"As Clinical Director at FCI Fort Dix Dr Lopez de LaSalle failed to follow prescribed comprehensive medical treatments as described below. Her failure to follow prescribed remedy actions also violates the program statement of the institution. These acts caused more serious, permanent injury and deformation to the claimant.
PROGRAM STATEMENT:
7. DESCRIPTION OF MAJOR DUTIES/RESPONSIBILITIES
a. Clinical
oversight of the
including:
Director
clinical
(CD) .
care
The CD is responsible for
provided at the institution,
Reviews applications and credentials for membership to the
medical staff;
Establishes practice agreements;
Implements and monitors in-house Continuing
Professional Education (CPE) training;
Maintains the quality of health records; and
Evaluates patient care through an ongoing program that
identifies problems and their resolution.
The CD will maintain a close working relationship with local
community hospitals and health care providers contracted by the
institution. The CD will make the community hospital aware that
care provided to inmates will be authorized in advance by the
institution, not at the inmate patient's request.
During outside hospitalization of an inmate, a physician,
normally the CD, will document on the SF-600 contact with the
attending physician to ensure that:
They remain fully informed of the patient's condition;
The care provided relates to the diagnoses on admission
and any complications that develop; and
! Every effort is made either to return the inmate to the
institution or transfer him/her to a Medical Referral
Center (MRC) as soon as the patient's condition allows.
The CD will review, initial, and date all outside hospital and
operative reports.
The CD is the clinical supervisor for Mid-Level Practitioners
(MLPs) and must provide input into the performance evaluations
concerning these individuals with theHSA or AHSA. However, the
HSA or AHSA are considered the primary supervisors of the MLPs
for administrative issues. The CD provides clinical supervision
for other clinical personnel (i.e., nurses, Emergency Medical
Technicians (EMTs), etc.). In institutions without an assigned
Bureau physician, the contract CD will perform clinical
supervision. The CD may designate a staff physician to provide
all or part of this clinical oversight, but such delegations must
be clearly defined.
! Staff physicians providing clinical oversight
other clinical personnel, will provide input
clinical care Performance Log entries.
for MLPs, and
for quarterly
The CD will ensure new health care providers are properly
trained and oriented prior to assignment to independent duty.
At a minimum, the CD or contract physician will provide the
following supervisory functions for MLPs:
(1) Review at least two health records, per provider, of
the patients evaluated by the day shift clinical staff (normal
work week) at the end of each workday. If this review is not
practical at the end of the workday, the review should take place
the next possible workday.
This review, when necessary, will include a discussion of the
case with the treating MLP and a treatment plan review.
The reviewing physician will initial and date those charts
reviewed.
(2) On the next normal workday, review all health records
of those cases clinical staff evaluated on the evening and
morning watch, weekend, and holiday shifts. If this review is
not practical, it should take place the next possible workday.
! This review,
case with the
review.
when necessary, will include a discussion of the
appropriate clinical staff and a treatment plan
The reviewing physician will initial and date those charts
reviewed.
When questions arise during record reviews, the physician
responsible
discussion
possible.
for clinical supervision will arrange a face-to-face
with the appropriate clinical staff as soon as
(3 )
attention.
Be available to consult on cases requiring urgent
(4) Review all unusual and interesting cases with clinical
staff individually, at staff meetings, and other appropriate
times.
_______________________________________________________________
On June 15, 2010,
the petitioner suffered what was originally diagnosed as a "relatively
minor injury to his right lower extremity". As
part of the treatment for this injury, a cast was applied from just
below his right knee to the joints of his toes and the Petitioner was
issued crutches for mobility.
Shortly after this cast was applied, the Petitioner developed
a Staphylococcus infection in his right leg and foot that was so severe,
he required hospitalization at st. Francis Medical Center, where he was
treated with intravenous antibiotics.
The original course of treatment called for the Petitioner to
remain in a splint until his wounds from the infection improved. This
splint was not designed to be weight bearing. After his wounds
"stabilized" the Petitioner was to be placed in a "short leg cast".
However, in the words of the Petitioner's Attending Physician, Dr. Mark
J. Pressman, "Unfortunately, the [Petitioner] was discharged prior to
this being performed. The Petitioner asserts that this premature
'discharge was an act of deliberate indifference by an unknown employee
or employees of the Bureau of Prisons. This act went against the
medical advice of the Petitioner's Attending Physician, and intentionally
interfered with a prescribed course of treatment. Such actions were
specifically proscribed by the Supreme Court's holding in Estelle
(Supra). The Petitioner does not know the identity of the Bureau of
Prisons employee or employees who were responsible for ordering his
premature discharge, but asserts that at least Dr. Lopez is responsible.
After his premature discharge from St. Francis, the Petitioner was
returned to FCr Fort Dix, where he waited for over an hour in the
Lieutenant's Office for someone from Medical to review his discharge
instructions and to bring him his crutches. When no one came after an
hour, the Petitioner was driven back to his Unit and was told to pick
up his crutches the next day. Because he was not furnished with his
crutches or a wheelchair, the Petitioner had no alternative but to put
weight on his right leg to navigate himself. Later that evening while
stepping into the shower, the Petitioner suffered a more severe fracture
of his right leg.
Had either the prison guards who escorted the Petitioner back
from St. Francis or the Fort Dix Medical Staff adequately planned for
his return, this injury could have been avoided simply by having his
previously issued crutches readily available to him upon his return.
The Petitioner asserts that as the Bureau of Prisons employees
disregarded the consequences of their actions, they should be found
liable for violating his Eighth Amendment rights pursuant to the
Supreme Court's holding in Connick (Supra).
The Petitioner further asserts that the Bureau of Prisons employees
who violated his rights include but are not necessarily limited to
Abigail Lopez de Lasalle, M.D. the Medical Director of Fort Dix who
failed to adequately plan for the Petitioner's return, the on-duty
medical officer who failed to review the Petitioner's discharge
instructions and provide him with crutches or a wheelchair and the
on-duty Lieutenant and Compound Officers who allowed him to return to
his Unit without being seen by medical personnel.
After sustaining this more severe fracture, the Petitioner was
re-admitted to St. Francis where he underwent surgery to repair this
fracture. The fracture was so severe that it required placement of the
permanent metal plate in the Petitioner's leg. Prior to this surgery,
an X-Ray showed that he had "significant angulation" in his right leg
(See Exhibit G). However, even after the surgery, an X-Ray showed that
he still had "mild angulation" in his right leg.
Approximately one month after the surgery, on August 5, 2010, the
Petitioner was examined by his Orthopedic Surgeon. This exam took place
at Fort Dix, and during the exam, a "short leg cast was placed on the
Petitioner's right leg" and a request was made for another exam in eight
weeks. However, this follow-up exam did not take
place until January 27, 2011, three months after the scheduled
examination date. The Petitioner asserts that this delay contributed to
the current condition of his right leg.
Whether the "mild angulation" which causes the Petitioner to
walk with a pronounced limp was the result of the delay in this followup
examination is unknown to the Petitioner. What is known to the
Petitioner is that the Bureau of Prisons has refused further treatment.
In addition to the January 27th examination, the Petitioner was
also examined by his Orthopedic Surgeon on March 24th and May 26th, 2011.
After the May exam, it became clear to the Petitioner that the Bureau
of Prisons planned no additional treatment on his deformed leg. He
therefore began the Administrative Remedy Process; however, he was
denied at every level.
The Petitioner asserts that this refusal is yet another example
of the Bureau of Prisons deliberate indifference to his injuries.
The deformity in his right leg and his resulting limp, are so obvious
that even "lay" people can recognize the problem, thereby meeting the
Third Circuit's "serious" standard as defined in Monmouth (Supra).
The delay in providing further treatment for this injury now extends
for almost two years which should easily meet the standard of denying
medical care established by the Supreme Court in Estelle (Supra). The
Petitioner asserts that the responsibility for this delay rests with
the Fort Dix Medical Director, Dr. Abigail Lopez de Lasalle."