The incident that prompted the investigation was a lurid blood spill. On September 11, 1996, prisoner Joseph Daniels, who was being treated for an infection, went to sleep with an intravenous tube secured in his arm. The tube, also called a heparin lock, was three years past its expiration date. That night a custody officer found Daniels saturated in blood: about a quart of blood had spilled out of the deteriorated heparin lock. A nurse with twelve years experience said that it was the worst blood spill she had ever seen.
Investigators found that health care staff were aware of the expired heparin locks at least two months previous to the incident, but that nursing supervisors had disregarded requests from nursing staff for new stock. Former MICC nurse Sherry VanHorn informed Chief Nurse Pat Callahan that the heparin locks were expired and prone to leakage months prior to Daniels' blood spill. Callahan ignored VanHorn's concerns. And five days after the spill, management still made no effort to replace the supply, and questionable heparin locks were still in use. When an inspector asked to see a heparin lock in good condition shortly after the incident, management tried to hide several seriously deteriorated heparin locks still in packages.
Staff at MICC also repeatedly complained to management about lack of safety and health care training. Numerous employees were exposed to toxic chemotherapy agents; nurses were expected to handle potentially lethal chemotherapy waste and ordered by management to administer chemotherapy drugs without proper training or equipment.
Employees who complained to management at MICC were most often reprimanded, publicly embarrassed, or harassed. Chief Nurse Pat Callahan delivered a letter of reprimand to staff nurse Barbara Jackson for filing complaints about the lack of safe worker-protection measures when in contact with a prisoner with TB. Jackson--a nurse with twenty-three years of experiencewas also threatened with further disciplinary actions should her complaints continue, and scolded for "jumping the chain of command." The same letter of reprimand also falsely stated that the health department and L & I had confirmed that MICC was in compliance, when both agencies had informed supervisors in healthcare services that they were in violation of state laws. When informed by investigators that the letter was in violation of state laws, and asked to remove the letter from the employee's files, Superintendent Belinda Stewart refused, saying that she couldn't allow employees to complain to outside agencies.
Nearly all nurses interviewed by investigators said they had nowhere to go with health and safety concerns. Ten out of eleven infirmary workers interviewed expressed fear of harassment or retaliation for airing safety complaints. One health care worker said, "There has been fear of retaliation for making complaints here for a long time." Almost all workers spoke to L & I investigators only on condition of anonymity.
Superintendent Belinda Stewart, who is African-American, summed up the investigation as a racist plot formed by hostile workers to upset her position. Stewart viewed the problems at MICC as related to her race and gender, and was quoted as declaring, "I'm not saying McNeil Island is a perfect world, but God put me here for a reason. Maybe it will make people understand what it's like to a woman, and what it's like to be African-American."
When asked recently whether she still held to the racist plot theory of worker-retaliation, Stewart admitted that "there were a lot of problems at MICC." But she added, "We have worked through those issues." When asked to provide examples of how MICC has worked through its issues, Stewart says she now works one late night a month, "to show staff who I am." She also emphasized that she spent $1,700 on a three-day workshop on team-building for MICC employees. As for staff's fear of retaliation and harassment, Stewart says she now "tries to communicate with staff, to demonstrate to management that I am willing to work with them." Stewart said the experience of the L & I investigation and subsequent penalties were "hurtful to me," and she doesn't know where people got the perception that they couldn't talk to her.
Stewart successfully appealed the L & I fine, which was knocked down to $9,550 in 1998. The meager penalty raises questions about how much impact the investigation ultimately will have in deterring aberrant prison administrators' behavior.
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