medication pass in the detention facilities.
POLICY:
It is the policy of the Fresno County Sheriffs Office Jail Division that custody staff shall
be present during medication pass to directly observe the medication process, maintain
order, and provide assistance, if necessary.
It is the policy of the Fresno County Sheriffs Office Jail Division that non-medical staff
(inmates and correctional officers) are prohibited from administering medications.
At no time shall medication be withheld from an inmate as a punitive action.
PROCEDURES:
I. DEFINITIONS
ADMINISTERING MEDICATION — the act in which a single dose of medication is
given to an inmate.
CHEEKiNG — Hiding medications inside the mouth rather than swallowing
them.
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: MEDICATION PASS NO: G-105
FILE: MEDICATION PASS
DIRECTLY OBSERVED THERAPY (DOT) - Dose-by-dose administration of
medications by licensed nurse which includes observation of ingestion of
the medication by the nurse.
ESSENTIAL MEDICATIONS — Medications that are essential to the safety or
well-being of the inmate and could result in a health problem if a dose is
eliminated (e.g., insulin, chronic disease, etc.).
KEEP-ON-PERSON (KOP) MEDICATIONS — Medications that have been
designated by the Medical Director as safe for the inmate to self-administer
(e.g., inhalers, nitroglycerin, commissary medications).
II. GENERAL PROCEDURES
A. Medication pass is conducted in every housing unit, twice a day, seven
(7) days a week. Inmates who require more frequent dosing (or
alternative medication schedules) will be routed to the Main Jail 2nd floor
to receive their medications, or housed in the Outpatient Housing Unit
(OHU), as appropriate.
B. Medical staff will identify the medication pass call times designated for
the administration of medications to inmates in the housing units.
1. The times will be established by the Health Services Administrator
(HSA) in coordination with jail management.
2. Any modifications to the prescheduled time shall be sent to the
Watch Commander and the Compliance Lieutenant two (2) weeks in
advance.
3. Due to circumstances in the facility, an urgent event (planned or
unplanned) or an emergency may occur and alter the schedule. This
shall be communicated between the Watch Commander and the
charge nurse to ensure medication is administered as soon as
practical.
C. Security Officers are to announce medication pass in such a fashion so
as to alert all inmates in the housing units. The lights shall be turned on
inside the OHU and administrative segregation lockdown cells in order
for nursing staff to observe the inmates ingest their medications. (The
light in an OHU cell may remain off if medically necessary.)
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: MEDICATION PASS NO: G-105
FILE: MEDICATION PASS
D. An officer shall accompany the medication nurse and be present during
medication pass to directly observe the medication process, maintain
order, and provide assistance, if necessary.
1. Whenever possible, the accompanying officer will position
themselves inside the housing unit, or other location (e.g.,
gymnasium, classroom, etc.), as applicable.
2. When not possible, practical or safe to do so, the accompanying
officer will position themselves so as to view the inmate and when
necessary, provide access by opening the associated feed hatch.
The officer shall remain in direct proximity in order to provide safety
and security for the nurse and the medication cart.
E. If there is an emergency call or urgent need of the officer elsewhere,
medication pass will cease until an officer becomes available to assist.
III. INMATE RESPONSIBILITY
A. It is the inmate's responsibility to be present for their medication and to
follow any instructions during medication pass. If an inmate's medication
is ordered for a specific time (for example, each morning after
breakfast), that is the time that the medication will be made available. If
the inmate oversleeps or chooses not to get up, they will not be offered
the medication later in the day.
B. General population and protective custody inmates who are scheduled
to receive medications are to form an orderly line. Green lines in the
dayrooms and other common areas have been added to create space
for privacy. Inmates are expected to remain behind the green line until
called upon to move forward.
C. Inmates are expected to be dressed, show their ID wristbands and have
a cup of water with them. Without doing these things, the nurse will not
give the inmate their medication and the inmate will be asked to comply
and return to the end of the line.
1. The medication nurse will provide water and cups for inmates who
receive their medications outside of their housing unit.
2. The medication nurse may provide certain medications mixed with
water ("crush and float") when prescribed.
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: MEDICATION PASS NO: G-105
FILE: MEDICATION PASS
D. With the exception of self-administered medications, the inmate will be
required to swallow their medication in front of the nurse. Inmates in
locked cells will be expected to bring a cup of water and come to the cell
front to be clearly visible. The officer shall ensure that the cell light has
been turned on and has not been covered.
IV. OFFICER RESPONSIBILITY
An officer shall accompany the medication nurse and be present during
medication pass to directly observe the medication process, maintain order,
and provide assistance, if necessary.
A. The accompanying officer shall not engage in any activity that distracts
him/her from concentrating on the medication pass process.
B. It is the responsibility of the accompanying officer to ensure that the
inmates obey the medication pass rules.
1. Only one inmate at a time is to approach the medication nurse.
2. Inmates are to have legible wristbands. Wristbands shall be
replaced, if necessary. (Refer to C-110/Identification Wristband
[FILE: WRISTBAND].)
3. Inmates are to conduct themselves in an appropriate manner and
not be disrespectful towards the nurse. Any inmate who fails to
follow the rules and/or becomes abusive towards the nurse should
receive a rule violation for failure to comply.
C. Officers shall assist the nurse in supervising the inmates and ensuring
they have swallowed their medication. With the exception of Keep-on-
Person medications, all medications are to be taken immediately and in
front of the medication nurse and officer. (Refer to Section V, as
follows.)
V. DIRECTLY OBSERVED THERAPY (DOT)
A. Nursing staff shall observe inmates taking medications. All medications
administered by the nurse shall be considered and treated as DOT
medications.
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: MEDICATION PASS NO: G-105
FILE: MEDICATION PASS
1. The medication nurse will advise the officer if an inmate is suspected
of cheeking, hoarding, and/or selling medication.
2. Officers will assist the medication nurses in doing a thorough check
for ingestion of a medication. This may include, but is not limited to,
the direct visualization of an inmate's open mouth while lifting his/her
tongue, checking the contents of the inmate's drinking cup, as well
as the inmate showing the nurse/officer his/her open hands.
B. Any inmate suspected of not swallowing their DOT medication shall be
isolated from other inmates. The officer should request assistance to
isolate and search the inmate. Until the assisting officer arrives, the
medication pass will be halted. The medication nurse should make an
entry into the inmate's medical record noting the inmate's attempt to
hoard medication.
C. Officers shall notify medical staff if it is later discovered that an inmate
hoards, cheeks, sells, or fails to swallow their medication. The
discovering officer shall document their discovery in a rule violation
report.
VI. MISSED MEDICATIONS
A. At the conclusion of the medication line, the medication nurse will
identify any inmates who did not present to the medication line to receive
their medications.
B. The medication nurse will advise the officer if an inmate who is
prescribed an essential medication has missed medication pass. The
officer will determine if the inmate is unaware (e.g., asleep, or not
expecting the medication), or otherwise unavailable (i.e., attending an
event outside of the housing unit), and ensure the inmate is notified.
1. Upon request by the nurse, the officer shall check on the welfare
and/or provide escort into the cell of any inmate who fails to respond
for medication.
2. The refusal of the offered medication shall be done with the nurse
present (at the medication pass area) whenever possible.
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: MEDICATION PASS NO: G-105
FILE: MEDICATION PASS
C. If an inmate misses medication pass due to attending an event outside
of the housing unit, the inmate will be located and the medication
provided in accordance with the Medication Pass Logistics chart (refer
to Addendum A).
D. If an inmate is out of the facility at the time of a medication pass, the
inmate should receive their medication upon return. The medication
nurse (or Charge Nurse) is to be advised of the inmate's return, and the
inmate will be routed to the Main Jail 2nd floor to receive their
medication.
VI I. RIGHT TO REFUSE
A. Health care treatment, including medications, shall not be forced over
the objections of a mentally competent inmate, except when permitted
by law (e.g., to prevent infectious disease). A court order is required
before involuntary medical treatment can be administered to an inmate.
B. Inmates who refuse an essential medication will be required to refuse
directly to the medication nurse and to sign a refusal form. The inmate
should be escorted to the medication pass area to refuse in person. Any
deviation to this directive will require the refusal form to be signed by
both the nurse and the officer.
Vill. INJECTABLE MEDICATIONS
Injectable medications shall not be administered through the feed hatches
or cell bars. If an injectable medication needs to be administered, the officer
shall escort the inmate to the clinical space in the housing unit (if available)
or to a clinic where the health care staff can safely administer the
medication.
IX. COURT MEDICATION PASS
A. Medical staff will print an OffenderTrak report that lists all inmates
attending court for the day.
B. Designated medical staff will provide medications to inmates scheduled
for morning court in the following locations and manner:
1. Main Jail — inmates scheduled for early morning transportation will be
routed to the Main Jail 2nd floor to receive their medications prior to
proceeding to court. Medical staff will administer the medication at
the elevator door.
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: MEDICATION PASS NO: G-105
FILE: MEDICATION PASS
2. South Annex and North Annex Jails — designated medical staff will go
to the housing floors and administer medications prior to the inmates
leaving the floor.
X. KEEP-ON-PERSON (KOP) PROGRAM
Inmates may self-administer medications in limited circumstances (e.g.,
KOP medications and medications purchased from commissary). The
Keep-on-Person (KOP) program allows inmates to maintain designated and
approved medications under their control.
A. The KOP program is limited to medications that have been approved by
the Site Medical Director and do not have a recognized abuse potential
or security problem (e.g., nitroglycerin, rescue inhalers).
B. Any medications used in the KOP program must be in the inmate's
possession at all times or provisions must be made for the secure
storage of medication when it is not on the inmate's person.
C. Health care and custody staff are to communicate with each other
regarding any violation of rules regarding self-administration
medications. Medication issues that involve a security or safety issue
(e.g., hoarding medications) shall be documented in a rule violation
report. The Watch Commander shall notify the Charge Nurse.
1. The medications may be removed from the inmate's possession
and/or the inmate may be referred to medical staff for assessment
and modification to the medication regimen (such as discontinuing
medication, or DOT), as appropriate.
2. Custody shall turn over any medication to medical staff and properly
document and photograph the medication for later identification
and/or auditing.
XI. EXCEPTIONS
Although this policy addresses the vast majority of inmates who require
medication, it will occasionally be necessary for inmates to report to the
Main Jail 2nd floor for their medication. Any exception/special circumstances
will be dealt with on a case-by-case basis between the medical provider and
custody staff.
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