EXHIBIT A - American Civil Liberties Union...discharge planning. The Armor patient population consists of inmates with serious mental illness (SMI) and other mental health diagnoses,

EXHIBIT A

UNITEDSTATESDISTRICTCOURTSOUTHERNDISTRICTOFFLORIDA

OllieCarruthers,etal.,vScottIsrael,etal.CaseNo.76-6068-CIV-MIDDLEBROOKS

INITIALREPORTOFJOINTMENTALHEALTHEXPERTKATHRYNABURNSMD,MPH

Iwasappointedtoserveasthejointmentalhealthexpertinaccordancewitha

SettlementAgreement(“Agreement”)intheabovecaptionedcase.Iwaschargedwith

assessingoperationsandconditionsattheBrowardCountyJailsandtorenderanopinion

regardingwhethertherearecurrentandongoingviolationsoffederalrightsaspertaining

toinadequatementalhealthcareandfacilities.IfIbelievetherearecurrentandongoing

violationsoffederalrights,Iwaschargedwithprovidingthespecificbasisforeachfinding

anddraftanImplementationPlandesignedtoremedytheviolation(s).

Ioriginallydraftedareportandimplementationplananddistributedthemtothe

parties.Ireceivedtheirresponsestothereportandcarefullyconsideredtheirfeedback

andsuggestions.IincorporatedtheirinformationandeditedthemainbodyofreportasI

deemedappropriate.Inthecourseofthisreviewandeditingprocess,thepartiesbeganto

discussandnegotiatethetermsoftheimplementationplanusingtheinitialdraftand

subsequentiterationstonegotiateanagreement.Subsequently,Ihaveremovedthe

portionofthisreportthatdealtwithanimplementationplanandsupportedtheeffortsand

ultimatelytheadoptionofajointlyagreeduponimplementationplan.Consequently,this

documentrepresentstheInitialMentalHealthReportwhichprovidessupportingrationale

CarruthersvIsraelMentalHealthReport08-08-18

2

forthetermsoftheImplementationPlan.Itrepresentsthestateofthejailandmental

healthservicesatthetimeofthedevelopmentoftheImplementationPlanandthebaseline

conditionsuponwhichtheagreeduponactionsandimprovementswillbemeasured.

Inordertoassessoperationsandconditionsatthejails,Iorganizedmyinquiry

aroundthesixcriteriaforconstitutionallyadequatepsychiatriccarethatwereoriginally

articulatedinRuizvEstelle(1980)1becausetheyformausefulframeworkforthe

discussion.Thecriteriaare:

• Systematicscreeningandevaluation

• Treatmentthatismorethanmereseclusionorclosesupervision

• Participationbytrainedmentalhealthprofessionals(inappropriatenumbers)

• Safeguardsagainstpsychotropicmedicationsthatareprescribedindangerous

amounts,withoutadequatesupervisionorotherwiseinappropriatelyadministered

• Accurate,completeandconfidentialrecords

• Suicidepreventionprogram

Itisworthnotingthatwhilethesesixitemsaredescribedseparatelyforpurposesof

reviewanddiscussion,theseparationissomewhatartificialinthattheyarenotonly

relatedbutactuallyentwinedwithoneanother.Forexample,systematicscreeningand

evaluationisnotpossiblewithoutparticipationbyanadequatenumberoftrainedmental

healthprofessionalsandtherecordsmustbeaccurateandcompleteinordertoprovide

treatmentinterventionsandmeasureprogress.Separatingthecomponentsissimplya

1RuizvEstelle,503F.Supp.1265(S.D.Tex1980)


3

waytoorganizethereviewanddiscussionandIwilladdresseachoftheminthesectionsof

thereportthatfollow.

TheBrowardCountySheriff’sOffice(BSO)operatesfourjailfacilitieshousing

inmates:MainJail(MJ),NorthBrowardBureau(NBB),JosephV.ConteFacility(Conteor

JVCF)andPaulReinDetentionFacility(PRF).Thefacilitiesdiffersomewhatintheir

missionsandthetypesofinmateshousedinthem.Forpurposesofthisreport,Iwillfocus

onthejailsandmissionsmostrelevanttothedeliveryofmentalhealthcaretoinmates

withseriousmentalillnessthoughIrecognizethateachofthefacilitiesservesother

equallyimportantandcriticalfunctionsfortheBSOandBrowardCounty.TheMJservesas

thebooking/intakefacilityfortherestofthejailsandthusservesakeyfunctionin

screeningandassessment,crisisintervention,suicideprevention,anddetoxificationfrom

alcoholanddrugs.MJoperatesalargeinfirmaryandalsohousesmaximumsecurity

inmates,administrativesegregationinmatesandyouthfuloffendersamongitsmany

missions.NBBisidentifiedasthefacilitytoprovidehousingandresidentialmentalhealth

caretoinmatesinneedofsuchcareduetotheirconditionand/orfunctionalimpairment

whichpreventstheirplacementingeneralpopulationhousingunitsatotherfacilities.

ConteandPRFhousegeneralpopulationinmatessomeofwhomreceiveprogramming

fromBSOstaffand“outpatient”psychotropicmedicationmanagementfromArmor

CorrectionalHealthServices(Armor)staff.(Armoralsoprovidesmentalhealth

assessmentsandcrisisinterventionasnecessaryatthe“outpatient”jailsbuthastheability

torequesttransferofinmatestoNBBforhousingandadditionaltreatmentifnecessary.)


4

ThejailshavebeenaccreditedbytheNationalCommissiononCorrectionalHealth

Care(NCCHC)since1998andreceivedreaccreditationin2015.Theyarescheduledforre-

accreditationin2018,inaccordancewiththeregularNCCHCthree-yearreaccreditation

cycle.TheNCCHCaccreditationisforallhealthservices,including,butnotspecificto

mentalhealthservices.ThejailshavealsobeenaccreditedbytheAmericanCorrectional

Association(ACA)since1996andunderwentare-accreditationauditinNovember2016,

receivingreaccreditationinJanuary2017.Thejailshavealsobeenaccreditedbythe

FloridaCorrectionsAssociationCommission(FCAC)since1998,receivingreaccreditation

inOctober2015.HavingbeenaphysiciansurveyorfortheNCCHCandinvolvementwith

ACAaccreditationinmyownfacilities,Iunderstandthesetobeimportantandhelpfulin

termsofprovidingajudgmentontheeffectivenessandefficiencyofcorrectional

operationsandhealthcarebycomparingafacilityorfacilitiesprocessestoasetof

standardsdevelopedbytheaccreditingbodyandprofessionalorganizations.However,the

accreditingorganizationsthemselvesarealsoclearthatwhilesuchaccreditationishelpful

andmayprotectagainstadverseeventsandreduceliability,theyalsoexplicitlyrecognize

thataccreditationdoesnotguaranteeorrepresentconstitutionaladequacyofafacilityor

system.

Medicalandmentalhealthcareprovidedtoinmateswithseriousmentalillnessand

othermentalhealthdiagnosesconfinedintheBrowardCountyJailsisprovidedthrougha

contractbetweentheBSOandArmor.Armormentalhealthstaffconsistofpsychiatrists,

advancedregisterednursepractitioners(ARNP),physicianassistants(PAs)andcounselors

(master’spreparedmentalhealthproviders.)TheBSOalsohasanumberofmentalhealth


5

professionalsatsomeofthejails(BSOProgramStaff)thatprovidepsychosocial

interventions,groupandcounselingandsubstanceabuseprogramming(SAP)tothe

inmatepopulation.BSOProgramstaffmayalsoprovidesomeindividualcounselingbut

theirprimaryinterventionsareprogramsprovidedtogroupsofinmates.Thereissome

overlapinthatbothArmormentalhealthstaffandBSOProgramStaffmayservethesame

inmateorgroupofinmates,butArmorisprimarilyresponsibleforscreening,evaluation,

psychotropicmedicationmanagement,crisisintervention/suicidewatchassessmentsand

dischargeplanning.TheArmorpatientpopulationconsistsofinmateswithseriousmental

illness(SMI)andothermentalhealthdiagnoses,theoverwhelmingmajorityofwhomare

prescribedorrequirepsychotropicmedicationfortheircondition(s).Thepersonsserved

byBSOProgramStaffmayormaynotbeprescribedorrequiremedicationandmayormay

nothaveamentalhealthdiagnosis.ItisimportanttonotethatBSOProgramStaffcannot

serveinmatesthataresofunctionallyimpairedbysymptomsofseriousmentalillnessthat

theyareunabletoparticipateinprogramsduetotheacuityoftheirillness.TheBSO

ProgramStaffareconsequentlyabletoserveonlyaportionoftheinmateswithSMI–both

inoutpatientfacilitiesaswellasintheresidentialMentalHealthUnit(MHU)atNBBasa

resultofinmateillnessacuityaswellasstaffinglevels,bothofwhicharediscussedmore

fullyinthesectionsthatfollow.

Deputiessupervisinginmatesinintake,segregationunits,theresidentialmental

healthunitsatNBBandotherprogramareasreceivea40-hourCrisisInterventionTeam

(CIT)trainingandparticipateinannualrefreshercoursesaswell.TheCITprogramfor

correctionalfacilitiesbettertrainsofficerstoidentifymentalhealth-basedproblems


6

promotingearlyreferraltomentalhealthstaff.CITtrainingalsoenhancescommunication

skillsfordealingwithpersonswithmentalillnessandusedbyofficersduringpsychiatric

emergenciestominimizeoravoidtheuseofforcewhichreducesinjuriestoinmatesand

staff,avoidsadverseincidentsandimprovesinmatementalhealthoutcomes.

Qualifications IamaMedicalDoctorlicensedinthestateofOhio.IamBoardCertifiedinthe

practiceofGeneralPsychiatryandForensicPsychiatry.IalsohaveaMaster’sDegreein

PublicHealth.IamaDistinguishedFellowoftheAmericanPsychiatricAssociation.Iam

BoardCertifiedbytheAmericanBoardofPsychiatryandNeurology(ABPN)inGeneral

PsychiatryandForensicPsychiatry.IhaveservedbothasaBoardExaminerfortheABPN

generaladultpsychiatryoralexaminationandontheforensicpsychiatrycommittee

writingexaminationquestionsandpreparingtheforensicpsychiatryboardexaminations.

SinceJuly2013,IhaveservedastheChiefPsychiatristfortheOhioDepartmentof

RehabilitationandCorrection,apositionIalsoheldfromMay1995toAugust1999.Ihave

providedpsychiatriccaretoinmatesinjailsandprisonsinadditiontoholding

administrativeposts.IhavebeenaphysiciansurveyorofhealthservicesfortheNational

CommissiononCorrectionalHealthCareinthepastandamaCertifiedCorrectionalHealth

Professional.Ihavewrittencorrectionalmentalhealthpoliciesandproceduresand

developedstaffingplansforcorrectionalmentalhealthservices.Ihavewrittenandbeen

publishedinjournalsandpeerreviewedtextbooksontopicspertainingtocorrectional

mentalhealthcare.


7

Ihaveservedasbothaconsultingandtestifyingexpertwitnessinlegalcases

involvingcorrectionalmentalhealthcare.Ihaveconductedassessmentsoftheadequacyof

mentalhealthcareinindividualcorrectionalfacilitiesaswellasstatesystemsincluding

Massachusetts,Pennsylvania,Indiana,Illinois,OhioandAlabama.Ihavealsobeena

monitoringexpertincorrectionallitigationcasesincludingColemanvBrown(California),

DisabilityRightsNetworkofPennsylvaniavWetzel(Pennsylvania),DisabilityLawCenterv

MassachusettsDepartmentofCorrection(Massachusetts),GravesvArpaio(Maricopa

County,Arizona)andCartyvMapp(USVirginIslands).

Acopyofmycurrentcurriculumvitae,whichincludesalistofallpublications

authoredandalistofallcasesinwhichIhavetestifiedattrialordepositionduringthepast

fouryearsisattachedtothisreport.

Informingmyopinions,Ihavereliedonmytrainingandexperienceingeneral

psychiatry,forensicpsychiatryandcorrectionalpsychiatry:Ihaveprovidedpsychiatric

caretoinmatesinjailsandprisonsandsupervisedthecareprovidedbyothermental

healthprofessionals;Ihaveexperienceinadministrationandoversightofcorrectional

mentalhealthcareandIhavevisiteddozensofcorrectionalfacilitiesandinterviewedstaff,

administratorsandhundredsofprisonersanddetainees.Iamfamiliarwiththestandards

forthedeliveryofmentalhealthcarepromulgatedbytheNationalCommissionon

CorrectionalHealthCare(NCCHC)aswellaspositionstatementsandguidelines

promulgatedbyotherprofessionalorganizationsincludingtheAmericanPsychiatric

Association.


8

Sourcesofinformation Inconductingtheassessmentandformingmyopinions,Iconsideredinformation

gatheredandobservationsmadeduringaseriesofsitevisitstothejailfacilities.Sitevisits

consistedoffacilitytours,meetingswithBSOstaff(includingProgramStaff)andArmor

mentalhealthstaff,observationofmentalhealthhousingandprogramareas,infirmariesat

MJandNBB,reviewsofmedicalrecords,interviewswithindividualinmates,reviewsof

variousdocumentsincludingjailhousingplans,organizationalchartsandstaffingrosters,

BSOprogramschedules,caseloadrostersandlogsmaintainedinthecourseofbusiness

includinghospitaltransfersandreturns,crisis/suicidewatches,restraintlogsandmental

healthappointmentschedules.

Ivisitedeachofthejailfacilitiesontheindicateddates:

• MainJail(MJ)–August22,2016;February9,2017;andMay15,2017

• NorthBrowardBureau(NBB)–August23,2016;February6,7and8,2017

• PaulReinFacility(PRF)–May17,2017

• JosephVConteFacility(JVCF)–May16,2017

Casesummariesofinmatemedicalrecordsreviewed,datesofreviewsand/or

interviews(whereapplicable)areappendedtothisreport.(TheAppendixalsoincludes

reviewsofmedicalrecordsrequestedofinmatesthatcommittedsuicideinthejailandjail

deathsofinmatesonthementalhealthcaseload.)Whileafewinmatecaseexamplesare

citedinvarioussectionsofthisreport,theAppendixcontainsmorecompletesummariesof

allinmateinformationreviewedinthecourseofmyreview.Eachsummaryisfollowedby


9

myassessment/conclusionsinitalics.Thecasescitedinthevarioussectionsofthereport

aresimplyillustrativeofacertainpointbutnottheonlyinstanceinwhichcertain

observationsand/ordeficienciesexisted.

Inadditiontofacilityvisitsandreviewofdocumentsonsite,Ialsorevieweda

numberofadditionaldocumentsthatincluded:

• CarruthersvIsraelSettlementAgreement

• ArmorCorrectionalHealthServices,Inc.Policies&Procedures

A- GovernanceandAdministration

B- ManagingaSafeandHealthyEnvironment

C- PersonnelandTraining

D- HealthCareServicesandSupport

E- InmateCareandTreatment

F- HealthPromotionandDiseasePrevention

G- SpecialNeedsandServices

H- HealthRecords

I- Medical/LegalIssues

• BSOStandardOperatingProcedures:

5.16UseofRestraints

5.21EmergencyRescueTool(revised6-9-15)

7.13InmatePrograms

7.30AdministrativeSegregation

7.31DisciplinarySegregation(revised11-30-15)

8.3GeneralPolicies–HealthCare(revised11-30-15)

8.4InmateHealthCareConsent(revised6-28-06)

8.5HealthCarePersonnel(revised)

8.6HealthCareServices(revised9-19-07)

8.7InmateHealthRecords(revised11-30-15)


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8.8LevelsofCare

8.9ManagementofChemicalDependency

8.24HealthScreeningsandExaminations(revised11-30-15)

8.27InmateMentalIllness&DevelopmentallyDisabledPolicy

8.30SuicidePreventionandIntervention–HealthCare(revised3-3-16)

• AgreementBrowardSheriff’sOfficeandArmorCorrectionalHealthServices

(February1,2014-January31,2017);amendmentforimplementationofelectronic

medicalrecordssystem(January21,2015);secondamendmentextendingtermsof

agreementforanotheryear(February9,2017)

• HospitalServicesAgreementbetweenArmorCorrectionalHealthServicesand

NorthBrowardHospitalDistrict

• AnexpertreportofJeffreyLMetzner,MDdatedMarch5,2006relatedtothe

deliveryofmentalhealthcareatthejailsmuchearlierinthislitigation.

• CommissiononAccreditationforCorrectionsStandardsComplianceReaccreditation

Auditsconductedinthefallof2013ofeachofthejailfacilities(MJ,NBB,JVCFand

PRF)

• ArmorCorrectionalHealthServicesQualityAssurance/QualityImprovement

reportsand/orauditsforthepasttwoyears2

• SpecialNeedsManagementMeetingMinutes

2ThisdidnotincludesomeexpectedinformationsuchasseveraloftheitemsoutlinedintheArmorContinuousQualityImprovementpolicyincludingincidentreports,severalMorbidity/Mortalityreportsandpsychologicalautopsies,suicidepreventioncommitteemeetingminutesandprocessandoutcomestudies.Iwastoldthattherewerenoprocessoroutcomestudiesspecifictomentalhealthconductedduringthetwelve-monthperiodforreviewwhichexplainstheirabsencefromthematerialsproduced.Iwasprovidedassurancethatallotheravailableinformationrequestedwasproducedandproceededonthisassurance.


11

MainJail(MJ)Sitevisits:August22,2016;February9,2017;May15,2017

TheMainJail(MJ)servesasthecentralpointofintakeforthejailsandbooking,

intake,healthandmentalhealthscreeningandassessmentaremajormissionsofthe

institution.Inaddition,thereisaninfirmary,drugandalcoholdetoxificationobservation

bedsaswellasgeneralpopulationhousingforadultmenofallsecurityclassifications,

protectivecustody,anddisciplinaryandadministrativesegregation.Thefacilityhouses

maleinmatesthoughtherearetwoverysmallholdingunitsontheintakefloorforfemales

untiltheyareassignedtoanotherfacility.

Thereare1542bedsintheMJ.ThepopulationcountatthetimeoftheFebruarysite

visitwas1111with385inmates(34%ofthepopulation)identifiedasbeingonthemental

healthcaseload.

Aspreviouslynoted,thejailservesasthebookingandintakefacilityforthejails.

Thejailhasexperiencedadeclineofapproximately2000-3000bookingsannuallyoverthe

lastfiveyears.In2012,therewere50,930bookingsandthenumberin2017was34,596;

thisiscertainlyawelcomereductionbuteven34,596bookingslastyeardemonstratethat

theMJintakeandbookingprocessremainsaverybusyservicearea.EmergencyMedical

Technicians(EMTs)areonsiteatthejailandprovidemedicalclearanceforadmissionto

thejailfordetaineesevenbeforetheyphysicallyenterthebookingareatobecertainthat

detaineesdonotneeddiversiontoemergencymedicalcarepriortoenteringthejail.The


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intakescreeningisthencompletedinsidethebookingareaandconsistsofmoredetailed

questionsabouthealthandmentalhealthhistoryinadditiontoobservationsofdetainee

conditionandbehaviors.Inmatesplacedonwatchorneedingwatchareexpeditedthrough

thebookingprocessandsenttotheinfirmaryorovertoNBBforsuicidewatchor

psychiatricobservation.(Additionalinformationabouttheintakeandassessmentprocess

isfoundintheIntakeScreeningandAssessmentsectionofthisreport.)

TheinfirmaryattheMJcontains30beds:4cellsareADAaccessibleand4cells

containclosedcircuitcamerastomonitorinmatesonwatchstatus.Inmatesundergoing

detoxification(detox)fromdrugsand/oralcoholareinplasticbeds(likeaboatorsled)on

theflooroutsideofthecells.Armormentalhealthstaffconductroundsintheinfirmary

andevaluateinmatesonmentalhealthwatchstatusdaily.The4thflooroftheMJalso

containsdetoxobservationbedsforinmatesthatarelessacuteintermsoftheir

withdrawalsymptoms.Theyaremonitoredandcontinuedonadetoxificationprotocolthat

includessymptomaticmonitoringandmedication(s).Thedecisionsonwhethertoadmita

patienttotheinfirmaryortothedetoxobservationunitaremadeonacase-by-casebasis

bymedicalstaff.Inmatesinitiallyplacedintheinfirmaryfordetoxificationarealso

generallysteppeddowntothedetoxobservationunitastheirconditionimprovesforsome

additionalmonitoringpriortobeingsenttogeneralpopulationhousing.Mentalhealth

staffmustalsoclearalldetoxinmatespriortoreleasetogeneralpopulation.Thereisafull

timeArmorpsychologistassignedtodoingthesementalhealthdetoxevaluations.Healso

doessomebrief,individualcounseling.


13

Juvenileoffendersarehousedonthe5thflooroftheMJwhichincludesgeneral

populationandlock-downhousingpodsforjuvenileinmates.Thereare3suicidewatch

cellslocatedthereforthispopulationinneedofwatchplacementaswell.Thereare

administrativesegregationcellsforadultmaleinmatesinsomeofthe7thfloorhousing

unitsandinallofthe8thfloorhousingunits.Thereare3additionalsuicidewatchcellson

the8thfloor.Priortoplacementinadministrativesegregation,thereisamedicalstaff

recordreviewoftheproposedplacementtoidentifyanycontraindicationsor

accommodationrequired.3Mentalhealthstaffconductweeklyroundsinthe

administrativesegregationunitsastheconditionsthereareconsidered“extremeisolation”

accordingtotheArmorpolicy.(Lesserformsofisolationrequirelessfrequentmental

healthroundsperpolicy.)Contactsduringroundsoccuratthecellfront.Roundsarenot

consideredtreatmentinterventionsbutratheraformofmonitoringtoassessconditionand

determinewhetheranyadditionalmentalhealthinterventionisnecessary.The

psychiatristseesinmatesbeingprescribedpsychotropicmedicationatleastmonthly.The

inmatesareseenbythepsychiatristinthenursingofficeoratthecellfront.

ArmormentalhealthstaffingattheMJ:

• Psychiatristworks4weekdaysperweek;0.8FTE

3WhileIsawsomeofthesereviewformsinmanyoftherecordsreviewed,Isawnoinstanceinwhichthereviewresultedintheinmate’sexclusionfromplacementinadministrativesegregation–evenwhentheinmatewasdiagnosedandbeingtreatedforaseriousmentalillness.Examplesareprovidedlaterinthisreport.Thisprocessandwhetheritresultedindiversionwouldbeanexcellentitemtomonitorthroughaqualityimprovementprocessinlightoftheknowndeleteriouseffectoflongtermsegregationoninmateswithseriousmentalillness.


14

• ARNPworks1dayperweek;0.2FTE

• ARNPworksweekendstodoroundsofpatientsoncrisis/watchstatus;fractional

FTE

• Psychologist–assignedtodetoxevaluationsandsomecounseling;1.0FTE

• LicensedMentalHealthCounselor–assignedtodoinitialpsychevaluationsand

somecounseling;0.8FTE

BSOProgramstaffatMJ:

• Part-time(0.6FTE)programspecialist–assignedtoprovideSubstanceAbuseand

LifeSkillsprogrammingforJuvenileandprotectivecustodyinmates,notspecificto

inmatesonthementalhealthcaseloadorSMIinmates

Mentalhealthstaffingisdiscussedfurtherinasubsequentsectionofthereport.

However,thementalhealthstaffinglevelsfortheMJarewoefullyinadequateforthe

numberofbookingsannuallyandthenumberandvolumeofdiversemissionsofthefacility

-medicalinfirmary,detoxification,suicidewatchesinatleast3areasofthejail(not

includingintake),juvenilehousing,protectivecustody,disciplinaryandadministrative

segregation.Otherthantheintakeandassessmentformsandpsychiatric(ornurse

practitioner)evaluations,medicationchecksandmedicationadministrationrecords

(MARs)indicatingthatorderedmedicationswereoffered/providedtotheinmate,there

wasnodocumentationinanyoftherecordsreviewedofanyotherformofmentalhealth

treatmentinterventionatMJwhichwasnotsurprisinggiventhementalhealthstaffing

levels.


15

NorthBrowardBureau(NBB)Sitevisits–8/23/16,2/6-8/17

TheNorthBrowardBureau(NBB)contains1206bedsinhousingunits11and12.

Housingunit12containstheresidentialmentalhealthhousingunitsfortheentirejailas

wellasaninfirmary.ThementalhousingunitsarelocatedinletteredhousingwingsE,F,G

andHandeachofthesecontainfivesmallerpodsnumbered1through5thatradiateoffof

acentralcorrectionalofficeroffice/commandcenterforthatparticularletteredhousing

area.Eachoftheletteredhousingunitsalsohavebothnumberedhousingpodsonthefirst

floorofthebuildingandcorrespondingnumberedpodslocatedonthesecondstoryofthe

building.

TheNBBinfirmaryhousesmedicalpatientsinneedofinfirmarycarebutalsohas

somesafecellsforinmatepatientsrequiringsuicidewatchorobservation.Unlikethe

otherhousingunits,itislocatedonlyonthefirstfloor.

Thementalhealthhousingpodsvaryinsizefrom3-4bedstoamaximumof21beds

andtheconstructionvariesfromsinglecellstolargermulti-inmate“rooms”thatremain

opentothecentralareaofthepod.Celledpodsareknownas“closedmentalhealth”units

andareusedtohouseinmateswhohavebeendeterminedtobetooilltohouseinthe

“openmentalhealth”pods,(i.e.,podsthatcontainmulti-inmaterooms)thoseservinga

disciplinarysanction(disciplinarysegregation)orthoseinmatesinadministrative

segregationstatus.Inmatesinclosedmentalhealth(CMH)arehousedaloneincells.Some


16

oftheindividualhousingunitpodsinhousingunit12havemissionsunrelatedtomental

health:twopodsinhousingunitFserveasstep-downforinmateswithmedicalissues,a

unitonEpodhousedchildoffenders.Theremaininghousingunitsaredescribedbelow.

HousingwingEcontainsprotectivecustody(1E1),closedmentalhealth(1E2,2E1,

2E2,2E3),openmentalhealth(1E4,1E5,2E4),a7-bedhousingunitforsuicidewatch

(1E3)anda3-bedhousingunitforsuicidewatchoverflow(1E2).Ehousesmaleinmates.

Notethatthenumberprecedingtheletterindicateswhetherfirstorsecondfloor,the

numberfollowingtheletterindicateswhichofthe5podsisindicated.

HousingwingFcontainsclosedmentalhealthpods(1F1,1F2,1F3,2F3),

disciplinarysegregationformentalhealthinmates(2F1,2F2)andtwoopenmentalhealth

units(2F4,2F5).Notethat2F5isconsideredtheIntensiveProgramUnit(IPU)inwhich

BSOprogramstaffconductdaily(weekday)treatmentprograms,includingaddiction

educationgroupsforinmateswithmentalhealthandsubstanceusedisorderssolongas

theyareclinicallystableandabletoparticipate.Theseprogramsareverygoodbutcan

onlyserveafractionofthepopulationhousedinMHUduetoprogramstaffinglevelsbut

alsobecausealargenumberofinmatesintheMHUaresimplyunabletoparticipatedueto

theirlevelofclinicalinstabilityorproblematicsymptomatology.Maleinmatesarehoused

onF.

FemaleinmatesarehousedintheGunits.Thereisasix-bedunitforwomenon

suicidewatch(1G1);closedmentalhealthunits(1G2,1G3,2G1,2G2,2G3),andopen


17

mentalhealthunits(1G4,1G5,2G5).2G5isthefemaleprogramunitservedbyBSO

programstaff.1G4isanopenmentalhealthunitbutitalsoservesasfemaleintakeinto

NBBmentalhealth.

HousingwingHcontainsmaleinmatesinbothclosedmentalhealth(1H1,1H2,1H3,

2H1,2H2,2H3)andopenmentalhealthunits(1H4,1H5,2H4and2H5).Housingpod1H4

isopenbutalsoservesastheintakeunitformenenteringNBBmentalhealth.BSO

Programstaffprovidetreatmentprogramsinhousingpod2H3–a7-bedtransitional

programunitprovidingtreatmentservices4daysperweektoassistintransitioningstable

inmatesfromclosedtoopenmentalhealthunits.BSOProgramstaffandprogramsarevery

goodbutabletoserveonlyasmallnumberofinmatesonthementalhealthcaseloadanda

fractionofinmateswithseriousmentalillnessduetostaffinglevels,programspaceandthe

severityofsymptoms,functionalimpairmentexperiencedbymanyinmateswithSMIthat

precludestheirabilitytoparticipateinthetypesofactivitiesoffered.

Inmateshousedintheclosedmentalhealthunitsreceiverecreationonceperweek.

Armormentalhealthcounselorsmonitorinmatesontheclosedmentalhealthunitsweekly

atthecellfront(asopposedtoanindividual,confidentialinteraction.)Thesecontactsare

conductedatthecellfront“forsafetyreasons.”Armormentalhealthstaffalsoseeksinput

fromsecurityandnursingstaffabouttheinmatesinclosedmentalhealthaspartofthis

monitoring.A“mentalhealthcontact”formiscompletedandfiledinthemedicalrecord.

(Suchcellfront“monitoring”visitsareknownas“rounds”–anotherkindofscreening

and/ortriagefunctioninwhichthestateoftheinmateisbrieflyassessedatthecellfront.


18

Roundsarenotmentalhealthtreatment.Thepurposeofroundingistodeterminewhether

someoneisdoingalrightorhasdecompensatedandinneedoffurtherassessmentand

treatment.)

Theopenmentalhealthunitsreceiverecreationtwiceperweek.Openmental

healthunitsalsoreceiveatleast1grouptreatmentofferedweekly.BSOprogramstaff

providethesegroupsandsomeindividualcounselingsessions.Armormentalhealthstaff

donotprovideanygrouptreatment.Armorreportedthattheirroleisprimarily

“identificationandstabilization.”Armormentalhealthcounselorsmaydosomeindividual

counselingsessionswithsomeinmateswhichissupportiveinnatureanddoneonan“as

needed”asopposedtoaregularbasisortoprovideanactualcourseoftreatment,whichis

alsotrueoftheindividualcounselingsessionsprovidedbyBSOprogramstaff.Counseling

andotherappointments(forassessments)areconductedatatableinthehallway,notin

confidentialtreatmentspace.Theonlyothermentalhealthinterventionprovidedby

ArmoratNBBispsychotropicmedicationmanagement.Intheseinstances,agiveninmate

mayseeoneofseveraldifferentprescribers,ratherthanhavingastandingtreatment

relationshipwithanyoneparticularperson.(Thisimpairstheformationofatrusting

treatmentrelationshipandalsoleadstofrequentassessment,reassessmentatevery

appointmentwithpersonshavingdifferentprescribingpractices.Itisnotidealcandelay

accesstoeffectivetreatment;psychotropicmedicationstake6-8weeksatatherapeutic

dosetoassesseffectiveness,frequentchangesofmedicationsdonotpermitadequatetime

toassesseffectivenessandtheneteffectcanbetodelayeffectivetreatment.)Medication

managementappointmentsoccuratintervalsof30daysgenerally.Afewmorefrequent


19

contactsarerequiredafterawatchisdiscontinued,butitquicklyrevertstothemonthly

frequencyasopposedtobeingdrivenbyclinicalneed.Medicationmanagement

appointmentsalsooccurinthehallwayoratcellfrontandnotinconfidentialtreatment

space.

BSOprogramstaffconductdailyprogramgroupsduringtheweekon2F5and2G5.

Eachofthesecontain21beds.Theprogramsarepsychoeducationalincontrastto

psychotherapeutic.Inmatesmustbepsychiatricallystableinordertoparticipateandthese

programsarenotavailabletoanyoneinclosedmentalhealth.Theprogramsarewelldone

butsimplynotanoptionavailabletothemajorityofinmateswithseriousmentalillnessin

thementalhealthtreatmentfacilityatNBB.

Therearenoregulartreatmentteammeetingstodiscusseachpatientonthemental

healthcaseloadhousedatNBB.Thereisatreatmentteammeetingtodiscusssome

patients(2-3patientsdiscussedinagivenweek)thatareselectedeitherbyBSOprogram

stafforArmormentalhealthstaffbecausetheypresentaparticularissueorissues

(readinessforadmissiontotheprogramunit,dischargefromNBB,releaseplanning,etc.)

ThemeetingisattendedbyArmormentalhealthstaffandBSOstaffandisconductedinthe

middleofthehallwayjustoutsidetheofficers’station.Itisnotprivateorconfidentialfrom

anyoneelsewhomaybeontheunit.Theinmateandtheprimarystaffpersonworking

withtheinmatesitatatablewhiletheotherspresentstandinasemi-circlearoundthem.

ThediscussionsIobservedprovidedusefulinformationbutwerenottypicalmentalhealth

treatmentteammeetings.Aprogressnoteiswritten,signedbythepersonsattendingthe


20

meetingandplacedintheinmate’sfile.Theactualtreatmentplanitselfisnotupdatedto

reflectanydecisionorplannedincreaseinintensity,frequencyortypesofcontactsforthe

inmatediscussed.

Aspreviouslynoted,suicidewatchesmaybeconductedinsomeofthecellslocated

intheinfirmaryoronhousingunits1E3(males)and1G3(females.)Suicidepreventionis

discussedmorefullylaterinthisreport.

ArmormentalhealthstaffingatNBB:

• Psychiatrist–1FTEand1part-timepsychiatrist

• ARNP–2FTE(1fulltimeand2part-timepractitioners)

• PhysicianAssistant–1FTE(primarilyadministrative)

• MHcounselors–2FTE(licensedmentalhealthclinicians)

• Dischargeplanners–2FTE

BSOProgramstaffatNBB4:

• Licensedpsychologist–2FTE

• MHcounselors–3FTE(master’slevelclinicians)

4TheBSOProgramalsosupportsmentalhealthprofessionaltraining.Thereare2FTEdoctoralinternsand2part-timedoctoralpracticumstudents(eachfor12hoursperweek).ThejailisanaccreditedbytheAmericanPsychologicalAssociationasanInternshipTrainingsite.


21

Staffingisdiscussedinasubsequentsectionofthisreport.However,itisclearthat

NBBArmormentalhealthandBSOprogramstaffinglevels(includingtraineeswhorequire

supervision),donotreflectthenumbersorvariedtypesofstaffnecessarytoprovidea

residentialtreatmentlevelofcare.Nothingotherthanmedicationmanagementis

providedforthevastmajorityofinmates,andeventhatisrelativelyinfrequent,notbased

onclinicalassessmentofneedandmaybeprovidedbysomeonedifferentateveryvisit.

Whileinmatesdonothavea“right”toseethesameproviderateveryclinicalvisit,failingto

dosoleadstofragmentationintheprovisionofcare,beingsubjectedtodiffering

prescribingpracticesandfrequentmedicationchanges;compromisesthedevelopmentofa

consistenttreatmentrelationshipsuchthateveryvisitisa“new”assessmentratherthan

furtheranceofacourseoftreatment.Suchfragmentationimpactscareprovidedand

prolongsthetimeittakesforsymptomstorespondtotreatment.Delaysintheprovisionof

carehavebeenshowntonegativelyimpactboththetimeittakestorespondtotreatment

aswellasthedegreeoftheresponse;ittakessymptomslongertorespondandthe

responseisnotasrobustasthatwhichoccurswhentreatmentisprovidedtimely.

Frankly,althoughthisisthefacilitycontainingthementalhealthunitstowhich

otherjailstransferinmatesinneedofahigherlevelofmentalhealthcare,therereallyisno

differentthantheoutpatientservicesprovidedatalloftheotherfacilities.Itdoesnot

representahigherormoreintensivelevelofcareforinmatesinneedofsuchcare,and

inmatesmayremainthereformanymonthsorevenyearswhileawaitingfurtherlegal

proceedings.Conditionsontheclosedmentalhealthunitsandintheinfirmaryforweeks

andmonthsonendactuallymimicsolitaryconfinement/segregationintermsofvery


22

limited(ifany)out-of-celltime,limitedopportunityforsocialinteraction,limitedproperty

andcellfrontinteractions,ratherthantheprovisionofactualmentalhealthtreatment.


23

JosephVConteFacility(ConteorJVCF)Sitevisit-05/16/17

Conteisamalefacilityhousingminimumandmediumsecuritymaleinmates.The

capacityofthejailis1328buttheaveragedailypopulation(ADP)hasbeen1000-1050for

thepastyear.Onthedayofthesitevisit,therewere1008maleinmatesatJVCF;319of

themwereontheMHcaseload(32%ofthepopulation.)

JVCFhasnoinfirmaryanddoesnothavethecapacitytoconductsuicidewatches.

InmatesidentifiedasneedingthatlevelofcarearetransferredouttoNBB.Thephysical

plantisstructuredsuchthattherearetwo“towers”ofhousing–A&Btower.Eachtower

contains8housingunits.Allofthehousingunitsaretwo-story,andthemajorityofcells

are2-mancellsthoughthereare4-manand6-mancellsalso.

Threeoftheunitshouseinmatesparticipatinginspecificprograms:aSpiritual

LearningprogramrunbyreligiouschaplainsislocatedonhousingunitB5,aSubstance

AbuseProgram(SAPonhousingunitA6)andaLifeSkillsProgram(A5)areofferedbyBSO

Programstaff.TheSAPandLifeSkillsProgramconsistofgroupinterventionsandbothare

4weeksinduration.Thereisnodocumentationofgroupnotescontainedinthemedical

records,butinmatesgetacertificateofcompletioniftheyparticipateforthe4weeks.Most

inmatesparticipatinginSAParecourt-orderedbutsomerequesttoparticipate.TheJVCF

alsoprovidesNarcoticsAnonymousandAlcoholicsAnonymousmeetingsonavoluntary


24

andcourt-orderedbasisaswellasGEDtraining.Thisfacilityhasampleprogramand

outpatienttreatmentspace.

Mentalhealthservicesconsistprimarilyofmedicationmanagementappointments

scheduledatmonthlyintervals.WheninmatesaretransferredfromMJ,medicationorders

remainineffectforthedurationorderedbythepsychiatristattheMJsothatcontinuityis

maintained.Medicalnursesprovidetwomedicationadministrationtimesdaily:9-10AM

and4-6PM.Othermentalhealthservicesmayincludenewassessmentsbasedupon

referral(staffreferralorinmateself-referral)thoughthevastmajorityofinmatesonthe

mentalhealthcaseloadwereidentifiedbyvirtueoftheintakeprocessattheMainJail.

TheMedicationAdministrationRecords(MARs)werereviewedonsiteduringthe

visit.Therewasverylittlepolypharmacy(inappropriateuseofmultiplemedications),

whichisapositivefinding.Somemedicationswereprescribedatverylowdoses(lower

thantherecommendedlowesteffectivedosesuchasRisperdal0.25mgandZoloft50mg

longterm).It’snotclearthatsuchlowdoseswouldhaveanytherapeuticbenefit,but

neitherisitharmfulexcepttotheextentthatitfurtherspreadsalreadythinstaffresources

formedicationmanagementappointments.Thisisnotjustadifferenceinprescriptive

opinion;requirementstoseeinmatesonmedication,evenifitisprescribedin

inappropriatelylowandineffectivedoses,taketimeawayfromseeinginmateswhoare

seriouslymentallyillandprecludetimetoholdtreatmentteammeetingsoninmatesonthe

mentalhealthcaseload,whichputsthematriskofdecompensationandimpedesaccessto

care.Asanaside,therewereanumberofpeoplethathadMARswhodidnotappearonthe


25

caseloadroster.Anynumberofreasonsexplainthis:arecenttransfer/admissiontothe

facilitynotyetaddedtotherosterortheintervalsatwhichtherosterlistis

updated/refreshedweeklyandtheinmatearrivedjustafterthelastupdateandbeforethe

nextone.Thereareprobablyothervalidandunderstandablereasonsforthediscrepancy

aswellbutintheworst-casescenario,inmateswillbemissedforfollow-upappointments

becausetheyarenotlistedontherosterwhichisusedforscheduling.Inanyevent,I

suggestedonsitethatdevelopingamechanismtoensuretherosterlistwasreconciled

moreregularlywiththeMARs/inmatesphysicallypresentatthefacilitytopromotebetter

tracking/efficiencyandfollow-upcouldbeworthwhileContinuousQualityImprovement

(CQI)project.

BSOProgramStaffatJVCF:

7.5FTE:1.0FTESupervisor(Jones),4.5FTESAPstaff;2FTEinLifeSkills(1FTEisvacant)

ArmormentalhealthstaffingatJVCF:

• Psychiatristworks3daysperweek;0.6FTE

• ARNPworks1dayperweek;0.2FTE(alsoworksatNBB)

• LicensedMentalHealthCounselorworks1dayperweek;0.2FTE(Healsoworksat

MainJail0.8)

BSOProgramstaffdonotprovidementalhealthtreatmentperse,theyprovide

programs.Therearesignificantdifferences.Tonamejustafew:BSOprogramstaffdonot

writeprogressnotesinthemedicalrecordandthespecificprogramsarenotreflectedas


26

aninterventionspecifictoaparticularmentalhealthproblemonthementalhealth

treatmentplan.Inmateprogresstowardgoalattainmentisnotmeasuredorreviewedby

membersofthetreatmentteamordiscussedintreatmentteammeetings.Thisisnot

intendedasacriticismoftheBSOprograms,whicharequitegood;theyaresimplynot

providedasmentalhealthtreatmentinterventionsspecifictoinmateswithmentalillness,

theyareprograms.Armormentalhealthstaffinglevelspermitnothingintermsofmental

healthtreatmentexceptverybriefmedicationmanagementappointmentsatmonthly

intervalsgiventhesizeofthejailandthenumbersofinmatesonthementalhealth

caseloadprescribedpsychotropicmedication.


27

PaulReinDetentionFacility(PRF)Sitevisit–5/17/17

PRFhousesminimumandmediumsecuritymaleandfemaleinmates.Thecapacity

ofthejailis1068butthecensusonthedayofthesitevisitwas728,whichhasbeenfairly

typicalforsometime.Therewere242inmatesatthefacilityonpsychotropicmedication

(33%ofthefacilitypopulationthoughproportionatelymorewomenthanmenwereon

medications.TheDirectorofNursingexplainedthatwhilewomenconstitutedonlyabout

¼ofthepopulation,theyrepresentedabout½ofthenumberofinmatesonmedications.

Thisisnotatypicalwithfemaleinmatesthroughoutthecountry.)

ThephysicalplantfloorplanatPRFisessentiallythesameasthatofContewiththe

exceptionthatawalldividesadjacentunits(ratherthansimplyopenspacebetweenthe

twoasatConte.)Therearetwotowers(CandD)containing8-9housingunits.Womenare

housedonCtower;MenonDtower.Supervisionisdirect–acorrectionalofficerisrighton

theunitindirectcontactwiththeinmates.Insomeofthehousingunits(fortheminimum

inmates),the“cells”aremulti-personandreallyjustcubicleswithpartialwallsthatdonot

reachtheceilingwithnodoors.Theseareonthethirdfloorofthefacilityandcalled“open”

units.The1stfloorhousingunitsare“closed”–containactualmulti-personcells.

Thereisamedicalexamroomoneachhousingunit.Itisusedformentalhealth

appointmentsaswellasnursingsickcall.Thereissufficientclassroom/grouptreatment

spaceinthehallwayjustoutsidebutconnectedtothehousingunit.Thiseliminatesthe


28

needforsecurityescortstoprogramsastheinmatessimplyenterthecentralcorridor

wheretheprogrammingspaceislocateddirectlyfromthehousingunitratherthanhaving

tobeescortedtosomeotherlocation.

CTower,housingfemaleinmates,containsunitsfordisciplinaryandadministrative

segregation.(HousingunitC4contains28bedsfordisciplinarysegregationandC5is

administrativesegregationandhas20beds.)Atthetimeofthesitevisit,therewere8

womenondisciplinarysegregation,3wereprescribedpsychotropicmedication(37.5%).

Therewere14womenonadministrativesegregation,12(86%)ofwhomwereon

psychotropicmedication.Thisdegreeofdifferencebetweentheprevalenceofwomenon

thementalhealthcaseloadinpopulationanddisciplinarysegregationversustheveryhigh

prevalenceofwomenonthementalhealthcaseloadinadministrativesegregationis

remarkableandisripeforaqualityimprovementstudytodeterminethecause(s)–

particularlyinlightoftheevidencethatinmateswithseriousmentalillnessdonotdowell

inlong-termsegregationsettings.Healthcarestaffconductafilereviewpriortoplacement

inadministrativesegregationtodeterminewhetherthereareanycontraindicationsfor

placementorneedforaccommodation.Thechartsofinmatesinadministrative

segregationcontainedthepre-placementdocumentationbutnoneofthemfound

contraindicationstoplacementorrecommendedanyaccommodations.InmateMD’s

confinementclearanceformindicatedshewasonpsychotropicmedication,hadaprior

historyofself-harm,wasdiagnosedwithmajormentalillnessandhadbeenonbehavioral

healthmonitoringstatuswithinthepreceding90days,butshewassenttosegregationin

spiteofmultipleriskfactorsandtherewasnodocumentationthatfacilitymentalhealth


29

staffwerenotifiedoftheplacement.(MD’scaseissummarizedintheAppendixonpage53.

AdditionalexamplesofinmatesclearedforplacementincludeinmatesSM,DCandSD

summarizedonpages54-55.)

Inmatesinadministrativesegregationarereviewedweeklyfor8weeksbya

multidisciplinarystaffthatincludestheDirectorofNursing;thereafter,theteamreviews

themmonthly.Areferralformentalhealthassessmentisroutineafter8weeksof

confinement.Inmatesinsegregationcanbeseenbymentalhealthstaffprivatelyina

medicalroomlocatedoffthedayroomorattablesonthedayroomfloor(whichisnot

confidential.)Staffreportedthatinmatesinsegregationarepermittedoutofcell1hour

perday,7daysperweek.Deputiessupervisinginmatesinsegregationunitsorother

programunitstake40-hourCrisisInterventionTeam(CIT)trainingandhaveanannual

refreshercourseaswell.

Therewasarestraintchairinthehallwaybetweensegregationunits.Iaskedabout

itsusetheDirectorofNursingreportedthatithadn’tbeenusedinatleastthelast5years.

Shefurtherreportedrecallingonly1instanceoftheneedforacellextractionduringthe12

yearsthatshehasbeenatPRF.

Also,similartoprogrammingatConte,BSOProgramstaffatPRFprovideSAP,Life

skillsProgramandaLifestylesprogram.ThereisalsoaGEDprogramatPRF.BSO

Programstaffdonotprovidementalhealthtreatment.


30

Armormentalhealthstaffprimarilyprovidepsychotropicmedicationmanagement.

ThereisaPsychiatricPhysician’sAssistantatPRFfourdaysperweek,0.8FTE.Alicensed

mentalhealthcounselorisatPRFonSundays.Inmatesrequiringcrisiscareorwatch

placementaretransferredtoNBB.StaffreportedtransfersaretimelythoughIdidnotsee

anylogstoquantifythetimelinessofthetransfers.Thereisasafespaceintheintakearea

ofthefacility–alargecellthatpermitsdirectvisibilityintoallareasfromtheofficer’s

stationimmediatelyacrossfromit(a“fishtank”cell.)Thisisusedtotemporarilyhouse

suicidalinmatesuntiltheyaremovedtoNBB.


31

SystematicScreeningandEvaluation TheMainJailservesasthecentralizedintakeandbookingfacilityforthejailsystem.

Aninitialscreeningisconductedbytrainedemergencymedicaltechniciansatthefront

doorofthejailoneveryinmateenteringthesystem.Theinitialscreeningprocessis

intendedtoensurethatinmatesaresufficientlymedicallystabletobeadmittedtothejail

andtoidentifyothercriticalneedssuchasdrugwithdrawal,theneedforsuicidewatchand

otherconditionsthatrequiremedicalattentionsuchasdiabetesandhypertension.There

areadditionallevelsofmedicalandmentalhealthscreeningfollowingthebooking

procedure.AppropriatelytrainedandcredentialedArmorstaffcompletethese

assessments.Inmateswhoscreenwithapositivementalhealthscreenarereferredonfor

amorecomprehensiveevaluation.

Basedonmyreviewofmanyrecords,themeasuredprevalencerateofinmateswith

mentalillnessinthesystemandArmor’sownqualityassuranceauditing,theprocesses

appearadequateprocedurally.However,therearesomecomponentsoftheprocess

requiringfocusedimprovementtofacilitateaccesstotheappropriateandnecessarylevel

ofcareattheearliestpossibletime,improvetimelinessofidentificationandsustain

adequacy.

Theinitialscreeningshouldcontainamechanismtodivertnotonlyinappropriate,

criticalmedicalconditionsfromthejail,butalsodivertcasesofcomplicateddrug

withdrawalthatrequirehospitalmanagementandexpeditethereferralofpersonsinneed


32

ofpsychiatrichospitalizationtothatlevelofcare.Severalexampleswerefoundinrecord

reviews.

InmateLBwas“agitated,bizarre”atthetimeofintaketothejail7/28/16tothe

extentthatthementalhealthscreeningcouldnotbecompleted,buthewasacceptedinto

thejailwherehehassteadilydeteriorated.AtthetimeofmysitevisittoNBB,hewas

lockedinaclosedmentalhealthunitandappearedregressedtothepointwherehe

expressednomeaningfulcommunication.(Afullsummaryofhiscaseisfoundinthe

Appendixonpages24-25.)Thisisanexampleofapersonthatshouldhavebeen

immediatelyreferredtoapsychiatrichospitalafterbeingprocessedratherthanbeing

maintainedatthejail.(Floridastatelawrequirespersonsarrestedforafelonybe

processedthroughajailbeforegoingtoapsychiatrichospital,althoughacceptanceintothe

hospitalisnotguaranteed.Nevertheless,thejailhastoreferthesecasesimmediatelyafter

processingratherthanmaintainingtheminthejailforweeksormonthsbefore

contemplatingattemptstopsychiatricallyhospitalize.)

InmateCBhadahistoryofsubstanceabuseandtreatmentfordepression.This

informationwasknownatthetimeofhisbookingintothejail,buthismentalhealth

referralwas“routine”althoughhewasplacedintoadetoxunit.Therefore,hewasnot

evaluatedbymentalhealthpriortohisdeathbysuicidethefollowingday.Substanceabuse

andtreatmentfordepressionaresignificantriskfactorsforsuicideandshouldhave

triggeredanimmediatementalhealthreferralforasuicideriskassessment.Thesuicide

deathwasreviewedbutprocessestotriageandprioritizementalhealthreferralsfor


33

suicideriskassessmentofindividualswithpsychiatrichistoryanddrugwithdrawalhave

notchangedanddonotincludeanimmediatereferralwhenthesefactorsarepresent.

(ThefullsummaryofCBisfoundonpages64-65oftheAppendix.)

Attemptingtopsychiatricallyhospitalizeinmatesinneedofahigherlevelofcare

thancanbeprovidedinajailattheearliestpossibletimeisparticularlyimportantfor

severalreasons.Onereasonistobeabletoensurethatcareisprovidedtimelysothatthe

responsetotreatmentistimelyandtheresponsetotreatmentisbetterthesoonerthat

treatmentisstarted.Anotherreasonisthatasinmatescontinuetodeteriorateandbecome

increasinglyill,civilhospitalsarelesslikelytoagreetotakethemwhichmakestimely

accesstoinpatientcareessentiallynon-existent.Theclinicalneedforpsychiatric

hospitalizationtakesabackseattocontainment–civilhospitalswillnotaccept“violent”

jaildetaineesandeventheBakerAct5pre-screenerswhocometothejailtodetermine

whetherornottoapproveinmatesforadmissiontothehospitalseemtobelievethat

holdingpeopleinsegregation,oraclosedmentalhealthunitorainacrisiscell,without

treatmentistheequivalentofpsychiatricinpatientcareanddon’tapprovethetransfertoa

hospitallevelofcare.(Thiswillbediscussedmorefullyinthetreatmentsectionofthe

reportrelatingtohospitalization.)Aftertheinmateisdeniedaccesstoahospitallevelof

carebywayoftheBakerAct,theonlyeffectivemeansofaccessingcarerequiresalegal

findingofincompetencetostandtrial,butthatgenerallydoesn’thappenuntilaftermonths

5TheBakerActistheFloridalawregardinginvoluntarypsychiatrichospitalizationandpre-screenerscometothejailtodetermineeligibilityforhospitaladmissionwhenArmormentalhealthstafffileanapplicationforhospitaladmission.


34

ofajailstay,severelydelayingaccesstocare.Delayedaccesstohospitallevelofcareleads

toworseningofsymptomsincreasingtheriskofharmtoselfandothers,adelayed

responsetotreatmentandalessrobusttreatmentoutcome.

Multipleinstancesofpersonsbeingconsideredtoopsychiatricallyill,uncooperative

orunsafetocompletethemedicalintakeprocesswerediscoveredinrecordreviews.In

theseinstances,medicalassessmentformsweresimplymarkedas“refused”or“unableto

complete.”Therewasnodocumentationthattheintakeevaluationwascompletedata

laterpointintheinmate’sjailstay,regardlessofthelengthofstay.Personswithserious

mentalillnesscanalsohaveseriousmedicalproblemsthatmustbeassessedandtreated.

Failingtodosocanhavedisastrousconsequences.

InmateRPwasunabletobescreenedatthetimeofintakebecausehe“sitsthereand

talkstohimself,won’tanswerquestions.”Thehealthassessmentformhasalinedrawn

acrossthepagediagonallywiththeword“Refused”hand-writtenonthepaperaswell.RP

wasacceptedintothejailandhousedinNBBmentalhealthunits.Hedisplayedsignsof

seriousmedicalproblemsthatincludedsignificantweightloss,bloodinhisurineand

swollenfeetwith“wounds”accordingtothementalhealthPA.Eventually,RPwassentout

toamedicalhospitalwherehewasadmittedtotheintensivecareunit.Whenhereturned

tothejailafterhishospitalstay,hewasinitiallyadmittedtotheNBBinfirmary,butthen

senttoclosedmentalhealth.Heremainedthereuntilhewasdiscoveredunconsciousand

subsequently,hedied.(RP’ssummaryisonpages68-69oftheAppendix.)RPwasinthe


35

jailin2012,butcurrentrecordreviewsdemonstratethatthesetypesofproblemscontinue

toexist.

InmateSOwasphysicallyillwhenbookedintothejail3/22/16,havingbeen

hospitalizedmedicallyjustpriortohisbooking.Hehadcirrhosisoftheliver,ascites,

varicesandhepatosplenomegaly.Nevertheless,hewasadmittedtoadetoxfloorand

remainedthereforthedurationofhistimeinthejail.Hisphysicalconditioncontinuedto

deteriorate.On3/25/16,hewasfoundfacedownonthefloorwithlaboredrespirations

andunabletogetupwithouttheassistanceoftwootherpeople.Hewaskeptatthejailon

thedetoxunitanother10daysuntilanemergencytransferouttothehospital.Hedidnot

returntothejail.(SO’scaseissummarizedonpage74oftheAppendix.)6

Theabovecasesarerelevanttomentalhealthcarebecausetheyexemplifythe

problemswithaccesstoappropriatemedicalcarewhenhousedinmentalhealthordetox

unitswhichiswhythemedicalassessmentatintakeissoimportant–andcannotbeleft

undoneorincomplete.

ED,aninmatewithseriousmentalillnessinjailsince7/18/16,neverhadamedical

assessmentcompleted.Initially,herefuseditandthenthemedicalhealthassessmentform

contains“behaviorinappropriate”writtenacrossthesecondpagedated8/1/16.Asofthe

6BSOreportedthatthiscaseisinlitigationandthefactsaresubjecttodispute.


36

timeofhisfilereviewinNovember,theassessmentremainedundone.(InmateED’s

summaryisonpages12-13oftheAppendix.)

TheArmorqualityassuranceauditsofthementalhealthintakeprocessare

quantitativeinnatureandcontainnomeasureorassessmentofquality.Theauditsconsist

ofquestionsthataddresscompletionofforms,whetherreferralsareseen,andcompliance

withtimeframesarticulatedinpolicythatrequireonlya“yes”or“no”finding.Additional

multi-stepitemssuchaswhethermedicationsrequiringlaboratorytestinghavethose

multiplelabsordered,drawn,reportedandreviewed,containonlyonesimple“yes”or“no”

responsewhichdoesn’tpermitananalysisofwhetherthereareproblemsatanystepinthe

processorwithaparticularmedicationorlabstudy.Inmatesmaybeonmultiple

medicationsthatrequiremultipletypesoflaboratorystudies.Thepresenceorabsenceof

otherforms,suchasthetreatmentplan,providesnoindicationofwhethertheplanis

complete,individualized,meaningfulorrelevant.

Staffinglevelsandtaskassignmentimpactthequalityofpsychiatricassessments

completedattheMainJail.Theassessmentsarecursoryduetoinsufficientstaffingandthe

delegationofthistasktothepsychiatristandARNPattheMainJail,ratherthanincluding

otherlicensedmentalhealthstaffthatarepermittedtoassessanddiagnosementalillness

byvirtueoftrainingandstatelaw.(Thepart-timelicensedmentalhealthcounselordoes

dosomeinitialpsychiatricassessments,butdiagnosisandtreatmentplansarelefttothe

prescribingprofessionals.Thefull-timepsychologistdoesdetoxevaluationsandsome

counseling.)Inaddition,thereispotentiallyanissuewithregardtowhethertheMainJail


37

psychiatristhasatendencytominimizeinmatepsychiatriccomplaintsand/orattribute

theirreportsofsymptomstomalingeringforsecondarygain.Thereweremanyexamples

ofthistendency.Onecase,inmateCSenteredjail4/27/17.Hewastearfulatthetimeand

facingchargesofmurder.ARNPKeanedidtheinitialmentalhealthevaluation4/28/17.

Thepsychiatristsawtheinmate5/1/17anddiagnosed“adjustmentdisorderwith

depressedmood”thoughbothantidepressant(Celexa)andantipsychotic(Risperdal)

medicationswereorderedforhim,whichwouldseemtoindicatesomethingmoresevere

thananadjustmentdisorder.Eventually,thediagnosiswasupdatedtoMajorDepressive

Disorderwithpsychoticfeatures,butthecaseexemplifiesmyconcernregardingthe

tendencytominimizesymptomatology,diagnosesanddrawconclusionsaboutsecondary

gain–andparticularlythepsychiatristatMJ–thefrontdoortoservices.(TheCScaseis

summarizedonpage39intheAppendix.)OtherexamplesincludeHB(page2inthe

Appendix),CWandLT(page34),W(pages36-37)andRA(page41).Thisissueshouldbe

monitoredandaddressedwithameaningfulpeerreviewprocess,andalthoughthereare

othermechanismsforreferralandassessmentlaterinaninmate’sjailstay,identificationat

thefrontdoorisabsolutelycriticaltoensuretimelyaccesstocare.Delaysinaccessingcare

increasestheriskofworseningsymptomsandincreasedsufferingandtheriskofharmto

selfandothers.Sufficientstaffinglevelstopermitamoretimetoconductthese

evaluationswouldalsobehelpfulaswouldpermittingrotationofpsychiatricstaffto

performthistaskatintaketopreventburnout.

Itwasoftendifficulttodeterminewhetherornotoutsidetreatmentrecordswere

requested,muchlessreceivedandreviewedinmanyofthechartsIreviewed.Armorstaff


38

reportedthatmanytimesevenwhenrecordsarerequested,outsidetreatmentfacilitiesdo

notsendthem.Thisseemstohavehadtheeffectofdiscouragingtheprocessofrequesting

suchrecords(inspiteofapolicyrequirementtorequestthem)ratherthanstimulatinga

discussionwithoutpatienttreatmentproviderstosendtherecords.Reviewand

incorporationofinformationcontainedinoutsidetreatmentrecordspermitsamorewell-

roundedassessmentofdiagnosisandfunctionalcapacitythancanbecompletedwitha15-

20-minuteexaminationinajailwheretheonlyinformationisself-reportanditimproves

continuityofcare,particularlywithregardtopsychotropicmedicationmanagement.Itis

particularlyimportanttoverifyoutsidemedicationprescriptionsandthereappearstobe

noreliableprocesstodothisineverycaseofaninmatebookedintothejail.Medication

continuityisimportantforpatientcaretomaintainstabilityorimproveconditionwitha

medicationknowntohaveworkedinthepastratherthanstartingtheprocessfromscratch

overandoverwithdifferentmedications,riskingare-emergenceofsymptoms,needless

sufferingandincreasedriskofharmtoselforothersasaresultofdecompensation.

Additionalexamplesofproblemswithfailingtogetorconsiderinformationfrom

outsidetreatmentrecordsincludeinmateIIwhowastransferreddirectlyintothejailfrom

theSouthFloridaEvaluationandTreatmentCenter,wherehehadbeenhospitalizedfor3

½months.Uponreceptionatthejail,IIrefusedhisinitialhealthassessmentincludinga

testfortuberculosis.Forthisreason,hewashousedinaninfirmaryisolationcellfrom

7/29/16“untilfurthernotice.”IIwasstillinthatinfirmaryisolationcellatNBBattheend

ofAugustwhenIvisitedthejail.WhenIlearnedhehadcomedirectlyfromthestate

hospital,Iaskedtoseetherecordsandinfact,IIhadatuberculinskintestatthehospital–


39

whichwasnegative.Hedidnotneedanotheroneatthejailandhedidnotneedtobekept

inisolationintheinfirmary.Therecordsfromthehospitalwereactuallyatthejailbuthad

notbeenreviewedwhichledtohousingIIininfirmaryisolationunnecessarily.Aftermy

sitevisit,IIwasrelocatedtogeneralpopulationhousing.(II’scaseissummarizedonpages

13-14oftheappendix.)

InmateMWhadalong-standingdiagnosisofschizophreniaandreceivedoutpatient

care,includingpsychotropicmedication,attheVeteransAdministration(VA).Herefused

totakepsychotropicmedicationinthejailuntiltheVArecordscametothejailtoverifythe

medicationregularlyprescribedtohim.Hesignedareleaseofinformationtogetthe

records.MWexplainedthistomeinAugust2016andagaininFebruary2017anditisalso

documentedintheprogressnotesofhischart;hewaswaitingforverificationofhis

medicationfromtheVAandsaidhewouldtakethatmedication,butnotothersubstitutes.

WhenIinquiredwhethertheVArecordshadarrived,ArmorPAShootescheckedandfound

astackofrecordsfromtheVAthatwasabout2”tall.Itwasnotclearwhentheyarrived,

butitwasclearthattheyhadn’tbeenreviewed.MWwasprescribedasmalldailydoseof

SeroquelfromtheVA.PAShootestoldmethatitwasnotonformularyandshewouldnot

makeanon-formularyrequest.MWremainedpsychoticinthejail,outsidetreatment

recordswerenotreviewedwhentheyarrivedandinspiteofverificationofavalid

prescription,Armorrefusedtoprescribethemedicationforhim.(MW’scaseis

summarizedintheappendixonpage17.Hiscasealsoillustratesissuesaround

psychotropicmedicationwhicharemorefullydescribedinalatersectionofthisreport.)


40

InmatePwashousedinadministrativesegregationwhenIsawhim2/9/17.Hehad

beenreturnedfromthestatehospitalaftera3½monthstayandunderwentintaketothe

jail1/4/17.Theonlyinformationthataccompaniedhimfromthestatehospitalwasa

medicationlist.Medicationswereorderedatthejailasthe“inmateiswellknowntojail

frompriorstays.”Therewasnoindicationthatanyadditionalinformationabouthis

hospitalstaywasrequested.WhenIspokewithhim,hewasclearlypsychoticand

providedirrelevantandmostlyincoherentresponsestoquestions.Continuedconfinement

inadministrativesegregation,whichmakessymptomsworse,wascontraindicated.Review

ofhospitalrecordsdescribingtheinmate’sconditionthere,progressintreatmentand

interactionswithothersisusefulinformationindetermininghousingplacementatthejail.

IfArmormentalhealthstaffgaveanyconsiderationtohisplacementinsegregationbeing

contraindicatedbaseduponhisbeingastatehospitalreturnandcurrentpsychoticmental

state,itwasnotdocumentedintherecord.(InmateP’scaseissummarizedintheappendix

onpages37-38.)

Failuretorequestandreviewoutsidetreatmentrecordscanresultindelayedaccess

tocareorevendenialofeffectivetreatment;itprolongsjailstaysandleadstoneedless

sufferingandmentaldecompensationincreasingtheriskofharmtoselfandothers.

Requestsforoutsidetreatmentrecordsshouldbemadeatthetimeofintake/receptioninto

thejailwhichiswhythesecaseexamplesareprovidedinthissectionofthereport

althoughmuchofthesameinformationisalsorelevanttothelatersectiononRecords.

Actuallyreviewingoutsidetreatmentrecordsandconsideringtheinformationcontainedin


41

themareequallyimportantwithrequestingtherecordsindevelopingatimelyand

clinicallyappropriatetreatmentplansforinmatesinthejail.


42

TREATMENT Treatmentismorethanmereseclusionorclosesupervision.Jailinmateswith

seriousmentalillnessmusthaveaccesstothecontinuumofmentalhealthcare,including

timelyaccesstoaninpatientlevelofcare.InmatesintheBrowardCountyJailsarenot

givenaccesstoadequatementalhealthcare.Accesstoinpatientcareisnearlynon-existent

exceptwhencourtorderedforrestorationofcompetencetostandtrial.

Deficienciesrelatedtotheprovisionofmentalhealthtreatmenthavebeengrouped

underseparateheadingsandsub-categoriesthoughthereareitemsthatmaycutacross

severalareas.

Outpatientmentalhealthcare Thislevelofcareisanalogoustooutpatientcareinthecommunity.Patientsare

clinicallystable,andtheirbehaviorandfunctioningarenotimpairedoronlymildly

impaired.Patientsfunctionwellinacommunitysettingandhaveperiodicappointments

withamentalhealthprofessionalthatmayincludeamentalhealthcounseloranda

psychiatrist(orotherpersonlicensedtoprescribemedication.)Thefrequencyof

appointmentsisbasedupontheclinicalstabilityofthepatientaswellasthetypeof

treatmentinterventionsbeingprovidedandmayrangefromweeklygrouptreatmentor

counselingappointmentstomonthlysupportsessionsandquarterlymedication

managementappointments.Inthecommunity,mentalhealthstaffinglevelsaresufficient

tobeabletorespondquicklytocrisesandincreasetherapeuticcontactsuntilthecrisisis

resolved.Unfortunately,thisisnotthemannerinwhichoutpatientservicesareprovided


43

inthejails.Althoughthemajorityofinmateswithseriousmentalillnessarehousedin

generalpopulationandreceiveoutpatientcare,thereareinsufficientnumbersofArmor

stafftoprovideanadequateleveloftreatmentservicetoinmateswithseriousmental

illnessresidingingeneralpopulation;therearenomentalhealthgroupsofferedand

individualcounselingisnotavailabletothevastmajorityofinmatesonthementalhealth

caseload.

OutpatientcareattheBrowardCountyJailsconsistsalmostexclusivelyof

psychotropicmedicationiftheinmateconsentstotakeit.Thereisvirtuallynoother

mentalhealthtreatmentasaconsequenceofinsufficientstaffing,bothintermsofthetypes

ofmentalhealthstaffprovidingservicesaswellasthenumbersofstafftoprovidecareto

themajorityofinmates.Inmatesareseenatintervalsofthreemonthsformedication

managementandhaveabriefmonthlycontactwithamentalhealthcounselor,although

sometimesthesetwotypesofvisitsarecombinedintoonecontacttoensurethateveryone

onthecaseloadgetsseen.Thereisnotenoughpsychiatric7timetoprovideadequate

assessmentandfollow-upinresponsetoclinicalneed.Mentalhealthclinicianpositionsare

alsoseverelydeficient.ConteandPaulReinFacilitieseachhaveamentalhealthcounselor

availableonlyonedayperweekforacombinedpopulationofapproximately1700inmates,

morethan550ofwhomareonthementalhealthcaseload.Outpatienttreatmentplansare

meaningless;purporttoofferservicesthatsimplydon’texist;containnomeasurable

7Inthissection,thetermpsychiatristisintendedtoincludepsychiatricphysiciansaswellasmid-levelproviders(ARNPsandPAs).


44

objectives;andareneverupdatedtoreflectanychangeintheinmate’scondition(suicide

watchplacements,transferstoNBB,etc.)nomatterhowlongthejailstay.

InmateARishousedatConteandreceivesoutpatientservices.Heisseenmonthly

bythementalhealthcounselorwhocompletesaMentalHealthRounds/ContactFormand

isprescribedantipsychoticmedication.Themedicationwasincreased5/8/17becausehe

reportedaworseningofsymptoms.However,therewasnoplanformorefrequentcontact

byeitherthecounselororpsychiatristtodeterminewhetherthedoseincreasewas

effectiveortoprovideanyothermentalhealthinterventioninresponsetotheinmate’s

break-throughsymptoms.(AR’scaseisonpages45-46oftheAppendix.)

DIwashousedindisciplinarysegregationatthetimeofthePRFsitevisit.Herinitial

mentalhealthevaluationwasdated2/17/17andshewasdiagnosedwithananxiety

disorder.ShewasprescribedAtaraxforanxiety.InMarch,themedicationwas

discontinued,andshewasprescribedadifferentmedication,Buspar.ThedosageofBuspar

wasincreasedatsubsequentpsychiatryappointments4/12/17and5/10/17becausethe

inmatereportedcontinuedsymptomsofanxiety.Noothertreatmentinterventionswere

provided;nocounseling,nogrouporindividualtherapy.Thefrequencyofcontactswas

notincreasedinresponsetocontinuedsymptoms.Thetreatmentplan,dated2/16/17(the

daybeforethementalhealthevaluationwasdated),wasnotupdatedorchangedinany

way.(AmorecompletesummaryofDIisfoundintheAppendix,pages52-53.)

InmateHAwassentfromtheMainJailtoNBB4/8/17;fromNBBtoPRF4/13/17;

fromPRFbacktoNBBsayingshedidn’twanttoliveanymore;andreturnedfromNBBto


45

PRF4/26/17.Shewashousedinadministrativesegregationatthetimeofthesitevisit.

HAwasnotseenforfollow-upfromhavingbeenonsuicidewatchuntil4/30/17,fourdays

afterreturningfromNBB.Shewasnotseenbypsychiatryuntil5/11/17.HAhasbeen

bouncedbackandforthbetweenfacilities,buthertreatmentplanisnotchanged,shehas

notreatmentexceptmedicationandiscurrentlyhousedinadministrativesegregation.(HA

caseissummarizedonpage55oftheAppendix.)HAalsoreportedthatshestoppedtaking

hermedicationsbecauseshefeltshenolongerneedsthem.HApresentsmultiplerisk

factorsforsuicide–historyofpsychiatrichospitalization,priorsuicidewatchplacements,

non-compliancewithmedication,placementinadministrativesegregationtonameafew.

Yet,thereisnochangeinthefrequencyofintensityortypesofcontacts,supportorcloser

mentalhealthmonitoringofhercondition.

Maintenancecareandaccesstocareatanearlystageofaproblemorattheearliest

signofsymptomrecurrencecanpreventtheprogressiontoafull-blowncrisis,suicide

watch,transferandadmissiontoNBBorneedforinpatientlevelofcare.Infrequent

contactsandArmorstaffinglevelsdonotpermittheprovisionofthislevelofcare–

patientsnotidentifiedearlyandevenifidentified,donotreceiveadditionaloutpatient

interventions,morefrequentcontactsormentalhealthsupportandmonitoring.Clinical

studieshavedemonstratedthattheeffectsofpsychotropicmedicationareenhancedwhen

combinedwithotherformsofmentalhealthtreatment.Outpatientservicesareinadequate

andthisplacesinmateswithmentalillnessatriskofharmtoselforothersandto

experienceneedlesssuffering.


46

Outpatientmentalhealthcliniciansshouldplayarolewithsecuritystaffin

attemptingtode-escalatecrisesininstanceswhenaplanneduseofforceiscontemplated.

Thiscanhelpinavoidingtheplanneduseofforce,whichcanresultininjuriestoinmates

andstaff.(Obviously,thisisnotapplicableinaspontaneousorreactiveuseofforce

situation.)ThisfunctionisnotarticulatedinBSOormentalhealthpolicyandIfoundno

documentationthatthisfunctionoccurredintheclinicalrecordsreviewed.

Mentalhealthcliniciansshouldalsoplayaconsultativeroleinthedisciplinary

processforinmatesonthementalhealthcaseloadorforanyotherinmateforwhomthere

isaconcernabouthisorherunderstandingoftheprocess,behaviorormentalcondition.

Suchconsultationmayleadtotemporaryorpermanentdiversionoftheinmateinto

residentialmentalhealthtreatmentorhospitalizationifthebehaviorisbelievedtobea

manifestationofseriousmentalillness.Inotherinstances,analternativesanctionto

confinementinsegregationmaybeproposed.IdidnotfindthisfunctionarticulatedinBSO

proceduresorArmorpolicy.Iunderstandasimilartypeofinformalconsultationmay

occursomeofthetimeinsomesituations,butitneedstobeformal,routineandoccurinall

relevantsituations.Thiscanleadtoearlyidentificationofsymptomrecurrence,diversion

intotreatmentandriskreductionthroughtreatmentinterventionsaimedataddressingthe

problematicbehaviorsratherthanplacementintosegregationwhichisharmfultoinmates

withseriousmentalillnessandsimultaneouslymakesaccesstothemmoredifficultdueto

therequiredsecurityprecautionsineffectinthoseareas.


47

Mentalhealthservicesinsegregationunits

Thereisgrowingrecognitionwithinthecorrectionsprofessionoftheharmful

effectsofsegregation,particularlyoninmateswithseriousmentalillnessthoughothers

alsoexperienceharmfulpsychologicaleffects.Inmatesenteringsegregationshouldbe

screenedforcontraindicationstosegregationplacement.Ingeneral,inmateswithserious

mentalillnessshouldnotbeplacedinsegregationforprolongedperiodsoftime.(The

2012PositionStatementoftheAmericanPsychiatricAssociationdefinesaprolonged

periodoftimeas3-4weeks.)Inresponsetothegrowingrecognitionoftheharmfuleffects

ofsegregationoninmateswithseriousmentalillness,somecorrectionalsystemshave

developedhighsecuritylivingunitswithintensivementalhealthcareintowhichinmates

canbedivertedforplacementwhennecessaryforthesafetyofothersorasaconsequence

ofaruleinfractionratherthanbeingsenttosegregation.Insystemsorfacilitieswithout

thisoption,thereisrecognitionthatifinmateswithseriousmentalillnessareputinto

segregationevenforashortperiodoftime,mentalhealthtreatmentmustcontinuein

accordancewiththeservicesonthetreatmentplanorbeenhancedbasedupontheclinical

stateoftheinmateandtheconditionsofconfinement.Mentalhealthstaffinglevelshaveto

besufficienttoconductregularroundsinsegregationandclinicalinterventionswhen

necessaryforotherinmateshousedthere.

Currentstaffinglevelsinthejailsarenotsufficienttoprovideadequatemental

healthcaretoinmatesinsegregation.Firstly,althoughthereisamedicalscreening

conductedinthejailspriortosegregationplacement,itappearedroteanddidnotleadto


48

diversionofinmateswithseriousmentalhealthriskfactorsfrombeingplacedin

segregation.Infact,itdidn’tappeartoresultinnotificationofmentalhealthstaffofthe

placementoftheinmateintosegregationwhichiscriticalintermsofcontinuingmental

healthcareduringplacementinsegregation.Mysamplewassmallbuttheprocessseemed

tobedonetocomplywithpolicyrequirementsratherthanwithanunderstandingofthe

importanceorpurposeofdoingthetask.

The“UseofConfinement/RestraintClearance”forminthechartofinmateFJ

indicatedshehasamajormentalillnessbutitdidnotprecludeherplacementinto

segregationorensureanyadditionalmentalhealthcontactormonitoringwhenshewas

there.Infact,itdidnotindicatethatmentalhealthstaffhadbeennotifiedofherplacement

inordertoassuretheprovisionofregularlyscheduledon-goingcare.(FJsummaryison

page53oftheAppendix.)

InmateDCwasplacedintosegregation5/4/17.Pre-placementscreeningindicates

“Yes”inresponsesrelatedtobeingonpsychotropicmedication,havingmajormental

illnessandbeingonspecialaccommodation(detoxprotocol).However,shewasstill

“cleared”forconfinementandmentalhealthwasnotnotified.(DCsummaryisonpage54

intheAppendix.)

InmateSDwasonsuicidewatchatNBB4/6/17–4/17/17forhavingplaceda

plasticbagoverherheadinanattemptedsuicide.Thewatchwasreducedtopsych

observationuntil4/20/17.ShewastransferredtoPRF5/11/17andwasplacedinto


49

segregation.Pre-placementclearanceindicates“Yes”responsestohistoryofself-harm

(plasticbagoverhead)andbehavioralhealthmonitoringstatusinthelast90days.She

wasnotexcludedfromplacementinsegregation,norwasmentalhealthstaffnotifiedofthe

placement.(SD’scaseissummarizedonpage55.)

Ifnotdivertedaltogether,itisimperativethatmentalhealthstaffareatleast

notifiedoftheplacementofcaseloadinmatesinsegregation–anareawhere

proportionatelymoresuicidesarecompletedincorrectionalfacilitiesofalltypes.Asit

stands,mentalhealthstaffinglevelsatthejailspermitonlybrief,cellfrontcontacts(rounds

insegregation),butminimally,mentalhealthstaffshouldbeawarethattheirpatientsare

insegregationandatrisk.

MentalHealthUnit(MHU)Residentialcare–NBB

ThementalhealthunitsatNBBpurporttobetreatmentunits,butdeficientstaffing

levels,inadequateconfidentialtreatmentspaceandoverallfailuretoappreciatethe

missionofresidentialtreatmentperse,maketheseopenmentalhealthunitssimplyan

extensionofanyothergeneralpopulationoutpatienthousing.Theconditionsof

confinementintheclosedmentalhealthunitsactuallyappeartomimictheconditionsin

segregationalongmanyparameters(limitedoutofcelltime,cellfrontcontacts,limited

socialization)ratherthanintensivetreatmentsettings.

Treatmentmodalitiesincorrectionalfacilityresidentialmentalhealthhousingunits

generallyincludepsychoeducationalgroups,psychotherapeuticgroups,psychosocialand


50

activitygroups,individualcounselingandmedicationmanagement.AtNBB,thereis

virtuallynotreatmentexceptmedicationforthemajorityofinmatessentthereformental

healthtreatment.Averyfewinmatesreceivedoccasionalsupportivecounselingsessions,

buteventhesearenotconductedinaconfidentialsetting.Individualappointmentsare

conductedatatableinthecommonareaofthehousingunit,inthehallwayoutsideofthe

housingunitoratthecellfront.8Confidentialityisanecessaryrequirementforallof

healthcare,butparticularlymentalhealthcare.BSOprogramstaffprovide

psychoeducationalprogrammingintwooftheopenmentalhealthunitsthoughthisis

limitedtoinmatesthatarestableandconsidered“programming”ratherthan“treatment”

accordingtostaff.

TherearenoclearadmissionordischargecriteriafromtheNBBmentalhealthunits.

Therearenoregularlyoccurringtreatmentteammeetings.Individualinmatecondition,

progresstowardgoalattainmentandadjustmentofinterventionstoachievedesired

outcomesshouldbereviewedbyamultidisciplinarytreatmentteamatregularintervals

andanytimethereisachangeintheinmate’scondition.Everyinmateshouldhavean

updatedtreatmentplanwhenadmittedtothementalhealthunits.Aswithoutpatient

services,thetreatmentplansinthementalhealthunitsaremeaningless.Theydonot

reflectservicesactuallyprovidedoravailablecontainnoobjectivecriteriabywhichto

measureprogressandarenotupdatedtoreflectachangeintheinmate’scondition,

placementordiagnosis.Therearenotreatmentprogramguidelineswithrespecttothe

8Thispracticeappearsunchangedsinceatleast2006whenDr.Metznerrecommendeditbeaddressed.


51

typesandfrequencyoftreatmentinterventionstobeprovidedintheopenandclosed

mentalhealthunits.Therehasbeenalong-standingrecommendationthatinmatesin

residentialtreatmentbeofferedatleast10hoursofunstructuredout-of-celltimeand10

hoursofout-of-cellstructuredtherapeuticactivityperweek.TheBSOstaffprogramming

unitsexceedtheseguidelinesandtheotheropenmentalhealthunitsprovidemorethan

therequisite10hoursofunstructuredoutofcelltime.Theclosedmentalhealthunits

provideneither.9Therearenopracticeguidelinesfortransitioninginmatesoutofthe

mentalhealthunitsbackintopopulation.(Preparationoftheinmateforthedischarge,

frequencyofcontactsinthenewjail,etc.)Thelackoftransitioningcanhavesevere

consequences.

InmateJVenteredjail2/15/13asastatehospitalreturnwithdiagnosesof

“malingering,adjustmentdisorderwithmixedanxietyanddepressedmood.”Whilein

booking,hewasfoundtryingtohanghimself.Hewasplacedonsuicidewatchand

admittedtotheinfirmaryintheMainJail.HewastransferredtoNBBonsuicidewatch.

JVremainedatNBBforalittleoverayearandwas“transferredperclassification

requesttoMJ”onMarch3,2014thoughthetransferacceptanceformwasnotcompletedat

theMainJailuntilMarch7,2014.(HeappearstohavebeenreleasedtopopulationatNBB

foramatterofhourspriortobeingsenttopopulationintheMainJail.)JVcommitted

9ThisalsoappearsunchangedsinceDr.Metzner’scriticismofitandrecommendationsmadein2006.


52

suicidebyhangingattheMainJailonMarch8,2014.(JV’scasesummaryisonpages67-68

oftheAppendix.)

TheNBBmentalhealthunitsfailtoprovidementalhealthtreatmentinterventions

otherthanpsychotropicmedicationforthemajorityofinmatessenttherefortreatment.

BSOprogramstaffprovidedailyprogramgroupsontwooftheopenmentalhealthunitsas

describedearlierintheNBBsectionofthisreport,eachofwhichhouses21inmates.

However,programmingintheclosedmentalhealthunitsisespeciallyproblematic.

Coincidentally,inmatesintheclosedmentalhealthunitsarealsobyandlarge,themost

seriouslyillandsymptomatic.Thereislittlestructuredprogrammingofferedintheclosed

unitsandinmatescanremainthereformonthsandmonthsandmonths,sufferingand

withouttreatmentoftheirseriousmentalillnesses.Someoftheseinmatesrefuse

medicationandthejailcannotoverridetheirrefusal.Consequently,theyaretooillto

participateinwhatlittlestructuredtreatmentisoffered(an“open”mentalhealthgroup)

andsometimestooilland/ordangeroustobeletoutoftheircellsforanyopportunityfor

otherpsychosocialinteractionsorindividualassessmentorcounseling.Someofthe

inmatesinclosedmentalhealthwereinneedofpsychiatrichospitalization.

InmateLBwasmentionedintheScreeningandAssessmentsectionofthisreport,

buthiscaseisalsorelevanthereandasanexampleofaninmateindesperateneedof

psychiatricinpatientcare.Whenseeninhisclosedmentalhealthunitcell,LBwasmaking

gutturalsoundsandwearingsomethingthatlookedlikeadiaperorswaddlingshorts.He

appearedveryregressedanddidn’tverbalizeanythingthatwascomprehensibleasspeech.


53

Theinmatehadbeenlockedinwhatamountstosegregationforalmostayearwithno

treatmentinterventions.Therewasnodocumentationthatpsychiatrichospitalizationwas

beingconsidered.Mentalhealthstaffstoodoutsidehisdoorperiodicallytoroundonhim.

LBwastooregressedformeaningfulinteractionorcommunication.(Amorecomplete

summaryonpages24-25ofAppendix.)Thereisnowaythatthismanwouldbeableto

appearincourtinthiscondition,norcouldtherebeanysortofreleaseplanningifhis

chargesweredropped.(NotethattheDefendantsreportedthatLBwastransferredtothe

stateforensichospitalon5/26/17.Ibelievethiswasforrestorationofhiscompetencyto

standtrialratherthanasaresultofaBakerActcommitmentgivenhisconditionand

pendingfelonychargeswhichwouldallowcivilhospitalstorefusehimadmissionunder

Floridalaw.)

Insummary,thereareanumberofseriousissuesintheMHU.Non-compliantand

acutelyseverelymentallyillinmateswhorefusemedicationandaredeniedaccessto

inpatientcaremustwaituntiltheyaresenttoastatehospitalforrestorationof

competencytostandtrialbeforetheyreceivetreatmentisthemostseriousoftheissues.It

isaconstitutionalviolation.WhiletheBSOanditscontractorcannotcontrolwhetheror

notcivilhospitalsagreetoacceptseriouslymentallyillinmates,thereareotheroptions

thatarenotroutinelyexercisedthatwouldaddressandifnoteliminatethisissue,would

certainlyamelioratethesuffering.Apartiallistoftheseoptionsincludes,enactingan

internalinvoluntarymedicationprocess(discussedmorefullyintheMedicationsection

infra),initiatingguardianshipproceedingstoseekguardianpermissiontomedicateover

theward’sobjection,increasedout-of-cellstructuredtreatmentprogramming,


54

individualizedtreatmentplanningandtreatmentteammeetingsforeveryinmateto

increaseintensity,frequencyandtypesofinterventionsinordertoengagetheinmatein

treatmentparticipation.Otheroptionsarealsopossibleaswell.Ascurrently

operationalized,asinmateswithseriousmentalillnessrefusemedicationsanddeteriorate,

treatmentinterventionsarereducedratherthanintensified;theinmateisheldinclosed

mentalhealthhousingunitsandstaffseehimonlyatthecellfront.

Accesstoinpatientcare

Accesstoinpatientlevelofcareforpatientswhodesperatelyneeditisprofoundly

lackingandappearstobealong-standingproblemasitwasalsoafocusofconcernatthe

timeofDr.Metzner’sreportin2006.Thejaildoesn’tprovidethetypesofservicesavailable

inahospitalandBSOandArmorstaffacknowledgethatuseofFlorida’scivilcommitment

process(theBakerAct)isnotareliablepathtohospitalization.Inmateschargedwith

violentfeloniesarenoteligibleforhospitalizationviatheBakerAct.Theseinmatesmust

waitmonthstoaccessahospitallevelofcareuntilbeingfoundincompetenttoproceed

withtheircriminalcourtcase.DuringmyvisitstotheMHUandinfirmary,therewere

manyinmatesinneedofhospitallevelofcare.Generally,BSOandArmormentalhealth

staffagreedthattheseinmateswereinneedofhospitalization.Insomeinstances,theyhad

initiatedBakerActproceedings,butthereceivingfacilityassessorsrefusedhospital

admission.Inotherinstances,staffknewthatevenattemptingtousetheBakerActwas

futileandweresimplywaitingforthecriminalcourttofindtheinmateincompetentand

orderhospitalizationforrestorationofcompetency.


55

TheroutetocivilcommitmentviatheBakerActisnearlyunavailabletoinmatesin

thejail:receivinginstitutionscanrefuseadmissionsbasedupontheirassessmentthatthe

patientcannotbemanagedsafelyintheirfacilityandtheNorthBrowardHospitalDistrict

willnotadmitinmateswithpendingfelonychanges.Therealsoappearstobesome

strangeequivalencybetweenbeingheldinsegregation-likestatusatthejailwithno

treatmentandinpatientpsychiatriccareinthemindsofmanyoftheBakerActreceiving

facility“assessors”whichisabsolutelyridiculousanddefiestheobviousdifference

betweenjailsandhospitals.Whileitmaybetemptingtosimplysaythatsomeofthese

factors,suchastheBakerActitselfandthereceivingfacilities’refusaltoacceptinmates,

arewhollyoutsidetheBSO’scontrolandtherefore,theBSOshouldnotbeheldresponsible

oraccountableforfailingtoprovidetimelyaccesstoinpatientcare,theirresponsibilityis

notsoeasilydismissed.Armor’scontractwiththelocalhospitalsystemcoversmany

medicalspecialtiesbutissilentwithrespecttopsychiatricinpatientcare.Inmatesneeding

ahospitallevelofcareareheldinthejailandreceiveless,ratherthanmoreintensive

treatmentorattemptsattreatmentthanother,lessillinmatesashaspreviouslybeen

discussed;contactsareatthecellfront,frequencyandtypesofcontactarenotincreased,

thetreatmentplanisnotreviewed/updated.Nominally,increasingthefrequencyand

intensityoftreatmentmodalitiesandcontactsisrequiredwhileawaitinginmatetransferto

amoreappropriatelevelofcare.

InmateDWcameintothejailfromthestatehospital4/15/15;wasonwatch

multipletimesandforextendedperiodsoftime.Whennotonwatch,hewashousedin

closedmentalhealthandseenonlyforweeklyroundsatthecellfront.Notesindicatehe


56

“didn’tengage”andthatistheextentoftreatmentsummary.Heattackedstaff,ortriedto

attackstaff,butwasgivennomedications.Hewasconsideredtooviolenttotakeoutofhis

cellforanysortofmentalhealthassessmentortreatment.Hewasconsideredtoo

unpredictableandviolenttogototheclinicbutwasletouttothevisitingroomtoseethe

outsidepsychologistsenttodoacompetencyevaluation–andhetriedtoattackthat

person.Thisisanexampleofacasethatmakeslittlelogicalsense.Thejailreceivedthis

manfromastatehospital.Herefusedtreatmentatthejailandclearlydecompensated.He

washousedinisolation,bothinclosedmentalhealthandintheinfirmaryandstaff(BSO

andArmor)wereessentiallypowerlessintermsofgettinghimtreatment.Theycouldnot

ordidnotinvoluntarilymedicate;DWwasconsideredtooviolentandunpredictableto

civillycommitviaBakerActandsohecontinuedpsychotic,sufferingandhighly

symptomatictothepointwheremedicalandmentalhealthstaffcouldonlyattemptto

interviewhimfromoutsidethecellduetothedeputies’concernsforstaffsafety.He

presentedsuchahighriskofharmtoothersthathewasnotpermittedoutofcelltoattend

medicalormentalhealthappointments.Finally,andonlybyvirtueofhissevere

decompensation,DWwastransferredtoanoutsidetreatmentfacility9/22/16,butittook

morethanayearofneedlesssuffering,untreatedmentalillnessanddangerousness

towardsotherstogettotreatment.Jailinmatesmusthaveaccesstoahospitallevelofcare.

(AmorecompletesummaryofDWisonpage60oftheAppendix.)

InthecaseofTD,Armorstaffdidattempttohavehimevaluatedforahospital

admissionpursuanttotheBakerAct.InmateTDunderwentintakeintotheMainJail

9/8/16andwashousedintheinfirmaryandthenthedetoxunitforseveraldays.TDwas


57

onsuicidewatch9/16/16-9/25/16;10/3/16-10/24/16;11/21/16-11/23/16;11/25/16-

12/3/16;12/8/16-12/19/16andagain12/27/16.HewasmovedintotheNBBinfirmary

onsuicidewatch2/1/17becausehewasnotspeakingoreating.Theinmate’sbodyweight

andothervitalsignswerenotroutinelycollectedeitherbyvirtueoftheinmate’srefusalor

thedeputies’notpermittingnursingstafftoentertheinmate’scelltoexaminehim.Armor

staffdidattempttosendhimtoacivilhospitalinFebruary,buttheBakerActpre-screener

wrote:“Theclientiscurrentlyinahighlymonitoredandsecuredinstitutionthatwould

affordagreaterdegreeofsafetythananycommunityinpatientfacility.Assuch,the

assessingcliniciandeterminedtheclientdoesnotcurrentlymeetthefullandnecessary

criteriaforaninvoluntarypsychiatricassessmentatacommunityinpatientpsychiatric

facilitywhileremaininginahighlysecuredandmonitoredsettingasthatoftheBSO

DetentionFacilities.Thisassessmentshouldnotinandofitselfbeinterpretedtojustifythe

client’sreleaseorcontinuedplacementonanysuicidewatchprocess.”(Ofnote,thepre-

screenerdidnotinterviewtheinmatebecauseherefusedtocomeoutoftheinfirmarycell

foraninterview.)Thepre-screener’sconclusionthataninmatewhohasbeenonmultiple

suicidewatchesforextendedperiodsoftime,whoisrefusingtreatment,foodandto

communicatedoesn’tmeetthe“fullandnecessarycriteriaforinvoluntarypsychiatric

assessment”ispreposterous.BSOandArmorstaffreportedthathospitalizationhadbeen

deniedbythepre-screenerforsimilartypesofconclusionsonmanyotheroccasionsas

well.Ultimately,denyinghospitalizationforthesetypesofreasonshasachillingeffecton

thewillingnessofBSOandcontractstafftoevenattempttousetheBakerAct;thereisno

pointindoingsoifthehospitalizationisgoingtobedenied.Waitingforthecriminalcourt

toactontrialcompetencyisamuchsurerpathtohospitalizationeventhoughitcantake


58

monthstoaccomplish.TDissufferingneedlesslyandatriskofseriousillnessordeath.

(TD’scasesummaryisonpage29oftheappendix.)

Lackofaccesstohospitallevelofcareisalong-standingproblem.Ireviewed

recordsofinmateWHwhodiedin2012afterahungerstrikethatlastedmorethan40

days.Hewasoriginallyadmittedtothejail10/26/12thoughhewastherepreviouslyand

treatedwithantipsychoticandantidepressantmedication.Hewasidentifiedashavinga

psychoticdisordernototherwisespecifiedandbipolardisorder“byhistory.”Hesaidhe

wasfastingaspartofsome“spiritualbelief”andplacedonsuicidewatch.Hecontinuedto

fastandwasmedicallyhospitalizedfor5daysinNovemberduetoelectrolyte

abnormalitiesandcompromisedkidneyfunction(consequencesofprolongedfasting.)WH

wasreturnedtothejail11/13/12andhousedintheinfirmary.Nolabstudiesweredrawn

atthejailandnomedicationswereorderedforhim.Themedicalcenter’spsychiatrist

plannedtopetitionforacivilcommitmentviatheBakerActbutWHwasreturnedtothe

jailwherethedischargeplanneraskedthecriminalcourttomoveupthedateofacourt

appearanceinhopesthatthejudgewouldsendWHtoahospitalforcompetency

restoration.Thehearingdatewasmovedupto11/16/12butWHcollapsedinpolice

custodythatday.Hewastransferredasanemergencytothehospitalwherehewas

admittedmedically.WHneverregainedconsciousnessanddied12/23/12dueto

complicationsofelectrolyteimbalanceduetoprolongedfasting.(WH’scaseissummarized

onpage73intheappendix.)


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Inmateswithseriousmentalillnessaresufferingneedlessly.Therisksofuntreated

seriousmental illnessare increasedand include self-injury, suicide, assault and injury to

other inmates and staff. Furthermore, when treatment is delayed, it takes longer for

symptomstoimproveandtheimprovementisnotasrobustasitwouldotherwisehavebeen

iftreatmenthadbeenprovidedmoretimely.It’sabsolutelyinhumane.Shortofachangeof

thestatecivilcommitmentprocedures,Idon’tseeasolutionotherthanthejailcontracting

directlywithan inpatientprovidertopermitadmissionsof jail transfersoropeningtheir

owninpatientunit,whichisnotfeasible.

IntegratedCare

Chartreviewsdemonstratedthatthereareproblemswithintegrating/coordinating

medicalcareforinmateswithseriousmentalillness.Atthetimeofintake,iftheinmate

washighlysymptomaticoruncooperativewithmedicalstaff,themedicalassessmentwas

notcompleted.Itdidnotappeartohavere-attemptedatalaterdateandtheinmatenever

receivedthemedicalassessmentinsomeinstances.Caseexampleswereprovidedinthe

screeningandevaluationsectionofthereport.

Therewereissueswithaccesstomedicalcareforinmateswithseriousmental

illnessconfinedintheclosedmentalhealthunitsatNBB.Thiswasnotedinoneparticular

casesummarized,butalsorecognizedtobeanaccessproblembythemedicaldoctor.SB

hadseriousmentalillnessatthetimeofhisbookingintothejailinmid-February2016.He

wasinitiallyadmittedtothedetoxunitbuttransferredtoNBBandplacedintoaclosed

mentalhealth.Heexperiencedsomementalchanges(delusionsanddelirium)thatwere


60

attributedtohismentalillness,buthealsocomplainedofabdominalpainandhad

tenderness,lowbloodpressure,elevatedheartrate,vomiting,diarrheaandbecame

incontinentofurineandstool.Hewaseventuallyadmittedtotheinfirmarybutshould

havebeensentoutforemergencymedicalcare.Hediedofperitonitisduetoabowel

perforation.Inthiscase,neitherhispsychiatricconditionnorhisphysicalconditionwas

appropriatelyassessedortreatedpromptly.Inreviewingthecase,themedicalservices

physicianatthejailconcluded“diureticsshouldbeavoidedinclosementalhealthwhere

labsarenotregularlyandoftenmonitoredspeciallyifonmultipleBPmeds.”Oddly,rather

thanaddresstheveryseriousissueofaccesstopermitregularmonitoringandlaboratory

studies,theproposedsolutionwastolimitbloodpressuretreatmentoptionsthoughthisis

fairlyindicativeofthewayothercasesofpatientswithbothpsychiatricandmedicalissues

havebeenmanaged.(SB’ssummaryisonpages65-67oftheAppendix.)ThecaseofRP

wasalsomentionedintheScreeningandAssessmentsectionofthereport.Hewasthe

inmatewithsevereweightlossandbloodinhisurinethatwassenttotheintensivecare

unitbutputbackintoclosedmentalhealthbackatthejailwherehisaccesstomedicalcare

wasimpeded.(RP’scasesummaryisonpages68-69oftheAppendix.)

Finally,therewerecasesinwhichacutechangesinmentalstatewereincorrectly

attributedtopsychiatricillness.Insomeinstances,thisoccurredduringsubstanceuse

withdrawalbutinothers,therewereseriousmetabolicproblems.

AFwasbookedintothejailandplacedonawithdrawalprotocol.Shehadahistory

ofhavinghadawithdrawalseizureinthepast.Notesfromthenurseindicateshewas


61

“veryjaundiced”5/18/16at1800;shewasincontinentofurineandfeces5/18/16at0300,

anddisorientedand“inappropriate”sonolabsweredrawn.AFwasunresponsivearound

midnightwithnovitalsigns5/18/16andtransportedoutbyEMSaftermidnighton

5/19/16.AF’scasereviewraisesconcernsaboutthewayinwhichacutechangesin

mentalstatusaremanagedatthejail.(AF’ssummaryisonpages73-74oftheAppendix.)

TBwasbookedintothejail5/27/16.Hehadahistoryofschizoaffectivedisorder

andhadpreviouslybeenapatientattheSouthFloridaEvaluationandTreatmentCenter

(SFETC).Hewasplacedonpsychobservation5/28/16andsentfromtheMainJailtoNBB.

On6/8/16,therewasadeterminationthattheinmatehadbilateralpneumonia.Hewas

transferredouttothehospital’semergencydepartmentbutrefusedcare.Hewasreturned

tothejailthesamedayandplacedintheNBBinfirmary.Onthesameday,aBakerAct

certificatewascompletedindicatingtheinmatewas“medicallycleared”forpsychiatric

admission,thoughthisdoesnotappeartobethecasesincehehadpneumoniaandrefused

treatment.At1605,theBakerActteamandEMStooktheinmatetoBGH.Itdoesnot

appearfromtherecordthatheeverreturnedtothejail.(TBcasesummaryisonpages63-

64oftheAppendix.)

Finally,inthecaseofMV,summarizedonpages61-62oftheAppendix,themedical

physicianwasadvocatingforanimmediatetransfertoapsychiatrichospital.However,the

inmateinquestionhadveryseriousmedicalproblemsandhadrecentlybeenmedically

hospitalized.Heshouldhavebeensentoutformedicalstabilization.Asitwas,hedied

afterasecondemergencymedicalhospitalizationwhenfound“unresponsiveandgasping”


62

atthejail---notaconsequenceofmentalillnessbutrather,aseriousmedicalcondition.

Hewashousedinclosedmentalhealthandwasnoteating,buthismetabolicissueswere

notaddressed.Theproposedsolutionwastransfertoapsychiatrichospital.

Regularmultidisciplinarytreatmentteammeetingsthatincludeparticipationof

medicalandmentalhealthprovidersforeveryinmatewithco-existingseriousmedicaland

mentalhealthneedsarenecessarytoreducetheriskofworseningphysicalconditionand

death.

ContinuousQualityImprovement

AContinuousQualityImprovement(CQI)programistheprocessutilizedinhealth

careorganizationstoassessanumberofparametersincludingtimelinessoftreatment,

appropriatenessoftreatmentinterventions,costefficiencyandpatientresponseto

treatment,amongotherparameterstoidentifytrendsandpatternstodeterminewhethera

correctiveactionisrequiredtoimprovecare.Itincludescomprehensivereviewsofcritical

incidentsanddeaths,processandoutcomestudies,professionalpeerreviewandpatient

satisfaction.

AtthetimeofDr.Metzner’s2006report,theprogramwasrelativelynewatthejail

andhehadanumberofsuggestionsofqualityimprovementstudiesthatincluded:

• Timelinessofnewadmissionsreceivingprescribedpsychotropicmedication

• Participationrateofinmatesparticipatinginstructuredtherapeuticactivitiesinthe

closedmentalhealthunitswithfocusonhowratecouldbeincreased


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• Increasingstructuredtherapeuticout-of-celltimeandunstructuredout-of-celltime

offeredonadailybasistoinmatesontheclosedmentalhealthunits

• Treatmentinterventionsrelatedtoinmatesrefusingpsychotropicmedications

• Clinicalcourseofinmatesreturningtojailfrompsychiatrichospitalization

Clearly,giventhecurrentstateofmentalhealthcareprovidedatthejail,someofthe

suggestionsmadein2006cannotbecompleted:measuringparticipationratesfor

structuredandunstructuredout-of-celltimeisnotrelevantwhenthereissolittle

structuredinterventionontheclosedmentalhealthunits,staffinglevelsdonotpermitany

sortofinterventionforinmatesrefusingmedicationorincreasingstructuredtherapeutic

out-of-celltimeontheclosedmentalhealthunits.Theclinicalcourseofinmatesreturning

tojailisnotstudiedinqualityimprovementstudies.Unfortunately,whatmayhavestarted

asanambitiousCQIprogramappearstohavestagnatedintoamuchearliertypeof“quality

assurance”programofchartaudits,atleastasfarasmentalhealthisconcerned.10

TheinformationprovidedtomerelatedtotheQIprogrampertainingtomental

healthconsistedprimarilyofchartauditstomeasurethepresenceorabsenceofvarious

elementsrelativetospecificpoliciesandprocedures.(Exampleswereprovidedregarding

intakeinwhichauditquestionssimplycheckwhetherornotvariousformswerecompleted

requiringa“yes”or“no”responseandcompliancewithtimelinesstatedinpolicy.)The

10DefendantsprovidedstudiesofparticipationratesintheclosedmentalhealthunitsconductedinresponsetoDr.Metzner’ssuggestionsconductedin2006,2007and2009,nonemorerecent.


64

chartauditsarerepeatedatregularintervalsandhavenotchangedsubstantiallyinseveral

years.Therewerenoprocessoroutcomestudiesformentalhealthservicesduringthe

pasttwelvemonths.

Arobustqualityimprovementprogramconsistsofmuchmorethanchartauditsand

allowssystemstoidentifyproblems,takecorrectiveaction(s)andre-assesstheissueto

determinewhetherornotthecorrectiveactionwassuccessfulinreducingoreliminating

theproblem.


65

Staffing

Armorstaffinglevelsareinadequatetoprovideanytreatmentservicesotherthan

briefpsychotropicmedicationmanagementappointmentsandraresupportiveindividual

counselingsessionstoveryfewinmates.Thisistrueinthejailfacilitiesthatprovide

“outpatient”mentalhealthcareaswellasNBBthatcontainsthementalhealthunits.

Roundsandcellfrontcontactsdonotconstitutetreatment.Theremustbesufficient

numbersandtypesofstafftoprovideactualtreatment,includingindividualandgroup

counselingaswellaspsychosocialprogramming,mostespeciallyinthementalhealth

housingunits.

Armormentalhealthstaffappeartobeappropriatelytrainedandcredentialedto

providementalhealthcare–theresimplyaren’tenoughofthem.Mentalhealthstaffing

levelsmustbesufficienttoprovidescreeningandevaluation,crisiscare,routineoutpatient

careincludingroundsandtreatmentinterventionstoinmateswithseriousmentalillness

housedinsegregationstatusandaresidentialtreatmentlevelofcare.11Currentstaffing

levelssimplydoesnotpermitArmortoprovidethefullcontinuumoftreatmentandasa

result,inmateswithmentalillnessarenotreceivingadequatecare.

11IndiscussionswithArmorstaff,itwasnotclearthattheysharedthesamephilosophywithrespecttotheirinvolvementinprovidingacontinuumofservices.Iwastoldthattheyviewedtheirroleas“identificationandstabilization.”


66

TheAmericanPsychiatricAssociation’sbriefmonograph“PsychiatricServicesin

CorrectionalFacilities,ThirdEdition”recommendsthatforajailgeneralpopulationthere

be“oneFTEpsychiatristforevery75-100patientsreceivingpsychotropicmedication”and

oneFTEpsychiatristforevery50patientsinresidentialtreatmentunits.12These

recommendationsdonottakeintoaccounttheroleofpsychiatristsinthediagnostic

assessmentprocessanddailyassessmentsofallinmatesonsuicidewatchstatuswhich

resultsinagreaterneedthanasimpleratioofoneFTEto75-100generaloutpatients.In

otherwords,MainJailrequiresadditionalstaffingbasedonaverybusyreceptionprocess,

frequentandextendedsuicidewatchesconductedintheinfirmaryaswellasonthe8th

floor,detoxificationunitsandgeneraloutpatients.Applyingtheratiotothe385inmates

reportedonthementalhealthcaseloadattheMainJailatthetimeofthesitevisit,the

recommendedstaffinglevelwouldrangefrom3.8to5.2FTE.TheMainJailhasonly1FTE

psychiatrist(0.8FTEpsychiatristand0.2FTEARNP).Havingthisdegreeofdeficit

translatesintobrief,cursoryevaluationsincludingriskassessmentsofsuicidalinmates,

non-confidentialcellfrontcontactsatminimallyrequiredintervalsratherthanpermitting

theflexibilitytoscheduleappointmentsaccordingtoclinicalneed.JVCFandPaulRein

Facilityhadacombinedmentalhealthcaseloadof561atthetimeofthesitevisits.This

wouldrequireatleast5FTEpsychiatristsusingtheAPAratiosbuttheyhaveacombined

totalofonly1.8FTE.Inordertoactuallyprovidearesidentialtreatmentlevelofcare,NBB

requiresaratioofoneFTEpsychiatristfor50bedsandtherearepsychiatrists(1fulltime,

12TheAPAguidelinesdonotprovidestaffinglevelsforanyothertypeofmentalhealthprofessionalanddonotexplicitlyaddresstheroleofmidlevelproviderssuchasARNPsandPAsusedintheBrowardCountyjails.Forpurposesofthisdiscussion,theratiosexpressedshallberelevanttouseofeitherapsychiatricphysicianormidlevelpractitioner.


67

1part-time),ARNPs(3fulltimeand1part-time)andatleastoneFTEPA.(TheotherPAis

primarilyadministrative.)Thisfacilityismuchclosertotherecommendednumbersin

termsofthemedicationmanagementneedbuttheprimaryissueatNBBisthelackof

additionalmentalhealthtreatmentotherthanpsychotropicmedicationmanagement,for

patientsthatconsenttotakingmedication.ThereareonlytwoFTElicensedmentalhealth

clinicians,whichisinsufficienttodoanythingotherthanroundsandcellfrontcontacts.

Theremustbemanymorementalhealthcliniciansinordertoengagepatientsin

meaningfultherapeuticout-of-cellactivityonallofthehousingunits---notjustthe

programmingrunbyBSOprogramstaffontwoopenmentalhealthunits.Othermental

healthprofessionalssuchaspsychologystaffpositions,activitytechniciansandattendants

arealsorequiredtoprovideresidentialtreatment.

Theneedformentalhealthcounselorsattheotherjailsisequallydire.AtMainJail,

theloneArmorpsychologistisassignedtodetoxevaluationsanddoessomecounseling.

Thementalhealthcounselorisfulltimebut20%ofhistimeisspentasthesolecounselor

atConteonedayperweekforacaseloadof319inmates.AttheMainJail,heisassignedto

doinitialmentalhealthevaluationsandsomecounselingifthereisanytimeleftinhis32

hours.PaulReinFacilityalsohasmentalhealthcoverageonlyonedayperweekfor242

inmatesonthementalhealthcaseload.Thejailsofferingoutpatientmentalhealthcareare

very,veryshortstaffedintermsofmentalhealthcounselors.TheAPAGuidelinesdonot

addressmentalhealthcounselorstaffinglevels.However,Irecommendtherebeone

mentalhealthcounselorforarangeof50-100inmatesontheoutpatientcaseload,theexact

placementinthatrangebeingdeterminedbythenumberofothertasksrequiredatthat


68

facilitysuchasinitialassessments,segregationrounds,typicalnumberofmentalhealth

crisesataparticularjail(treatmentofinmatesonsuicidewatch)aswellasthesecurity

levelofthefacility.(Itiseasiertoaccesslowersecuritylevelinmatesbecausetheyare

permittedmuchbroaderandunescortedmovementtoappointments.Manymoreofthem

canbeseenthanwhenprovidingcaretohighersecurityinmateswhohavetobesearched,

cuffedandescortedtoandfromappointmentswithoneortwocustodystaffwhoalsohave

competingresponsibilities.)

Thejailmentalhealthstaffinglevelsareinsufficienttoprovideadequatemental

healthtreatmentatanylevelofcare:intake,outpatientandresidentialtreatment.


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Medications

Thisprovisionwasoriginallyarticulatedtopromoteappropriateuseand

monitoringofpsychotropicmedication.Theuseofpsychotropicmedicationininstitutional

settingshasacheckeredhistorythatinvolveduseofsomeofthesemedications

administeredasameansofchemicalrestraintratherthanbeingprescribedfora

psychiatricsymptomindication.Armormaintainsapolicyspecifictotheuseof

psychotropicmedication(J-D-02.5),whichrequiresreferraltoanappropriatelylicensed

andcredentialedproviderwithprescriptiveauthorityforallpsychotropicmedication

orders.Theseincludepsychiatrists,advancedregisterednursepractitioners(ARNPs)and

physicianassistants(PAs.)Psychotropicmedicationsarenotadministeredwithoutan

orderfromaprescriber.

Inmatesareprovidedinformedconsentformedicationsandhavearighttorefuse

them,exceptinverylimitedemergencysituations.Infact,inmaterefusalsabsentatime

limitedemergencycanbeover-riddenonlyiftheyaretransferredtoahospitalwhere

additionalproceedingsmaypermitadministrationoverrefusal.Howeverhelpfuland

clinicallyappropriatethesetypesofordersmaybe,theyarerelevantonlyduringthe

inmate’shospitalstayandnotuponreturntothejail–whereitismostlikelyinmateswill

againstoptakingprescribedmedications.

Thereisanother,infrequentlyusedoptionfortreatmentoverobjectionthoughit

alsooftenimpracticalandisnottimely.Thisoptionrequiresajudicialfindingof


70

incompetenceandtheappointmentofaguardiantomaketheward’streatmentdecisions.

Asmentioned,thisoptionisnotalwayspracticalinthatitinvolvesanextensiveclinical

examination,afindingthattheinmatelacksdecision-makingcapacityandtheavailability

ofasuitableguardiantoconsenttomedicaltreatmentandmanagealloftheward’sother

affairs.Thereisalsonoassurancethattheguardianwouldprovideconsenttothe

medicationrecommendedorconsenttoforcibleadministrationifthewardrefusedoral

medication.Thisoptionispossiblebutnotalwayspractical.

Forallintentsandpurposes,thecurrentlimitationstotreatmentoverobjection

presentseriousbarrierstotreatmentatthejail.Inmateswithseriousmentalillness

refusingmedicationmustgettoahospitalfortreatmentoverobjectionbuttheyaredenied

admission.Theycannotbetreatedoverobjectionatthejailandsoremainuntreatedand

eventually,isolatedandhousedunderconditionsthatresembletheconditionsof

segregation–conditionswhichfurtherexacerbatetheirseriousmentalillness,which

makesthemlesslikelytobeapprovedforhospitalization,andthecyclespiralsever

downward.

Othercorrectionalsystemsandfacilitieshaveadoptedaproceduresimilartoone

initiallydevelopedintheWashingtonstate.In1990,theUSSupremeCourtupheldthe

Washingtonpolicythatpermittedcorrectionalfacilitiestooverridemedicationrefusals

underlimitedcircumstances.13TheWashingtonpolicymadeprovisionsforaninternal

13WashingtonvHarper494US210(1990)


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hearingprocessinvolvingmentalhealth/medicalprofessionalswithnocurrenttreatment

relationshipwiththeinmatewhowerechargedwithmakingthedecisionaboutwhether

theinmatecouldbeinvoluntarilytreated.Theinmatealsohadanumberrightsatthe

hearingincludingtherighttobeevaluated,therighttonoticeoftheproceduralhearing,

therighttobepresentatthehearing,presentevidenceandcrossexaminewitnessesand

therighttoappealthedecisionofthehearingpanel.Additionally,ifthehearingpanel

approvedtreatmentoverobjection,theadministrationofmedicationunderthese

circumstanceswastimelimitedandrequiredperiodicre-hearingswithalloftheattendant

rightsforcontinuationofmedication.Considerationofasimilarsortofinternalprocessfor

treatmentoverobjectionproceedingscouldbeveryusefulinthejailsunderlimited

circumstancessuchaswheninmatesposeaseriousriskofdangertoselforothers–the

typeofcircumstancesthatprecludeBakerActacceptancefortreatmentincivilhospitals.

Turningattentiontothevoluntaryuseofmedication,theArmorpsychotropic

medicationpolicycontainssomeseriousdeficiencieswithregardtoimplementationand

appropriateuseofpsychotropicmedicationinthejail.

Themedicationformulary(listofmedicationsapprovedforuse)islimitedwhichin

andofitselfisnotuncommon,particularlysincethereisamechanismtorequestapproval

forpsychotropicmedicationsnotonthelist.Theproblemliesinthefailuretoactually

makeuseofthis“DrugExceptionRequest”topreservecontinuityofcareinessentially

everysituationwiththeexceptionofstatehospitalreturns.Suchpracticeleadsto

unnecessarydelaysintheprovisionoftreatmentandcausesneedlesssuffering.Delaysin


72

treatment,evenifthemedicationselectedbyArmoriseffective,willleadtoaslower

responsetotreatmentandalessrobustresponseand,thereisnoguaranteethatthe

chosenmedicationisgoingtoprovidetheintendedimprovementinresponseatall.Itis

inexplicablewhyonewouldoptnottouseamedicationofdemonstratedefficacy.Evenif

themedicationismoreexpensive,theindirectcostsofdelayingtreatmentcanfaroutweigh

theexpenseofthemedication.Inmateswithuntreatedorundertreatedseriousmental

illnessusemorecostlyservices:transfertoNBB;placementonwatchstatus;housingina

singlecellratherthanamultiplepersoncell;longerjailstaysduetoafindingof

incompetencetoproceedorinabilitytofindacommunityplacement;potentialstaffand/or

inmateinjuryduetopsychoticsymptoms,etc.

Issuesregardingmedicationcontinuityarenotlimitedtothejailadmissionprocess.

TherearemultipleprescribingcliniciansatNBBandaninmatemaybeseenbyanyoneof

severalpeople,allwithdifferingprescribingpracticesandtreatmentphilosophies.

Medicationchangesarenotinfrequent–again,inandofitselfnotunusual,butitcouldbe

remediedwiththeadoptionofprescribingguidelinesandassignmentofcasestospecific

prescribersratherthanthe“prescriberdujour”processcurrentlyinplace.Thisis

problematicfromanynumberofperspectives,nottheleastofwhichisfrequentchangesin

medicationbutalsofromtheperspectiveofthefailuretoestablishatherapeutic

relationshipbetweenthemedicationprescriberandthepatient.Everyvisitisessentiallya

new,introductory,assessmentvisitwhenapatientisseeinganewprescriber.

Documentationofthepreviousmedicationmanagementappointmentisnotalwayshelpful:

areasofformsthataretodescribetheinmate’sconditionatthetimeoftheappointment


73

arefairlycursory,iftheyarefilledoutatall;thereisnoindicationoftheresponseto

currenttreatmentoradocumentedmentalstatusexamination.Everymedication

managementvisitisthusa“first”appointment.Remediesforthisproblemalsoinclude

staffinglevelsthatpermitandpromotecontinuityofprescriberandadditionalmental

healthstaffthatareabletoprovidemedicationeducationandcounselingwithagraduated

responseofinterventionstoaddressinstancesofmedicationnon-compliancebefore

mentaldecompensationfollowedbythedownwardspiraldescribedearlier.

Inmatesareseenregularlyatmonthlyorthree-monthintervalsformedication

managementappointments.Thereislittletonoroominthescheduletopermitmore

frequentcontactinresponsetochangesinclinicalcondition,assessresponsetonew

medicationsordoseadjustmentsanditisnotclearthatmedicationcomplianceisregularly

reviewedwiththeinmateinthatitisnotroutinelydocumentedintheprescriber’snote

(thoughitisavailableuponreviewofthemedicationadministrationrecord.)

Reviewofmultiplerecordsalsorevealedsomepositivefindings.Forexample,there

wasverylittlepolypharmacy-thepracticeofprescribingmultiplemedicationswithno

clinicalrationaletosupportthepractice.Medicationswereprescribedforlegitimate

psychiatricindicationsandindosesconsistentwithgenerallyacceptedstandardsofcare

whenprescribedforaclearpsychiatricindication.


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RECORDS

Thefifthcriterionisaccurate,completeandconfidentialrecords.Theconcerns

withregardtothemedical/mentalhealthrecordsarerelatedprimarilytotheuseofpaper,

ratherthananelectronichealthrecordsatthecurrenttime.Somepsychiatricnotesare

barelylegiblewhichishighlyproblematicgiventhatmultipleprescribersmayseethesame

inmatepatient.(The“new”prescribermayormaynotbeabletodecipherthenoteofthe

previousonetounderstandtheconditionoftheinmate,themedicationsanddoses

prescribed,etc.)Inotherinstances,formsareincompletelyfilledoutandcliniciansprovide

verylittlenarrativemakingitdifficulttoascertainpatientcondition,typeandseverityof

symptomsexperiencedandplanforfollow-up.Ingeneral,thefilingwasuptodateand

paperswerefiledintheappropriateplaceoftherecord.

Problemscanandshouldbeaddressedthroughchartauditingandultimatelywith

theadoptionandimplementationofanelectronichealthrecord.Illegiblehandwritten

notesareeliminated;formscanbedevelopedsuchthatthenotecannotbe“closed”unless

allrequiredfieldsarecompleted.

Moresubstantiveconcernsrelatetothefailuretorequest/reviewandusethe

informationfromoutsidesourcesandcontainedintherecord.Forexample,inmates

returningfromthestatehospitalaresentwithverylittleinformationaboutthecourseof

theirtreatmentwhilehospitalized.Ifanadmissionanddischargesummaryisnot

provided,itisnotclearthatArmorstaffconsistentlyrequestit.Ifandwhentherecordsare


75

provided,itisnotclearthatArmorstaffreviewthemandthattheinformationisutilizedin

thecurrenttreatmentoftheinmate.Thisistrueofpriorhospitalinformationaswellas

communityoutpatientrecords.

Twoexamplesthatillustratetheeffectsoncareduetothefailuretouserecords

weredescribedearlieronpages35-36inthesectiononScreeningandEvaluation.(Inmate

IIwhohadrefusedatuberculinskintestandhousedinisolationintheinfirmary.His

outsiderecordswereatthejailbutnotreviewed;he’dhadarecentnegativetestand

wouldn’thaverequiredinfirmaryisolation.InmateMWrefusedmedicationbecausehe

wantedtotakethemedicationprescribedforhimattheVAMedicalCenter.Hisrecords

hadalsobeenreceived,butnotreviewed.Then,whentherecordswerereviewed,thePA

refusedtoordertheVAmedicationbecauseitwasn’tontheformulary.Asaconsequence

ofreceivingnopsychotropicmedication,MW’sthoughtprocessingwasdisjointedand

circumstantial.Hisseriousmentalillnesswasuntreated;mentalhealthtreatmentwas

severelydelayed,hisjailstayextendedandlegalproceedingsdelayedbyquestions

regardinghiscompetencytostandtrial.)

Accurate,completeandconfidentialrecordsarevitallyimportantandusingthem

appropriatelyhasaprofoundimpactonthedeliveryofcare.


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Suicideprevention TheNationalCommissiononCorrectionHealthcare,whichaccreditsthejail’s

medical/mentalhealthservices,identifieselevenessentialcomponentsofacorrectional

suicidepreventionprogram:training,identification,referral,evaluation,treatment,

housingandmonitoring,communication,intervention,notification,reviewanddebriefing.

ArmorpolicyJ-G-05liststhesekeycomponentsandinsubsequentparagraphsdescribes

therelatedproceduresforthecomponentinsomedetail–exceptthetreatment

component.Thepolicyissilentonthiscomponent.Thissilencealsoreflectedin

implementation.Inmatesonwatchreceiveassessmentsanddailyreassessments,butfew

receivetreatmentotherthanmedicationifitisorderedandtheinmateagreestotakeit.

Thisisacriticaldeficiency.Treatmentmustbeprovidedtoaddressthesuicidalthoughts

andbehaviors.Treatmentismorethanabriefdailyassessmentwhichisconductedin

privatesometimesbutmoreoftenatthecellfront(MJ8thfloor,NBBinfirmary)orina

hallway(NBB).

Theassessmentsthatarecompleteddonotcontainauniform,standardizedrisk

assessmentinstrumentofwhichthereareseveraltochoosefromwhichwouldpermitthe

developmentofasafetyplanandtreatmentinterventionsthatareindividualizedand

aimedatreducingrisk.Theassessmentsreviewedintherecordswerehighlyidiosyncratic

totheprescriberconductingtheassessment.Isawnocasesinwhichatreatmentplanhad

beenmodifiedtoaddressaninmatepatienthavingbeenplacedonwatch,maintainedon

watch(sometimesformonthsandmonths)orthosehavingmultiplewatchplacements.


77

Uponreleasefromwatchstatus,afollow-upappointmentisscheduledtooccurwithin7

daysofrelease,butsubsequentfollow-upsrevertbacktotheusualminimumcontact

scheduledictatedbypolicy(briefmonthlymedicationmanagementappointmentwhich

mayormaynotbewithaproviderpreviouslyseen),ratherthandictatedbytheinmate’s

clinicalneed.ExamplesoflengthywatchplacementincludeinmatesES(Appendixpage8)

andTD(Appendix,page29).TDwasalsoidentifiedasapersonwithmultiplewatch

placements.

Useofastandardizedassessmentinstrumentwouldalsoeliminatetheneedfor

automaticplacementonsuicidewatchstatusifenteringthejailfollowingatransferfroma

hospitalorrecenthospitalization.Atthetimeofintake,2/6/17,inmatePTwasputon

watchbaseduponrecenthistoryratherthancurrentriskassessment.Shewassentfrom

theMainJailtoNBBandalthoughthewatchwasrelativelybrief,itwascompletely

unnecessary.(PT’scaseinonpage31intheAppendix.)

Additionally,theconditionsexperiencedbytheinmateplacedonwatchareattimes,

unnecessarilypunitive:thereisnoprivacyinsomejailareasusedforwatcheswhichis

especiallyproblematicwhenstrippedofundergarmentsandjailissueclothingandgivenan

ill-fittingsuicidesmock.Inmatesarenotgivenshoesorshowerslippers,notpermittedto

showerregularly,andprovidedpapereatingutensils.Whilesomefairlydrastic

restrictionsarenecessarytopreventorameliorateanimminentandimmediateriskof

suicide,theconditionsthemselvesarenottherapeuticandcarehastobeexercisedthatthe

restrictionsbedonefortheminimumamountoftimenecessaryandthattheplacement


78

andrestrictionsarenotusedasatypeofpunishment.Conditionsshouldnotbesopunitive

soastodiscouragepersonsfromreportingdepressedfeelingsandsuicidalthoughtsinfear

ofbeingplacedandheldundertheseconditions.

TheArmorsuicidepreventionpolicydescribesthreelevelsofsuicidewatch:

continuousobservation,closeobservationandcloselymonitoredwhilethecorresponding

BSOstandardoperatingprocedureusessomewhatdifferentterminology:close

supervision,directobservationandcloselymonitored.Thesevariouslevelsof

observation/supervisionalsocontainsomevariationsinexpectations/conditionsaswell.

Itisveryimportantthattheseconceptsarereconciledsothereisaclearunderstanding

betweenArmorandBSOstaffaboutthelevelsofwatchanddegreeofmonitoringrequired,

particularlyforsuchacritical,potentiallylife-savingprocess.

Iwasprovidedonlyaverysmallsampleofpost-suicidereviews.Itwasnotclear

whetherthiswasduetonoreviewhavingbeenconducted,nodocumentationofthereview

thatwasconductedorwhetherthereviewsweresimplynotprovided.(Althoughthere

wassomeinitialdelayinreceiptofsomerequestedmaterialsbaseduponArmor’squality

assuranceconfidentialityconcerns,wewereabletoworkthroughthisandIdonotbelieve

existingrecordswereintentionallywithheld.)TheindividualrecordsthatIreceivedand

reviewedarelocatedintheAppendix.Iamabletosayherethatasageneralobservation,

thereviewprocesswouldbesignificantlyimprovedwithbettercorrelationbetween

custody,medicalandmentalhealthfactorsfoundduringtheinvestigationsconducted

separatelybyallthreeoftheseprofessions.Custodyreviewscontainanassessmentof


79

whethermonitoringwascompletedasrequiredbycustodypolicyandcustody’sresponse

upondiscoveryoftheinmate.Medicalreviewslookalmostexclusivelyatthemedical

responsetotheevent.Mentalhealthdoesapsychologicalreview.Thefindingsfromthese

variousanddifferentreviewscanhaveprofoundimpactonconclusionsandpotential

actionstepstoimprovetheprocess.Forexample,ifcustodyhastoleavethesiteofa

hanginginmatetogetacut-downtool,medicalshouldbeawareofthisfactorintheir

reviewoftheincidentbecauseadelayofmereminutesisimportantinrescueandcan

makethedifferencebetweenlifeanddeath.Thepointofthesereviewsistoidentifythese

sortsofpotentialproblems/issues,evenifdeterminedthattheyhadnoparticular

relevancetothecaseathand,theycouldimpactfuturerescueresponses.Inthiscase,

ensuringthatcut-downtoolsaremoreimmediatelyavailablecertainlyhaspotential

ramificationsinfutureinstances.(Somefacilitieshaveofficersassignedtocertainlocations

carryaformofcut-downtoolontheirbelts.)14Mentalhealthreviewsconsideredalone

won’tnecessarilyuncoveraninstanceinwhichaninmatecamebackfromacourt

appearancewhereheorshereceived“badnews”thoughcustodystaffareawareofit.

Integratingthisinformationcouldhavechangedaspecificoutcomeorpolicyregarding

noticetomentalhealthsothatinmatesreturningfromcourthearingsarereferredto

mentalhealthstaffforabriefassessmentandtreatmentinterventionifnecessary.(Inmate

NWreportedlywasoverheardtellinghermotherthatshewasgoingtokillherselfifshe

receivedbadnewsinherupcomingcourthearing.Informationwasnotrelayedtomental

14InmateCBsummarizedinAppendixpages64-65;autopsyreportindicatesdeputylefttheinmatetoretrievecutdowntool;alsoaquestionofwhetherproperperiodicchecksweredoneontheunit.


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healthstaff.Shewenttocourt9/2/14anddiedbysuicide9/6/14.Thisisalsoanother

casewherethedeputyhadtoleavethescenetoretrieveacutdowntool.TheNWsuicide

wastwoyearsaftertheCBcase;theissueregardingthecut-downtoolpersisted.NWcase

issummarizedonpage70.)Asasecondgeneralobservation,thereviewswouldbebetter

iftheassessmentsweremoreself-criticalsothatimprovementscouldbemade.There

weresomerecordsinwhichaccesstomedicalcarewaslimitedorseverelylimitedfor

inmateswithseriousmentalillnesshousedatNBB.Inonecase,themedicalreview

recommendationwasnottousecertaintypesofmedicationinclosedmentalhealth

becauseofthedegreeofmonitoringrequiredasopposedtoactuallyimprovingeaseof

accesstoinmatesinclosedmentalhealthunits.Iunderstandthatreviewersareoften

reluctanttodocumentcriticalfindingsoutoffearofdiscoveryintheeventthattheincident

leadstolitigation.However,ifthathappens,aplaintiff’sexpertislikelytodrawthesame

negativeconclusionsanywayandasasystem,itisfarbettertoself-identifyandthereafter

takestepstoaddressorcorrecttheproblemthantowaitforlegalproceedingstomakeyou

doit.Frankly,itdemonstratesafarhigherdegreeofcommitmenttocontinuousquality

improvementthanincompleteandcursoryself-assessment.

Recordreviewsofthesecasesarefoundamongthosecasessummarizedinthe

Appendixonpages60-74.


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CONCLUSIONS

Asstatedattheoutsetofthisreport,Iwaschargedwithassessingoperationsand

conditionsattheBrowardCountyJailsandtorenderanopinionregardingwhetherthere

arecurrentandongoingviolationsoffederalrights.Iorganizedmyinquiryaroundsix

criteriaandhaveconcludedthattherearecurrentandongoingviolationsoffederalrights

astheypertaintoinadequatementalhealthcareandfacilities,mostparticularlyasrelated

tothelackoftreatmentexceptpsychotropicmedication,lackoftimelyandadequateaccess

toinpatientpsychiatriccareresultinginprolongedstaysintheclosedmentalhealthunits

andinfirmaryatNBBunderconditionsthatareasisolatingasthosefoundinsegregation

andmakesymptomsworseandaccesstotreatmentmoredifficult.However,inasmuchas

allsixofthecriteriareviewedareinterconnected,eachofthemcontributestothecurrent

andongoingviolations,sometoagreaterandsometoalesserdegree.Ihaveorganizedmy

conclusionstoarticulatetheareasneedingimprovementtocorrectthedeficiencies.This

organizationalsoservedasthebasisfordevelopmentoftheImplementationPlan.

SystematicScreeningandEvaluation

Generallyappropriatetoidentifypersonswithmentalhealthneedsforfurtherassessment

andplacementonthementalhealthcaseload.

Areasforimprovement:

• Diversionofseriousdrugwithdrawaltohospitalsforcomplicatedmedical

detoxificationandreferralofinmateswithobviousandseverepsychiatricillnessto

ahospitalsettingassoonaspossibleconsistentwithFloridastatuteratherthan


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housingtheminthejailforweeksormonths,withnoabilitytotreatthemtoawait

criminalcourtaction.

• Documentthatoutsidetreatmentrecordshavebeenrequested,reviewedand

consideredinthetreatmentoftheinmateatthejail.

• Preservecontinuityofcarewithrespecttopsychotropicmedicationswhen

prescriptionsareverifiedandresponsehasbeenfavorable.

• Whenmedicalassessmentscannotbecompletedatintakeduetotheconditionor

refusaloftheinmatewithseriousmentalillness,furtherattemptsmustbemadeso

thatthemedicalassessmentiseventuallycompleted,documentedandfiledinthe

chartintheareareservedforphysicalexaminations/medicalassessments.A

medicalprogressnoteshouldalsodocumentthereasontheinitialintake

assessmentwaspostponed,andsubsequentmedicalprogressnotesshould

documentattemptstocompletetheassessment.

• Postponedevelopmentofamentalhealthtreatmentplansothatitisanaccurate

reflectionoftheinmate’sconditionanddescribestheinterventionsthatwillbe

provided,bywhomandinwhattimeframeasopposedtohavinganon-specificplan

drawnuponthebasisofasinglepsychiatricassessment.

Treatmentthatismorethanmereseclusionorclosesupervision

Thereisverylittlementalhealthtreatmentprovidedotherthanpsychotropicmedication

forinmatesthatconsenttotakeit.



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• Theoverwhelmingmajorityofinmateswithseriousmentalillnessmaybe

appropriatelytreatedasoutpatientsingeneralpopulationsettings.However,

outpatientmentalhealthtreatmentmustincludeopportunitiesforcounseling,

individualand/orgrouptreatmentinterventionsasclinicallyindicatedandcrisis

interventioninadditiontoperiodicmedicationmanagementappointments.

• Residentialcaremustincludemorestructuredout-of-celltherapeuticactivitiesas

wellasunstructuredout-of-celltime,particularlyintheclosedmentalhealthunits.

ThisistrueforallinmatestransferredandmaintainedatNBBfortreatmentof

mentalillness,notjustthosehousedonsomeofthehousingunits.

• Mentalhealthtreatmentmustbeconductedinspacethataffordssoundprivacy;not

atthecellfront,inthehallwayorinnon-privateareasofthehousingunit.

• Admission,dischargeandmentalhealthtreatmentprogramsmustbedevelopedfor

thementalhealthunitsatNBB.

• InmatesrequiringahigherlevelofcarethancanbeprovidedatNBBmustbetimely

transferredtoinpatientcare.Inpatientcaremustbereadilyavailableand

accessible.Accesstocarecannotwaituntilacourtdeterminesatransferis

necessaryforpurposesofcompetencytostandtrialrestoration,oruntiltheinmate

isreleasedfromjail.

• Confinementinaclosedmentalhealthunitorinfirmaryforseriouslymentallyill

inmatesistheequivalentofsegregationintermsofsocialisolation,amountoftime

confinedincellandcellfrontcontactswithstaff–notmentalhealthresidentialcare.

Thismustchangeimmediately.


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• Mentalhealthandmedicalcaremustbebetterintegratedtoprovideappropriate

servicestoinmateswithbothconditions.Accesstomedicalservicesshouldnotbe

impededduetothepresenceofaseriousmentalillnessorbeinghousedinamental

healthunit.

• Ensuretreatmentcontinueswheneveraninmateisconfinedinsegregation.

• Incorporatementalhealthcliniciansintocrisisde-escalationwhenpossibletoavoid

asituationinwhichtheuseofforceisplanned.

• Formalizetheroleofmentalhealthintheinmatedisciplinaryprocess.

• ResumedevelopmentofacomprehensiveCQIprogram.

Staffing

Vendorstaffaretrainedmentalhealthprofessionalsandappropriatelylicensedand

credentialedforthetaskstheyareassignedwithinthefacilities.Infact,mastersprepared

andlicensedmentalhealthcounselorscouldexpandtheirroleintheprovisionof

diagnosticassessmentsandgrouptreatmentinterventions.Theprimaryissuewithregard

tostaffingissimplyrelatedtodeficientstaffnumbers,whichprofoundlylimitstheamount

andtypeofcarethatcanbeprovided.


• Increasestaffinglevelsofmentalhealthcliniciansandprescriberstopermitthe

deliveryofappropriatelevelsofoutpatient,crisisandresidentialcare.

• Ensurethattherearesufficientcustodystafftoprovideescortandsupervision

whenmentalhealthtreatmentisprovided.


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Safeguardsregardingprescriptionofpsychotropicmedication

Generally,psychotropicmedicationsareprescribedinappropriatedosesforrecognized

indications.


• Betterdocumentationofpatient’sconditionandresponsetoprescribedmedication;

betterdocumentationoftherationaleformedicationsprescribedorchanged.

• ImprovecontinuityofcarewithoutsideprovidersaswellasamongvariousArmor

prescribers.

• Inmatesshouldbeseenmorefrequentlyifclinicallyindicatedthantheminimum

intervalsdictatedbypolicy.Staffinglevelsmustbesufficienttopermitthis.

• Monitoringandinterventionforcasesmedicationnon-compliancetoinclude

medicationeducationandcounselingbynursingstaffinadditiontonotificationand

referralbacktotheprescribingclinician.

Accurate,completeandconfidentialrecords

Forapaperrecordsystem,therecordswereavailableandfilingwasuptodate.Problems

includedillegiblehandwrittennotesandincompletedocumentationbyindividual

clinicians–butthesecanhaveaprofoundimpactoncare.


• Movetoadoptionofanelectronichealthcarerecord.


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Suicidepreventionprogram

SuicidewatchescanbeinitiatedatanytimeandinanyjailintheBrowardCountyJail

system.However,moreemphasismustbeplacedontheprovisionoftreatmentduring

watches,transfertoahigherlevelofcareiftheinmate’sconditiondoesnotimproverather

thancontinuedwatchplacementbecausetheconditionsareundulyrestrictiveandmay

contributetothefailureoftheinmatetoimprove.

• BSOandArmorsuicidepreventionpolicies/procedureshouldtrackoneanotherin

termsofmonitoringintervalsandstaffdutiessuchthattherearenotcontradictions

orconfusionbetweenthetwo.

• Treatmentinterventionsmustbeprovidedduringperiodsofsuicidewatchto

includeoutofcellcontactsbymentalhealthclinicians–notjustdailyassessments

bytheprescriber.

• Adoptastandardizedriskassessmentinstrumenttoassessriskandserveasthe

basisfordevelopingsafetyplanswhenappropriate.(Useofastandardizedrisk

measurementwouldalsopreventtheneedto“automatically”placeinmates

returningfromthehospitalonarestrictivewatch.)

• Updateindividualtreatmentplansandinterventionswheneveraninmateisplaced

onsuicidewatch.

• Reviewtheuseofsuicidewatchasaresponseortypeofpunishmentfor

“manipulative”behaviorandconsiderdevelopmentofbehaviorplanstoaddress

thesetypesofissues.

• Individualswhoremainsuicidalinjailshouldbeassessedforthepossibilityof

inpatienthospitalizationatappropriateintervals.


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• Suicidewatchmustrespectindividualdignityandprivacywhileensuringrisk

reductiontopreventself-harm.Conditionswhileonwatchshouldnotbepunitive.

• Mentalhealthfollow-upafterwatchesarediscontinuedshouldbebasedon

individualclinicalassessmentandneedandbeparticularlymindfuloftheinmate

duringthetransitionoffwatchandbackintopopulation.

Asindicatedintheopeningparagraphsofthisreport,theoriginaldraftofthis

reportsharedwiththepartiesincludedadraftimplementationplan.Thepartiesusedthe

draftplanandsubsequentiterationsofitasthebasisforon-goingdiscussionand

negotiationofthetermsforanImplementationPlan.Ihavethereforenotincludedsucha

planinthisreportbutprovidedthedataandbasisformyconclusionsaboutcurrentand

on-goingconstitutionalviolationsandmyrecommendationsforinclusioninthe

ImplementationPlannegotiatedbytheparties.

Submittedby:

/s/KathrynABurnsMD,MPH8August2018

Documents

EXHIBIT A - American Civil Liberties Union...discharge planning. The Armor patient population consists of inmates with serious mental illness (SMI) and other mental health diagnoses,