Opinion ID: 4387846
Heading Depth: 2
Heading Rank: 2

Heading: Withdrawal Initial Screening & Treatment Plan

Text: Kohl also filled out a Withdrawal Initial Screening & Treatment Plan. In the first section of the form, labeled “Subjective,” Kohl noted that Cross had consumed his last alcoholic drink, half a beer, three hours prior to his admission at the facility. Withdrawal Initial Screening & Treatment Plan, R. 103-2, Page ID # 660. She also noted that he had taken two types of opioids, Xanax and Lortab, and she marked “uk” (unknown) under “last opiate use.” Id. This section of the form also included a checklist in which Kohl marked “no” for both “Past History of Withdrawal” and “Present Withdrawal Complaints.” Id. Under “History of Psychiatric Problems,” she checked “yes,” and she noted that Cross had a history of bipolar disorder, depression, and anxiety. Id. Under “Past Medical History,” she wrote that he had “HTN [hypertension].” Id. For the second section of the form, labeled “Objective,” Kohl added information regarding Cross’s vitals, including his temperature, pulse, and blood pressure. Id. A sub-section headed “Level of Consciousness” contained a checklist with a range of “Alert & Responsive” (the highest level of consciousness) to “Non-Responsive” (no consciousness). Id. Kohl checked “Alert & Responsive.” Id. In the “Orientation” sub-section, she marked “Person,” “Place,” and “Time.” Id. She also noted Cross’s fingerstick blood sugar. 3 Case No. 18-5224, Blaine v. Louisville Metro. Gov’t In the third section of the form, labeled “Assessment,” under “Presumed Substance Abused,” Kohl assigned Cross a score of “<10 = mild” on the CIWA-Ar scale.1 Id. Under the type of risk that an inmate’s condition exhibits, the form included a checklist with a range of “Risk for Withdrawal” (the lowest risk) to “Severe Withdrawal” (the highest risk). Id. In the case of severe withdrawal, the instruction accompanying the checklist stated, “Immediate provider notification required.” Id. For less severe withdrawal, other instructions were included; for example, for mild withdrawal, the instruction stated, “Notify provider within 2 hours—Monitor at least every 8 hours.” Id. Kohl marked “Risk of Withdrawal,” which was accompanied by the instruction to “[m]onitor at least every 8 hours.” Id. The “Risk of Withdrawal” instruction did not include any directions to notify a provider. See id. In the last section, labeled “Plan,” Kohl checked “Orders received from provider—Note on order sheet.” Id. Within this section, Kohl checked a box indicating that Cross should be observed every eight hours for five days and continue to be reoriented. She also marked “Bottom Bunk assignment. Continue to monitor for falls,” “Notify security to observe patient for withdrawal symptoms,” “Every visit—encourage fluids. Ask patient if he is urinating,” and “Provide for comfort.” Id. For Cross’s mental health information, Kohl marked “Refer to MH if indicated based on Mental Health Intake Screening,” and she marked this as “Non-emergent.” Id. She also checked “Continue to monitor for suicide risk, depression[,] and psychiatric co-morbidities.” Id. Finally, she checked “Initiate Substance Abuse Withdrawal Flowsheet.” Id. The bottom of the form stated in all caps and in bold to “[n]otify physician immediately if severity score increases any time during withdrawal.” Id. 1 The Clinical Institute Withdrawal Assessment for Alcohol (“CIWA-Ar”) is a ten-item scale used in the assessment and management of alcohol withdrawal. University of Maryland School of Medicine, CIWAAr, available at https://umem.org/files/uploads/1104212257_CIWA-Ar.pdf. 4 Case No. 18-5224, Blaine v. Louisville Metro. Gov’t