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Court's Expert Says Medical Care at Idaho Prison is Unconstitutional

On March 19, 2012, a federal court in Idaho unsealed a report by court-appointed special master and expert on prison health care, Dr. Marc Stern which the state had attempted to suppress. In the February 2, 2012, report, Stern described much of the medical care provided prisoners at the Idaho State Correctional Institution in Boise as violating the constitutional prohibition against cruel and unusual punishment.

The report is the latest development in a long-standing class-action challenge to medical conditions at the prison originally filed in 1981.

Medical care in Idaho prisons is provided by Corizon, a private corporation based in Brentwood, Tennessee. Despite notable improvement in some areas, Stern's report paints a bleak picture of the quality of medical services provided by Corizon.

The court ordered Stern to address the status of conditions at the prison relative to the compliance plan promulgated in 1984 and assess the constitutionality of the currently-provided health care. Stern found it difficult to separate the two and also found that some of the issues addressed in the compliance order were no longer appropriate due to physical changes at the prison and developments in medical science.

Stern found that there were problems with the provision of medical diets, but the overall medical diet program complied with the spirit of the order so that this aspect of medical care was constitutional. However, there was medical-diet-related understaffing, in that the prison had no therapeutic dietician as ordered by court which may be a factor causing some problems.

The report also found that the prison was compliant with the medical records requirements of the compliance order, but that this was a recent development.

Stern noted "serious problems with the delivery of medical and mental health care" which "resulted or risked resulting in serious harm to inmates" and were "frequent, pervasive, long-standing" so that "authorities are or should have been aware of them" and thus "are being deliberately indifferent to the serious health care needs of their charges." He also noted that Corizon failed 23 of 33 categories audited by the Idaho Department of Corrections (DOC) in 2010 and failed 26 of 33 categories in the 2011 audit.

Stern found that prisoners had difficulty accessing health care and that there was no staff pharmacist as required by the court order. The report noted delays as long as five weeks in responses to prisoner's requests for health services, far in excess of the two-to-three-day response period considered timely. These delays occurred even when the prisoner's statements on the Health Services Request (HSR) form indicated a serious medical issue.

The quality of health care, once it was finally given, was poor according to Stern. The evaluations given at sick calls were often conducted by Licensed Practice Nurses (LPN) who are not qualified to make an independent assessment, the nursing equivalent of a diagnosis. The LPNs used a written protocol to assess the medical condition of prisoners. However, this is a flawed practice because expertise beyond the LPN level is needed to even select the correct protocol and a written protocol cannot substitute for clinical judgment. Additionally, Stern found instances where sick call evaluations were cursory, without any examination of the patient--not even vital signs--being noted before arriving at a conclusion.

Responses to urgent and emergency care was often delayed and the responding LPNs often exceeded their authority by, for instance, dispensing medication without a protocol or a physician's order. The LPNs also were not sufficiently prepared for some emergencies, arriving without necessary emergency equipment, such as parts for a bag-mask respirator. They also did not always perform basic and necessary tasks such as providing oxygen to and monitoring vitals signs of a prisoners who was unconscious and clearly suffering from insufficient breathing and blood supply. Nurses also sometimes interpreted electrocardiograms themselves, a task they are not qualified for.

Emergency response equipment was not kept in order with oxygen bottles that were low or empty and missing sizes of the tools used to hold airways open during rescue breathing. The log book intended to document the use of emergency equipment was in disarray and many sections which should have been filled out were blank.

Long-term and terminal care was also inadequate according to Stern. He found instances of patients who were unable to care for themselves being allowed to remain in soiled bedding and not being given food, water and/or medications.

The report also noted a failure to provide medication seamlessly and poor documentation of the delivery or administration of medication in the prison's pharmacy. This led to patients going days to weeks without essential medication. Also expired medications were being issued.

Medical care in segregation was also inadequate according to the report. Welfare checks were often not performed and, when they were performed, nurses often merely called out from the entrance that they were present if anyone needed them instead of making cell-to-cell rounds.

The structures to detect and respond to incompetent medical staff is insufficient. In one case, a staff member was apparently abusing prisoners because she didn't like them, yet went undetected.

Stern was unable to evaluate the compliance of mental health care at the prison due to a lack of documentation. Working with forensic and correctional psychiatrist Dr. Amanda Ruiz, be did find that the mental health screening did not consistently flag prisoners with serious mental illness, inadequate work up of prisoners involved in the mental health treatment program, underuse of group and individual therapy, inadequate care during acute illness and misuse of segregation for mental health problems.

According to the report, the documentation of mental health issues was so poor that mental health records might not even show a suicidal episode. The records often contained generic boiler-plate treatment plans which might not be appropriate for the diagnosed condition. Psychiatric staffing was less than a quarter of what it should be. This led to psychiatric practitioners writing orders for psychotropic medication without having seen the patient.

There was also inadequate staff training for suicide prevention and unsafe use of prisoners as companions during suicide watch. These prisoners, who were untrained volunteers, were sometimes suffering from mental health issues themselves. They were being used to replace, rather than supplement, supervision by staff. Less than half the staff received one hour of suicide training in 2010 and none received any in 2011 whereas every staff member should receive eight hours per year, according to a prison suicide expert.

The mental health section also had no provision for Continuous Quality Improvement, a system to find problems and correct them. This is in part due to a lack of data collection.

Overall, Dr. Stern found that the provision of both medical and mental health services at the prison was unconstitutional. See: Balla v. Idaho State Board of Corrections, U.S.D.C.-D.Idaho, Case No. 1:81-cv-01165-BLW.

Additional source: Associated Press

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Related legal case

Balla v. Idaho State Board of Corrections