Infirmary-Level Care

Does the infirmary standard require RN coverage of the facility’s infirmary 24 hours per day, seven days per week?

It is important to note that standard F-02 Infirmary-Level Care was updated in the 2018 jail and prison manuals to focus on the level of care provided in a facility, not a physical location. Staffing levels for qualified health care professionals should be based on the number of infirmary-level patients, the severity of their illnesses and the level of care required for each. However, the standard does require that, on a daily basis, a supervising RN ensures that care is being provided as ordered.

One of the most important aspects in determining compliance with this standard is the facility’s definition of the scope of services it provides. The general rule is, the sicker the patients, the higher the skill level and hours of coverage for staff required to attend to them.

— From CorrectCare Volume 32, Issue 4, Fall 2018

We have an infirmary in our jail and custody staff is always stationed outside of the infirmary, in full view through a very large window. Since standard G-03 Infirmary Care requires that patients are always within sight or hearing of a qualified health care professional, would we meet the “within hearing” requirement if we, on occasion, had the infirmary nurse, who carries a radio, work in another section of the infirmary away from any patients? The nurse could be readily be reached by radio by the custody staff who are at the infirmary post and able to fully view the patients.

The Infirmary Care standard requires that patients are always within sight or hearing of a qualified health care professional. The use of an officer to notify health staff of an infirmary patient’s needs does not meet the intent of the standard. Please keep in mind, though, that this applies only to patients admitted to the infirmary and not those in the infirmary area for sheltered housing.

— From CorrectCare Volume 29, Issue 4, Fall 2015

I would like some interpretation and clarification for the standard on infirmary care, and specifically how often the physician must actually see the patients in the jail infirmary. The standard states that the frequency of physician rounds is based on the categories of care provided, but are there some guidelines we could draw from? For instance, should each patient be seen by the physician daily, a minimum of three times per week, etc.?

We do leave it to the responsible physician to determine the frequency of rounding. It depends on the acuity of the cases that are admitted. It doesn’t make sense to require daily rounding by the physician when the patient with a postsurgical gunshot wound is in the infirmary for dressing changes. Nor would it make sense to require daily rounds when the physician provides only 20 hours a week in the jail. So the answer is that the “frequency of physician rounds is specified based on the categories of care provided.” Some facilities use midlevel providers, such as a nurse practitioner or physician assistant, to conduct daily rounds, with the physician rounding three times a week or even once a week. This approach would be fine.
— From CorrectCare Volume 24, Issue 2, Spring 2010

I was wondering if a history and physical is required as part of the infirmary admitting order, under the G-03 Infirmary Care standard?

No. A patient may have just had a health assessment prior to being placed in the infirmary, so an additional history and physical would not be required. An infirmary order should include the admitting diagnosis, medication, diet, activity restrictions, diagnostic testing required, frequency of vital sign monitoring and other follow-up (Compliance Indicator 8a). Admission to and discharge from the infirmary should occur only on the order of a physician (or other clinician where permitted by virtue of his or her credentials and scope of practice).

— From CorrectCare Volume 23, Issue 2, Spring 2009

We operate an infirmary and have a supervising registered nurse on every shift. Is this what is intended by the standard?

In standard G-03 Infirmary Care, Compliance Indicator 4 requires that “a supervising registered nurse is on site at least once every 24 hours” (emphasis added). A supervising RN need not be present on every shift.

— From CorrectCare Volume 22, Issue 3, Summer 2008

Please clarify your standards concerning inmate workers. In C-06, Compliance Indicator 3 states, “Inmates do not provide direct patient care,” but the Discussion says they may assist other inmates in activities of daily living, such as ambulation, bathing, dressing, feeding and toileting. In the community, ADLs are direct patient care for certified nursing assistants. How do you define direct patient care?

In general, NCCHC defines direct patient care as health interventions or services that in the free world usually are provided only by appropriate health professionals who have the necessary clinical skills. Inmate workers are not to take the place of health staff. However, ADLs can be provided on different levels and, depending on the patient’s status, may or may not require clinical skills.

In the free world, when assistance in ADLs is part of services provided by family members, volunteers, paraprofessionals, etc., in what are considered non-inpatient settings (home, assisted living situations, hospice care, etc.), it generally falls under the category of nonskilled nursing care. But when a patient is hospitalized, those same ADLs become part of the skilled nursing care provided by nurses of various levels according to the tasks needed.

Similarly, different levels of ADL assistance may exist in correctional settings. Here’s how NCCHC distinguishes between these levels to assess compliance with the intent of the relevant standards (C-06 Inmate Workers and G-03 Infirmary Care). When the patient is housed in general population (defined as any noninfirmary setting, such as medical housing, sheltered housing, segregation, hospice, etc.), trained inmate workers (known by various names in different facilities) may provide the ADL assistance. However, if the patient is admitted to an infirmary on infirmary status, the ADLs become part of the skilled nursing care required and inmate workers may not provide the assistance.

Some infirmaries may house patients who are not classified as on “infirmary status.” In such cases, it is possible for an inmate worker to assist one patient living in the infirmary who is there on sheltered care status, but not assist another patient who is there to receive infirmary care.

— From CorrectCare Volume 19, Issue 1, Winter 2005

In the infirmary, may inmate-orderlies assist patients with activities of daily living such as bathing, brushing teeth, transferring and feeding? Do the NCCHC standards allow this as long as the orderlies are directly supervised by nursing? If so, does it have to be an RN or can it be an LPN? I could not find anything about this in our state regulations.

The standards governing this matter are C-06 Inmate Workers and G-03 Infirmary Care, both of which are essential. (They are the same for prisons, jails and juvenile facilities.)

Infirmary care is skilled nursing care within the facility’s defined scope of practice. In the correctional environment it is considered inpatient care. It differs from outpatient care for those who may need sheltered housing or observation.

When a patient is on infirmary status, the usual activities of daily living (e.g., bathing, feeding, dressing) are within the nursing discipline’s scope of practice. Inmate orderlies, assistants or whatever they are called may not provide such assistance to patients, whether or not the inmate workers are under the direct observation of nursing staff. It does not matter how well they are trained. If an inmate needs skilled nursing care, assistance with these tasks requires the attention and assistance of nursing staff.

However, trained inmate workers can assist other inmates in general population or other outpatient housing areas with these tasks. In settings other than an infirmary they are providing assistance that parallels home care in the community. They also may assist inmates who happen to be housed in the infirmary, but who are not on inpatient status.

That said, it may be confusing to staff, patients and inmate-workers as to who’s who in the infirmary, so most clinicians prefer that such assistance by inmate-workers not take place in the infirmary.
— From CorrectCare Volume 18, Issue 3, Summer 2004; updated February 2010.

Given the national nursing shortage, could a paramedic take the place of an RN in an infirmary for the night shift? Paramedics can do assessments, which LPNs cannot.

In all three sets of standards (jail, prison and juvenile), the basic requirement for infirmary staffing is that the patients are within sight or sound of a health staff member at all times. This staff member does not have to be an RN, but must be someone authorized by the responsible physician who can meet the needs of the patients on a particular shift. The patients’ acuity levels and the types of services they need will determine the level of staff required. For example, if IVs are being given and only RNs may give this level of care in your state, then an RN would be needed. If the patients’ acuity level is lower and the services they require are within the scope of practice of a paramedic, a paramedic could work on that shift. In all cases, however, an RN must be on site in the infirmary at least once every 24 hours to review care, the functioning of the infirmary, etc. Whether the paramedic is a member of the health staff also matters. Officers who happen to be paramedics but are on duty functioning as officers could not do “double duty” under this standard.

— From CorrectCare Volume 16, Issue 3, Summer 2002

Infirmary-Level Care

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