Forensic Information

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Standard I-03 prohibits health staff from participating in the collection of forensic information. However, the compliance indicators allow for exceptions, including in the case of sexual abuse, when health staff may gather evidence from the inmate-victim with his or her consent. In our facility, health staff collects forensic information in cases of sexual assault. Is there anything that needs to be in place to allow the health staff to continue this practice while remaining in compliance with the standard?

Standard I-03 Forensic Information does allow for health staff to collect evidence from the inmate-victim with his or her consent. If evidence is collected on-site, then standard B-05 Response to Sexual Abuse elaborates more on the requirements for in-house procedures. One other standard to consider is B-04 Federal Sexual Abuse Regulations, which requires facilities to have written policies and procedures regarding the detection, prevention and reduction of rape consistent with the Prison Rape Elimination Act. [Note: This reply is accurate for both the 2008 and 2014 editions of the Standards, although the standard names used are from the 2014 edition.]
— From CorrectCare Volume 28, Issue 2, Spring 2014

 
 

Health services was asked to obtain blood samples for HIV testing from detainees who were involved in a significant blood exposure with an officer prior to arrest. Once the detainee was booked into the jail, the workman’s comp manager and the local community infectious disease office asked that health services obtain the samples. If health staff were to obtain blood samples from detainees for HIV testing, would there be a conflict of interest with compliance indicator 1a of standard I-03 Forensic Information?

This answer assumes the worker’s comp manager and community infectious disease office wanted the health staff to collect the blood sample with the intention of sharing the results with the officer involved. If so, then the standards that would be involved are J-H-02 Confidentiality of Health Records and J-I-05 Informed Consent and Right to Refuse. The collection of a blood sample to test for HIV is a medical procedure and the results are confidential. Therefore, the inmate would need to consent in writing to the procedure and sign a consent allowing the release of the information to the requesting parties. Standard J-I-03 would apply only if the information being collected may be used against the inmate in disciplinary or legal proceedings.
— From CorrectCare Volume 27, Issue 4, Fall 2013

 
 

We have a federal court security expert who has requested that detention medical staff provide data to security when they perform a presegregation assessment after inmate-on-inmate assaults and similar information when there is an exam following use of force by custody. Is this a violation of the NCCHC standard on forensic information (I-03)? Is there any information medical can provide under these circumstances? I think even asking the inmate to provide a release of information would be coercive.

First we must ask ourselves what is the purpose of conducting a presegregation assessment? What is the purpose of conducting an evaluation after the use of force? Such evaluations are generally performed for the benefit of the patient to ensure that he or she does not suffer from injuries as a result of the altercation. Hence, this medical information needs to be protected in the same manner as any other medical information. NCCHC holds to the same community standard of care when it comes to protecting confidential patient information.

The second question that has to be raised is what “data” is being requested? If it is information that breeches the patient–physician confidential bond, then it should not be released. However, if it is information that notifies security that there is or is not a contradictory reason to place the inmate in segregation, then yes, that is allowed. A patient release of information should be obtained if more information is required (photos, drawings, description of injuries or description of the event).

— From CorrectCare Volume 27, Issue 1, Winter 2013

 
 

Our health services team is clashing with security about collecting forensic information. Our facility is accredited, and we argue that we cannot be involved according to NCCHC standards. We also feel it is a conflict of interest and would interfere with patient relationships. Security claims that certain activities are “medical” and they want the nurses to take blood samples, DNA swabs, etc.

You are correct; standard J-I-03 intends that health staff serve the health needs of their patients, and this means that they should not gather forensic information because of the professional and ethical conflicts in taking actions that (a) are typically done without inmate consent, (b) could lead to adversarial action against the patient and (c) undermine professional credibility.

Some states require that certain forensics-related acts be conducted by health professionals; in those cases, the services should be provided by a staff member who is not involved in that patient’s care or by an outside party. That said, the standard does make an exception in Compliance Indicator 1. To summarize, health services staff may participate in the following circumstances:

  • State law requires a blood sample, so long as the inmate consents and health staff are not involved in punitive action if the inmate refuses to consent
  • A physician orders a body cavity search or blood/urine testing for medical purposes (e.g., to test for alcohol or drugs in the blood)
  • With inmate consent, conducting court-ordered lab tests, exams or radiology procedures
  • With inmate consent, gathering evidence from a victim of sexual assault

Finally, you should educate security officials that many techniques for collecting forensic information do not require health expertise. These include urine testing and oral and buccal swabs for DNA testing.
— From CorrectCare Volume 24, Issue 4, Winter 2010

 
 

Where do we draw the line on what is considered “confidential” patient information? Health services conducted a urine toxicology screen of a prisoner and the results indicated the presence of an illicit drug. Is this protected medical information or should we notify custody? Do we just drop a hint, or do we name names?

Assuming that the test was for clinical purposes (and it should have been, as per standard I-03 Forensic Information), the results should be used for clinical reasons only. You may share with the appropriate officials your concern that the substance may be present in the prison so that they can look into the possible security breach. However, the inmate’s identity must be protected. To avoid conflict or pressure from custody, health services policies and procedures should address the role of health staff in such an event and the warden and custody staff should have a clear understanding of this role. (See A-03 Medical Autonomy and H-02 Confidentiality of Health Records.)
— From CorrectCare Volume 24, Issue 3, Summer 2010

 
 

I work at a detention facility whose function and purpose are defined under state laws. There is some controversy about blood draws here. Only one RN is on site at any given time, and when someone is arrested for driving under the influence, that nurse is asked to draw the inmate’s blood for analysis. We only draw it and give it to the arresting officer; we do not analyze it. One of the RNs thinks that under state standards we are not supposed to draw the blood and is reluctant to do so.

NCCHC is not expert in state regulations or standards. We base our reply on the 2003 NCCHC Standards for Health Services in Jails. Standard J-I-03 Forensic Information prohibits health services staff from participating in the collection of forensic information based on the bioethical principle of protecting the patient-provider relationship. When health staff are involved in collecting information for punitive matters (and which is usually done without an inmate’s consent), the therapeutic relationship with the inmate is jeopardized. The health services staff should protect their ethical boundaries to serve the health needs of their patients first. The credibility of health staff with their patients should never be compromised.

If the state requires that such acts be performed by health professionals, the facility should use the services of outside providers or someone on staff who is not involved in the therapeutic relationship. If neither of those options is possible, health services staff may comply with state laws and take forensic blood samples so long as the inmate gives consent and, if the inmate refuses to participate, health services staff are not involved in any punitive action taken as a result of the refusal.
— From CorrectCare Volume 22, Issue 1, Winter 2008

 
 

Custody staff often seek medical clearance before using pepper spray on an inmate. Does this act of clearance, giving the “yea or nay,” qualify as partaking in a disciplinary proceeding? Does such an act undermine the intent of the forensic information standard? One can argue that if health staff did not participate, it would cause more harm than good (because those with contraindications would be sprayed). However, reasonable people could conclude that any participation undermines the credibility of health professionals.

The answer relates to standards A-08 Communication on Special Needs Patients and I-03 Forensic Information. The responsible physician decides how health services will respond. Usually the physician is the staff member to determine what would prohibit an inmate from being sprayed because of possible negative consequences. The determination may be done at the time of the incident, or it may be done routinely as part of the initial health assessment, with a notation in the same place in each health chart. The wording of the “clearance” should be simply that there is or is not any health contraindication to the use of pepper spray for the inmate. The physician is not giving an order for the spray nor saying that it is OK to use it.

All health and custody staff should be able to reference a written protocol as to any health intervention required after the spray is used. Any inmates who do receive pepper spray are taken to medical staff for appropriate interventions.

You imply that health staff may not participate in disciplinary proceedings. Actually, health staff may consult in disciplinary hearings or decisions provided that they do not make the decision. In such cases, health staff, including mental health staff, should indicate whether any health or mental health condition may have contributed to the behavior in question. Health staff also may alert custody to the potential negative effects on the inmate of the proposed disciplinary action, and to help find appropriate alternate measures if the disciplinary action is contraindicated.
— From CorrectCare Volume 21, Issue 4, Fall 2007

 
 

Standard J-I-03 Forensic Information addresses DNA testing for inmates. But how would NCCHC review situations in which jail staff collect DNA samples for non-inmates as requested by court order? For instance, the court may require that an individual at trial must have his DNA taken, although he is not currently in jail.

The NCCHC standards do not address services for or interactions with non-inmates. We suggest that if you do draw the samples, you do so only with the individual’s consent, just as you would for an inmate. Your system may want to consider buccal DNA sampling, which is easily done by trained nonhealth staff.
— From CorrectCare Volume 20, Issue 3, Summer 2006

 
 

Does NCCHC have a policy or guideline about doing drug screens on intake for inmates suspected of substance abuse problems? Assessment is difficult without testing since drug intoxication and withdrawal often present with mental illness symptoms.

NCCHC standards require that you conduct your clinical practice as you would in any other setting, modifying nonclinical issues as required by the correctional setting but not compromising your clinical guidelines.

Health staff in facilities accredited by NCCHC are often cautious about substance abuse testing, being mindful of standard I-03 Forensic Information and the need to avoid getting into potential adversarial situations with inmates they are trying to treat.

However, your intent is a clinical one: to assess a substance-abusing inmate for diagnostic and treatment planning purposes. An important caution is that the results of such testing are not to be shared with corrections; results should be treated with the same confidentiality as any other blood or urine testing and recorded in the medical record.
— From CorrectCare Volume 20, Issue 2, Spring 2006

 
 

I am the health services administrator at a county jail. We have been asked to draw the blood alcohol test specimens used to determine DUI charges. Can a trained medical technician or phlebotomist draw this, when requested, as part of the intake bloods? This staff member would be permanently assigned to the intake area and would not float to other areas in the medical unit. Two samples would be drawn: The blood alcohol test sample would be given to the officer; the intake sample would be in a separate tube. The inmate would be told the specimen was for DUI and a consent form would have to be signed. I do not think there would be a problem with compliance with standard J-I-03 Forensic Information.

You are correct. Phlebotomists or trained med-techs who only draw blood are not considered to have a therapeutic relationship with the inmates as defined by NCCHC and standard J-I-03. The safeguards you mention need to be reflected in your policies and procedures.
— From CorrectCare Volume 19, Issue 3, Summer 2005