DRAPER – Two employees have been fired and department action taken against three others at the Utah State Prison in Draper related to an inmate death at the prison in April.
On Thursday, the Utah Department of Corrections served termination notices to a physician assistant and a supervising nurse, according to a press release. A second supervising nurse was demoted, and a registered nurse received a 40-hour suspension. Additionally, the director of the prison’s Clinical Services Bureau will return to work but in the capacity of a medical doctor.
Four of the employees have been on administrative leave in the wake of the inmate’s death, according to the press release.
Between April 3 and April 5, all the affected employees had responsibility in some capacity for seven dialysis patients being treated at the prison’s on-site Dialysis Center, which is operated by University of Utah Health Care.
On April 5, prison inmate Ramon C. Estrada, 62, died after he and the six other inmates did not receive their scheduled dialysis during the period of April 3-5. A preliminary investigation indicated this failure of medical personnel to provide dialysis services could have been a contributing factor in Estrada’s death.
Technicians for South Valley Dialysis, which is the University of Utah’s contracted provider, failed to come to the prison April 3-5 due to a scheduling error, the press release said, which resulted in Estrada and the other inmates not receiving their needed dialysis.
The Utah Department of Corrections said in the press release:
The Department implemented several measures immediately following Estrada’s death to improve communication with and oversight of the dialysis contract provider. Since then, the Department and South Valley Dialysis have added additional measures to improve care and tracking of inmates receiving dialysis. These include provision of weekly summary sheets of inmate dialysis treatment; a procedure for monitoring and tracking inmates who refuse or stop scheduled dialysis treatment; sharing of treatment protocols and notes/orders between the Department and South Valley Dialysis; holding quality assurance protocol reviews every six months; and mandatory joint training of Department and South Valley Dialysis staff who work in the Olympus Facility (where the dialysis clinic is located).
The state medical examiner’s office has not yet completed its autopsy report on Estrada, according to the press release.
The Utah Department of Health is conducting an external review of the prison’s dialysis operation and also has access to two additional, separate investigations: an internal investigation conducted by the Utah Department of Corrections Law Enforcement Bureau and an outside audit conducted by Wellcon, a nationally recognized health care consulting firm.
The Wellcon audit examined the prison’s dialysis program; its overall health care delivery program, as it relates to dialysis patients; and delivery of mental health services to these inmates. The final review is expected within 90 days, the press release said.
The Utah Department of Corrections is not releasing the names of the disciplined employees.
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