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Cripa Enid Ok Investigation Findings 4-17-03

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April 17, 2003

Mr. Wendell Vencl
Garfield County Board of Commissioners
114 West Broadway
Room 101
Garfield County Courthouse
Enid, OK 73701
Re: 	 Investigation of Garfield County Jail and

Garfield County Work Center, Enid, Oklahoma

Dear Mr. Vencl:
We write to report the findings of our investigation of
conditions of confinement at the Garfield County Jail (“Jail”)
and Garfield County Work Center (“Work Center”) in Enid,
Oklahoma. On June 6, 2002, we notified you of our intent to
investigate the Jail and Work Center pursuant to the Civil Rights
of Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997.
Our investigation focused on issues of fire safety, personal
safety, medical and mental health care, environmental health and
safety, opportunities to exercise, and access to the courts.
We conducted tours of the Jail and the Work Center on
July 23-25, 2002, and September 19-21, 2002, with our expert
consultants in the fields of corrections, medical care, fire
safety and environmental health and safety. During our on-site
inspections, we interviewed the Sheriff, the Undersheriff, the
Jail Administrator, detention officers, Sheriff’s Department
administrative staff, and inmates. Before, during, and after our
visit we reviewed a number of documents, including policies and
procedures, incident reports, use of force reports, shift logs,
and investigative reports. We also interviewed the
community-based health care providers and reviewed medical
records maintained by those individuals. At the end of each
tour, our expert consultants conducted informal exit meetings
with the Sheriff in which they conveyed their preliminary

- 2 

We commend the Sheriff, Undersheriff, Jail Administrator,
and detention officers at the Jail and Work Center for their help
throughout the course of the investigation. They have cooperated
fully with our investigation and have provided us with
substantial assistance.
Based on our investigation, and as described more fully
below, we conclude that certain conditions at the Jail and the
Work Center violate the constitutional rights of inmates. We
find that persons confined at the Jail risk serious injury from
deficiencies in the following areas: fire safety; security and
protection from harm; access to medical and mental health care;
environmental health and safety; opportunities to exercise; and
access to the courts. Further, we find that persons confined at
the Work Center risk serious injury from deficiencies in access
to medical and mental health care and access to the courts.



The Jail occupies the top two floors of the five story
Garfield County Courthouse in downtown Enid, Oklahoma. The
Courthouse was built in 1933 and the Jail was refurbished in the
1960’s. The County utilizes the basement and floors one, two and
three for offices and courtrooms.
The first floor of the Jail includes a the Jailer’s Office
and dispatch center, the kitchen, a pantry, a visiting room, a
four-man cell reserved for trustees, two ten-man congregate
cells, and four two-man cells, reserved for the most violent or
mentally ill inmates. The second floor includes a converted cell
used for storage and medical examinations, two ten-man congregate
cells, three four-man cells, and three four-woman cells. In
total, the Jail has 76 beds, of which 12 are reserved for women.
During our July 2002 visit to the
approximately 66 inmates housed at the
inmates and 11 female inmates. During
the facility, there were approximately
Jail, including 56 men and 14 women.

facility, there were
Jail, including 55 male
our September 2002 tour of
70 inmates housed at the

- 3 The Work Center occupies a two story building located on the
Garfield County Fairgrounds. The Sheriff created the Work Center
in 2001. The first floor includes a Jailer’s Office/intake area,
two bathrooms, kitchen, pantry, and a dormitory room with 18
beds. The second floor includes a television room, a library, a
meeting room and a bathroom. There were 11 male inmates housed
at the Work Center during our July 2002 visit and 12 male inmates
housed there during our September 2002 visit.


Pursuant to CRIPA, the Department of Justice has authority
to investigate and take appropriate action to enforce the
constitutional rights of inmates in jails. 42 U.S.C. § 1997.
With regard to sentenced inmates, the Eighth Amendment requires
humane conditions of confinement; prison officials must ensure
“that inmates receive adequate food, clothing, shelter, and
medical care and must ‘take reasonable measures to guarantee the
safety of the inmates.’” Farmer v. Brennan, 511 U.S. 825, 832-33
(1994) (quoting Hudson v. Palmer, 468 U.S. 517, 526 (1984)). The
Eighth Amendment protects prisoners not only from present and
continuing harm, but from the possibility of future harm as well.
Helling v. McKinney, 509 U.S. 25, 33 (1993).
The county must also ensure that all inmates in the Jail and
the Work Center receive adequate medical care, including mental
health care. Riddle v. Mandragon, 83 F.3d 1197, 1202 (10th Cir.
1996) (citing Bowring v. Godwin, 551 F.2d 44, 47 (4th Cir.
1977)); Young v. City of Augusta ex rel Devaney, 59 F.3d 1160
(11th Cir. 1995).
The majority of inmates at the Jail are pre-trial detainees,
who have not been convicted of the criminal offenses with which
they have been charged. The rights of pretrial detainees are
protected under the Fourteenth Amendment, which ensures that
these inmates “retain at least those constitutional rights . . .
enjoyed by convicted prisoners.” Bell v. Wolfish, 441 U.S. 520,
545 (1979). In addition, the Fourteenth Amendment prohibits
punishment of pretrial detainees or the imposition of conditions
or practices not reasonably related to the legitimate
governmental objectives of safety, order and security. Id. at


- 4 


Inmates at the Jail depend entirely on detention officers
for their safety in the event of a fire or other emergency that
might require evacuation. Detention officers must unlock each
individual cell, as the Jail does not have a central unlocking
mechanism. This factor makes fire suppression and detection a
critical issue. Inadequate fire safety measures at the Jail
compromise severely the safety of inmates and detention officers.
These deficiencies include the lack of fire alarm and sprinkler
systems, insufficient smoke detection units, inadequate
protection from smoke exposure, excessive combustible materials,
and substandard evacuation preparation.

Detection, Alarm and Sprinkler Systems

The Jail has substantial deficiencies in fire detection, and
suppression. The Courthouse lacks a sprinkler system and does
not have a standpipe system to which fire fighters could attach
their hoses to draw water to fight a fire. Further, there are no
smoke detection or fire alarm systems installed in the building.
Rather, some, but not all, of the hallways outside the inmate
sleeping quarters are equipped with battery operated smoke
detectors. Because the alarms are not part of an integrated
building-wide system, only an alarm in the immediate area of the
smoke or fire would sound. Individual alarms are not loud enough
to penetrate the steel doors that separate the cells from the
main hallways. In the event of a fire, an alarm might go
unheeded if detention officers are not in close proximity to it.
Further, there is no system for inmates to communicate with
detention officers. Rather, inmates routinely beat on their
shower stalls to gain the attention of detention officers.
Because the Jail is regularly short staffed, there is often a
significant delay before a detention officer responds to an
inmate’s attention generating behavior. In the event of a fire,
such a delay could prove fatal.

Smoke Exposure

The Jail does not protect residents from dangerous exposure
to smoke. A single staircase rises from the basement of the
Courthouse to the first floor of the Jail (the fourth floor of
the building). A separate, open staircase connects the first and
second floors of the Jail. These stairwells are not fully

- 5 
enclosed. In the event of fire, they would become avenues by
which heat, smoke, toxic fumes and other products of combustion
could spread unimpeded through the Courthouse and Jail, making
the stairs impassable and unreliable means of escape.
The lack of a self contained breathing apparatus (“SCBA”),
for staff to use in the evacuation of prisoners, compounds the
inadequate smoke exposure protections. Given the amount of
combustible material in the Jail, the lack of smoke containment,
and the laborious process to open all the cell doors, a SCBA is
essential to ensure that detention officers will be able to
evacuate all prisoners and staff.


Many of the cells and other locations in the Jail contain
excessive amounts of combustible materials, including clothing,
books, paper, bedding material, linens, and other personal
property. Inmates store their personal property either on their
bunks or in paper bags underneath the bunks. Any inmate property
not stored in cells is kept in a converted cell which is open to
the corridor. Further, trash in cells is stored in plastic waste
receptacles without covers. These waste receptacles could fuel
any fire that occurred in a cell.
During a tour of the Jail on September 17, 2002, we observed
the storage of three plastic jerricans of gasoline and a portable
generator in the detached staircase that serves as the primary
evacuation route from the Jail. The jerricans and generator
partially blocked the staircase. The storage of the combustible
material presented an extreme danger in the event of an
emergency. At our insistence, the Sheriff removed the gasoline
and the generator from the staircase and stored them outside of
the Courthouse.
The floors below the Jail contain a dangerous abundance of
combustible materials. Many areas are lined with wood paneling
and contain typical office supplies and furniture. In addition,
there are several record storage areas. A fire in these lower
floors exposes the Jail to significant smoke exposure.

Fire and Evacuation Preparedness

In the event of an evacuation, inmates and detention
officers have two routes to exit the Jail. Inmates may evacuate

- 6 
the Jail by either traversing the staircase that runs from the
first floor of the Jail to the basement or by exiting the Jail
through a door on to the roof of the third floor and then
crossing a steel bridge that connects to a free standing stair
(and then descending down to ground level).
Manual key-locks secure all cell doors and doors to the
hallways and it requires seven separate keys to release all
inmates from their cells and evacuate them. Throughout the Jail,
detention officers could not identify the keys that open cells or
exit doors without first looking at the keys. Conditions may
arise during a fire which make visual identification impossible,
and, therefore, the inability to identify keys by touch may
prevent resident evacuation. Further, a number of the cells have
difficult or faulty locking devices. It took one detention
officer over ten minutes to open one of the cells. Such a delay
could prove to be fatal in a fire emergency.
Even if detention officers could identify all keys by touch,
they neither carry nor have reasonable access to all keys
necessary to unlock doors in the evacuation route. We asked a
detention officer on duty in the Jail to gather all keys required
to open the doors in the evacuation route. A considerable delay
ensued before the detention officer completed this task. In the
event of a fire emergency, a detention officer will not have a
surfeit of time to gather the keys and unlock the cells.
The Jail has a good, written evacuation plan in its policy
and procedure manual. However, some detention officers seemed
unaware of evacuation procedures. Although the detention
officers understood the routes to follow to evacuate the Jail,
which are posted on the walls, they did not know the procedures
necessary to evacuate inmates safely and securely. This appears
to be the result of the failure to conduct frequent fire drills.
No detention officer with whom we spoke had ever participated in
a fire drill, nor could any officer recall receiving instruction
on what do in the event of a fire.
The Jail relies on the local fire department to respond to
any emergency related to fire. The local fire and police
departments reportedly have keys to the exterior doors of the
Courthouse, but they do not have keys to unlock the door to the
Jail. Detention officers would have to unlock the door on the
first floor of the Jail in order for the emergency responders to
enter the Jail.

- 7 Jail officials have not conducted any emergency planning
with the fire department to ensure effective emergency response.
Given the number of prisoners housed at the Jail, the amount of
combustible material within the building, and the cramped design
of the facility, it is imperative that local fire officials
acquaint themselves with the evacuation procedures and physical
layout of the Jail.


Inmates are constitutionally entitled to incarceration in an
environment that offers reasonable protection from harm. Inmates
at the Jail face crowded conditions, no opportunities for
exercise, and few alternatives to idleness, all of which increase
tensions among inmates. Numerous lapses in basic security and
supervision at the Jail significantly increase the risk of harm
faced by inmates in this environment.


The Jail does some classification of inmates, principally
segregating sentenced from unsentenced inmates. Aside from that
basic classification system, detention officers base their
housing assignment decisions primarily on available space rather
than an “objective” classification system. An objective
classification system uses a behavior-based numerical scale to
identify potentially predatory inmates as well as inmates likely
to be victimized by others. This sytem minimizes violence in
shared housing units.
The failure to use an objective assignment system places
inmates at significant and unnecessary risk of harm. For
example, detention officers placed an inmate accused of child
molestation in a 10-man congregate cell. The inmates in the
cell, aware of the charges against the man, severely beat him on
at least two separate occasions in one day. The inmate required
hospitalization, spending several days in a coma. This incident
could have been avoided had detention officers considered the
safety risks of placing the inmate in a 10-man cell.


The Jail lacks the capacity to provide special housing for
inmates who may need it for purposes of disciplinary segregation,
protective custody, or to accommodate medical or mental health

- 8 
needs. The Jail reacts to reports of fighting and conflict by
moving inmates between cells, and, ultimately, by transferring
some inmates to other facilities. Because contract jails will
not accept inmates with violent tendencies, these inmates must be
housed at the Jail.
As the Jail lacks segregation space, the Jail has adopted a
practice of restraining particularly violent inmates by
handcuffing the inmate’s arms to the cell bars while the inmate
lay on the floor of the cell. The practice is inhumane and
dangerous and must cease.

Inadequate Staffing

Jail policy dictates that three detention officers should be
on duty at all times. However, the Jail often has two detention
officers on duty, as was the norm during our July 2002
inspection. Two detention officers are insufficient to staff the
Jail, particularly during the day shift when the energies of one
detention officer must be devoted exclusively to administrative
tasks. The other detention officer must supervise and address
the needs of the inmates on both floors of the Jail.
Because the Jail has so few officers on duty per shift,
detention officers do not sufficiently supervise the inmates.
Detention officers makes rounds of the cells approximately once
an hour on a regular schedule. This is insufficient to maintain
adequate supervision and control of inmates.
The shortage of detention officers has the potential to
create problems when an emergency or violence occurs at the Jail.
As there is no audio monitoring system, an inmate who is in
danger or in need of emergency medical attention in the further
reaches of the Jail must rely on his or her peers to make
sufficient noise to garner a detention officer’s attention. If
detention officers respond, and there are only two officers on
duty, it is Jail policy that they cannot extract an inmate from a
cell until a law enforcement deputy or Enid Police Department
officer arrives to assist.
The Jail does not always have a female jailer on duty. The
Jail must have a female detention officer on duty when a female
is in custody.


- 9 Training of detention officers is inconsistent at best.
Several of the detention officers at the Jail had not completed
the state-mandated three day training course. Although Oklahoma
State law requires annual in-service training, the Jail does not
provide such training. In addition, few detention officers had
current CPR certification. One detention officer on each shift
should be CPR certified.
The Jail has an outmoded policy and procedure manual last
revised in 1982. It should be revised to reflect current
standards, especially “Firearms, Ammunition and Chemical Agents”
(28.05 and 29.09); “Physical Force” (29.07); and “Security
Checks” (29.05). A current policy and procedure manual would be
particularly helpful at the Jail as some of the detention
officers lack any formal correctional training.

Suicide Prevention

During our July 2002 tour, our expert consultant noted
serious suicide hazards at the Jail. Each shower stall had a
non-structural bar at the top of its frame as well as a metal
shower curtain rod. An inmate could use either the bar or the
rod to hang herself or himself. During our September 2002 visit
to the Jail, we noted that the Sheriff had removed the bars from
the shower stall frames and had removed the metal shower curtain
rods, replacing the rods with a shower curtain that relied on
velcro strips.

Use of Force

Chemical agents are not stored or maintained in a proper
manner at the Jail. Detention officers keep canisters of
chemical spray in an unlocked cabinet in the Jailer’s Office,
accessible to anyone. Further, supervisors do not periodically
weigh the canisters to determine if an undocumented use of
chemical spray has occurred.
Jail policy requires that when a detention officer uses
force, be it a chemical spray or physical force, the officer must
prepare a post-incident “Use of Force” report. The Undersheriff
reviews all “Use of Force” reports for completeness and to
determine if the detention officer was justified in deploying
force. Although the use of force reporting form is sound, all
detention officers involved in or witness to an incident should

- 10 
independently prepare a Use of Force report, and not just the
officer that used force.

Failure to Inform all Inmates of Jail Policies

A correctional facility must provide all new inmates with an
orientation that covers the following areas: rules and
regulations; the process for obtaining medical or mental health
care; emergency procedures; commissary items and ordering;
visiting hours and regulations; and rules for sending and
receiving mail. The Jail does not provide an orientation to new
inmates. Instead, basic rules are posted on the walls outside
the cells.

Inmate Discipline

Written rules and regulations govern inmate conduct at the
Jail. Although the rules are posted throughout the Jail, the
method for dealing with infractions appears to be inconsistent.
There is no system for formal disciplinary reports and hearings
for alleged major violations of rules. Rather, individual
detention officers act as investigator, jury and sentencing
judge, doling out punishment on the spot, often engaging in group
discipline rather than penalizing individual inmates.


The provision of medical services to inmates at the Jail and
the Work Center is seriously deficient and places inmates at risk
of harm. Most fundamentally, the Jail has no on-site medical
care providers. In addition, no medical professionals screen
inmates for medical concerns or supervise or follow-up on outside
medical visits. From these fundamental deficiencies, numerous
unacceptable risks follow.

Intake Screening

The intake screening process is insufficient to ensure that
inmates receive necessary medical care while incarcerated. The
screening process is intended to ensure that inmates who suffer
from chronic conditions or otherwise need prompt medical
attention are referred to a medical professional for needed
follow-up care. The system at the Jail fails to provide timely
treatment to those who need it, and fails to collect accurate
information to guide future care.

- 11 Detention officers conduct intake screening as part of the
booking process in the Jailer’s Office. Detention officers ask
inmates a series of questions concerning different topics,
including medical and mental health care. Detention officers
enter the inmate’s responses into a database and the information
provided becomes part of the inmate’s correctional file.
Although detention officers record an inmate’s responses to
questions concerning medical or mental health problems, neither a
medical professional nor jail administrators review that
information. Even when detention officers identify an inmate
with serious medical needs during the intake process, the Jail
does not immediately refer those inmates to a medical
professional. For example, an inmate booked into the Jail on
June 3, 2002 informed a detention officer that he had a seizure
disorder that required medication. The inmate did not receive
that medication until July 10, 2002, after he had been examined
by the Jail’s community-based physician.
Detention officers conduct the intake screenings in a
setting which does not ensure confidentiality. The Jailer’s
Office is open and adjacent to the elevator lobby, where other
inmates wait to be booked, as well as the main staircase of the
Jail. The lack of confidentiality minimizes the likelihood that
inmates will respond truthfully to questions about whether they
have serious medical or mental illness. Insufficient screening
puts people at risk both because inmates may not be provided with
timely medical care and because inmates with communicable
diseases, including easily-spread respiratory infections like
tuberculosis, may infect the general population.
Because neither the Jail nor the Work Center have on-site
medical providers, have review of intake information by a medical
practitioner, or have oversight by a responsible medical
authority, detention officers effectively serve as the
gatekeepers for medical care. This is a significant and
unacceptable departure from universally accepted standards of

Health Assessments

Physical examinations,
be conducted within 14 days
facility. Further, inmates
tuberculosis at this time.

including a medical history, should
of admission to a correctional
should receive a screening test for
A health assessment serves the

- 12 
purpose of establishing a baseline health status for an inmate,
and documents health problems for which a treatment plan should
be initiated. Inmates currently receive health assessments only
if they request to be seen by the doctor or nurse. The medical
care provided at the Jail and the Work Center is only reactive to
emergent crises.

Sick Call

Detention officers collect sick call requests and give them
to the nurse. The expectation in a jail setting would be for
inmates to place their requests in a locked box to which
detention officers would not have access. This system allows for
confidentiality and reduces concern that detention officers might
restrict access to medical services.
A local registered nurse conducts sick call at the Jail and
at the Work Center each week or every other week and is available
at all time by beeper. The nurse evaluates inmates and either
provides treatment or refers the inmate to a doctor. It can take
up to four weeks to see a physician. The sick call system is
inadequate to provide timely and appropriate care.
The nurse follows no treatment protocols, policies or
procedures when providing care to the inmates. The nurse does
not have the training to evaluate patients without guidance from
treatment protocols and supervision from a physician. The nurse
is practicing beyond her clinical scope.
The nurse does not generally conduct physical exams or take
vital signs when evaluating inmates. This practice is not in
conformance with medical community standards. In addition, the
nurse documents little of the care provided. Detention officers
or the nurse enter any information captured in the exam into the
inmate’s correctional file, which is accessible to all detention
officers. The Jail should document all treatment in a
confidential file separate from an inmate’s correctional file.
The area used for medical examinations is wholly inadequate.
The nurse evaluates inmates in a cluttered, dirty, converted cell
on the second floor of the Jail that primarily serves as a
storage room. The room is outfitted with a desk and refrigerator
for the storage of medicines and vaccines. The medicine
refrigerator lacks a thermometer to check that proper
temperatures are maintained. Further, the vaccines stored in the

- 13 medicine refrigerator were expired, some by as much as four
years. The examination room lacks any medical equipment,
including an examination table or a sink. Because it is an open
cell, without sufficient sight and sound separation from the rest
of the Jail, there is no opportunity to maintain appropriate
privacy. The setting for medical evaluations is inadequate for
medical services as it is virtually impossible to properly
evaluate inmates.

Medication Storage and Distribution

At the Jail, detention officers store all medications,
including controlled substances, in a locked box in the Jailer’s
Office. However, the lock on the box was broken and reportedly
has been for some time. Controlled substances have the potential
for abuse and misuse and should be stored in a secure environment
to which access is limited.
Detention officers dispense medications without adequate
training or supervision. The inconsistent documentation of
medical treatment and medication distribution increases the
likelihood that inmates will suffer harm.


The Jail currently does not verify the licensure of its
outside medical providers. The Jail should verify these licenses
at least annually; that medical care is provided off-site does
not negate this requirement.

Acute Care

The Jail and Work Center lack any policies concerning the
management of medical emergencies. Instead, detention officers
and jail administrators must decide whether to contact the nurse
to have her ascertain if the inmate should receive immediate
medical attention. This practice presents an unacceptable risk
of harm to inmates’ health, and makes it likely that inmates will
endure unnecessary pain before a worsening condition is
ultimately brought to the attention of a medical care provider.
For example, according to the log kept by detention officers, an
inmate was involved in a fight with another inmate on August 9,
2002. Although the inmate complained of dizziness and a
detention officer noted the inmate suffered a “cut,” the inmate
did not receive medical attention at that time. Two days later,

- 14 
detention officers transported the inmate to the local hospital
where he was treated with medical staples for a laceration to his
scalp. Hospital medical staff allegedly instructed the inmate to
return in one week to have the staples removed. The inmate
informed us that, one week later, detention officers refused to
transport him to the hospital. Instead, another inmate allegedly
removed the staples from the inmate’s scalp with a pair of toenail clippers.

Chronic Care

In order to properly treat inmates with chronic illnesses, a
medical professional must see inmates on a regular schedule
appropriate to the disease, so that their illnesses may be
monitored, the symptoms controlled and documented, and
medications delivered and adjusted in a timely manner. The need
for chronic care is not hypothetical. At the time of our visit,
two inmates had been incarcerated at the Jail in excess of two
years. Further, as there is no oversight of the medical
screening conducted at the Jail and Work Center, it is likely
that there are a number of inmates in need of chronic care.


The Jail and Work Center fail to deliver adequate mental
health care to its residents who need such services.
Specifically, the Jail and Work Center do not provide sufficient
access to care or adequate suicide prevention.
The Jail and Work Center have not contracted with a
psychiatrist to provide care for the inmates. The Jail and Work
Center do utilize the services of a local mental health center
for crisis intervention. However, the assistance the mental
health center provides is limited to determining whether an
inmate already in crisis is suicidal. The mental health center
does not provide any follow-up or aftercare.
Once an inmate is deemed suicidal, whether by detention
officers, jail administrators, or the local mental health center,
the Jail has no mechanism to monitor that inmate. Instead,
detention officers, at the direction of the Sheriff and Jail
Administrator, place the suicidal inmate on the floor of the cell
and handcuff the inmate’s hands to the bars. This treatment is
cruel and inhumane. It provides no psychiatric intervention and

- 15 demonstrates a gross indifference to the medical needs of
The practice of handcuffing inmates to the bars of a cell,
which is also employed to restrain inmates that pose a physical
threat to others, creates a situation that places an inmate in
danger. The handcuffed inmate is left to the mercy of the other
inmates who are free to abuse or otherwise victimize the
prostrate inmate. Given the limited number of detention officers
on duty at any one time, the Jail cannot properly supervise the
restrained inmate and the other inmates in the cell. For
example, the Jail logbook notes that on June 12, 2002 an inmate
on suicide watch was cuffed to the bars of his cell. The inmate
informed the supervisor on duty that another inmate had
threatened him with physical violence. Neither the supervisor
nor any detention officer removed the handcuffed inmate from the
cell. The practice also raises issues concerning bathroom use,
access to drinking water and eating. One inmate stated that he
was dependent while handcuffed to the bars on other inmates to
feed him each meal, spooning the food into his mouth. Although
the other inmates ministered to the handcuffed inmate’s needs,
they could have taken his food and consumed it themselves.


The Jail does not provide adequate diet, clothing, or
environmentally adequate shelter.

Nutrition and Food Service

The food service operation at the Jail does not meet
nutrition or sanitation requirements and puts residents at risk
of developing food borne illness.
The menu used by the Jail at the time of our July 2002 visit
was inadequate and did not provide adequate nutrition. In
addition, the Jail did not have written instructions on preparing
medical or religious diets. A registered dietitian or medical
professional should provide written protocols for the preparation
of such diets.
Trustees prepare all food served at the Jail without
supervision from detention officers. This practice brings into
question the quality of the food served. In addition, neither a
medical professional nor a detention officer medically screen

- 16 
trustees before assigning them to food preparation. The failure
to medically screen and periodically monitor the health of
inmates associated with food preparation possibly exposes the
inmate population to a number of communicable diseases.
Food is improperly stored in the kitchen and pantry as well
as in refrigeration and freezing units. We found powdered and
dried foods left in open containers permitting contamination by
dirt, moisture and insects. We found numerous examples where
refrigerated and frozen foods were not kept at temperatures low
enough to inhibit growth of food borne bacteria.
Major pieces of food storage and service equipment were
either damaged or broken. The pieces of food storage and service
equipment that were serviceable, as well as the utensils, trays,
preparation equipment and pots, tended to be dirty and covered
with dried food. In addition, these items were not consistently
sanitized as required. We observed inmates washing dishes by
hand in a manner that would not ensure the cleanliness of the
The floors in the kitchen are not properly sealed, which
exposes food to insects and rodents. Broken window panes in the
kitchen also permit the entry of insects. We noticed flying
insects in and on a potato masher in the kitchen. We also
observed roach and rodent droppings near the freezers in the

Physical Plant

In general, the cells in the Jail are extremely dirty,
odoriferous and poorly maintained.
The facility has serious problems with lighting. Lighting
must be a least 20 foot candles to provide for reading,
sanitation and personal hygiene. In addition, poor lighting
makes it very difficult for a detention officer to observe what
is going on in the cells, and leaves both the inmates and the
officer at risk. Only one cell had light levels that met or
exceeded minimally acceptable levels. At least two cells had
levels of lighting that measured less than one foot candle of
The Jail provides adequate ventilation to circulate fresh
air and prevent the transmission of communicable diseases.

- 17 
However, in at least five cells, either inmates blocked the air
supply vents or the vents were clogged with dust and mold. These
vents must be opened and, if occluded by dust and mold, properly
The Jail has a number of plumbing problems. In the kitchen,
there exists the potential for back siphonage which could result
in contamination of the potable water supply. In the cells, the
showers were dirty and mildewed and several of them were leaking.
In addition, the temperature of the water supplied to the cells
was inadequate. Two cells lacked hot water altogether and a
third cell produced water at a temperature too low to be
conducive to good hygiene. Five other cells had water that
flowed at temperatures high enough to cause skin burns.
The risk of insect and pest infiltration in the cells is
high. Inmates consume all their meals in their cells. The
possibility of food spillage and hoarding presents a pest and
rodent problem. Further, the Jail permits inmates to purchase
and store in their cells unlimited quantities of snack foods and
soft drinks from the Jail’s commissary list. This creates a
trash problem as well as a rodent and pest problem.


Our inspection revealed torn and cracked mattresses
throughout the facility. Such mattresses cannot be cleaned or
sanitized properly.

Inmate Clothing and Bedding

There are deficiencies in the Jail’s issuance and
maintenance of clothing and bedding that result in unsanitary
conditions, facilitating the spread of disease. The schedule for
the laundering of personal clothing is inadequate from a personal
hygiene perspective. At present, prisoners exchange their
clothing once a week. At least two exchanges of outer clothing
and three exchanges of undergarments should be permitted per
week. While inmates can send their wash to be laundered by
trustees, inmates reported that trustees return the laundry in a
more soiled state than when it was sent. Many inmates forgo
having the trustees launder their clothes and linens and,
instead, wash them in the toilets in their cells.

- 18 The Jail requires inmates, or their families, to provide
their own undergarments. If an inmate does not have family
members to provide clothing, then that inmate never receives
another pair of undergarments. Instead, inmates released into
the community often “donate” their undergarments to other
inmates. This practice is unsanitary and must cease. Instead,
the Jail should place undergarments on its commissary list for
sale to inmates, or, if an inmate is indigent, should provide
new, clean undergarments to such inmates.
The Jail regularly holds more prisoners than it has bunk
space. Inmates without a bunk sleep on mattresses placed on the
floor. This practice impedes proper sanitation and may present
health, fire and safety hazards.


Inmates receive no opportunity for exercise and out-of-cell
time. All prisoners are confined in small cells twenty-four
hours per day. As of July 23, 2002, two inmates had been
incarcerated at the Jail for over two years. Not once had those
inmates had the opportunity for fresh air or to exercise out of
doors. The lack of out of cell time and opportunity for exercise
can exacerbate the conditions of residents with mental illnesses,
lead to violence among inmates, and can put inmates at risk of
developing anxiety and symptoms of depression.


The County has the responsibility to provide inmates with
reasonable access to the courts in order to challenge their
sentences, directly or collaterally, and the conditions of their
confinement. The County is not providing inmates at the Jail or
the Work Center with access to legal materials.
The law library in the Courthouse offers little effective
assistance to most inmates. Although the materials in the law
library appear to be up to date, inmates are neither permitted
access to the materials nor are detention officers trained or
available to assist the inmates in legal research.
Attorneys may meet with their clients in a small visiting
room on the first floor of the Jail. This visiting room presents
a safety risk to the attorney as the door must be locked once the
attorney enters the room with the inmate. Detention officers do

- 19 
not visually monitor the meetings. Rather, an attorney must use
a two-way radio to alert detention officers to unlock the door.
Several local attorneys expressed hesitation about meeting with
clients in the visiting room, citing safety concerns. We met
with an inmate in the visiting room during one of our tours. The
two-way radio provided by a detention officer did not work. It
took over 15 minutes for detention officers to respond to
repeated, periodic banging on the door of the interview room. In
addition to the safety hazards, attorneys may meet with clients
only when there are a sufficient number of detention officers on
duty to permit such a meeting.
Our review of inmates’ access to legal services at the Jail
was limited, and we did not identify any inmate whose ability to
pursue a claim was impaired because of the deficiencies of
service. Nonetheless, we are concerned that such an injury is
likely to occur.
In order to rectify the identified deficiencies and to
protect the constitutional rights of the facility’s inmates and
detainees, the Jail should implement, at a minimum, the following


Ensure that detention officers conduct adequate
fire drills for all shifts, covering all
institutional areas.


Add sprinkler capability to the Jail.


Install sufficiently loud, listed fire and smoke
detection systems.


Properly enclose stairwells, piping, chases and
smoke barriers.


Provide metal containers in which to store all
combustible personal property stored in the Jail.


Institute the use of non-combustible waste

- 20 

Use door keys that can be identified without the
benefit of sight; train staff in their use; ensure
that all keys to doors on exit routes are readily
available; and maintain an extra set of “emergency
keys” in the Jailer’s Office to expedite
evacuation of inmates in the event of an


Maintain emergency exit routes so that they are
free of obstacles, safe and available for use.


Obtain self-contained breathing equipment and
train detention officers in use.

10.	 Work with the local fire department to develop
plans for evacuation and fighting fires at the
11.	 Connect an emergency generator to the Courthouse
electrical system to ensure the automatic transfer
of power in the event of an outage.
We recognize that the County has instituted a sales tax to
fund the construction and continuing operation of a new
correctional facility to replace the existing Jail. Should it
appear that construction of a new jail will occur, we will work
with the County to develop interim measures to ensure fire safety
before occupancy of the new jail.


Develop and implement an objective classification
system and house inmates accordingly.


Provide adequate housing in which to segregate
inmates for disciplinary, security, medical or
mental health reasons.


Investigate suspicious inmate injuries for
evidence of potential assault, and document the
result of these investigations.


Hire a sufficient number of detention officers to
supervise inmates, ensure the safety and security
of inmates and detention officers and ensure that

- 21 there is at least one female detention officer on
duty for each shift.

Provide detention officers with sufficient
training, particularly in-service training,
regarding jail operations and use of force.


Develop and implement policies, procedures and
practices requiring each detention officer
involved in a use of force incident to
independently prepare a Use of Force report.


Develop and implement policies, procedures and
practices regarding the use of physical
restraints, including banning the practice of
handcuffing inmates to bars as a form of suicide
intervention or punishment.


Ensure frequent, irregularly timed and documented
rounds by detention officers.


Install an audio communication system so that
inmates can report emergency conditions to
detention officers without delay.

10.	 Provide an adequate orientation to all inmates
entering the Jail.
11.	 Develop and implement policies, procedures and
practices for an inmate discipline system.


Retain the services of a medical doctor, whose
responsibilities will include: supervising all
medical care rendered to inmates; providing
physician’s sick call; reviewing revised medical
intake screening forms and processes; monitoring
care of serious and/or chronic conditions;
ensuring that all inmates receive a health
assessment within 14 days of intake; and annually
reviewing policies and procedures concerning
medical or mental health screening and/or the
provision care.

- 22 2.	

Provide inmates with a health assessment,
comprehensive medical history and physical
examination, performed by appropriately trained,
licensed and, if appropriate, supervised
personnel, within 14 days of their arrival at the


Develop site-specific written policies and
procedures governing the provision of health care,
including medication distribution.
Provide for an appropriately confidential
environment to conduct intake screening.


Ensure that inmates who need medically appropriate
nutrition receive an appropriate diet as ordered
by a physician.


Establish policy, procedures and practices for
handling inmate sick call requests.


Verify the licensure of all medical care providers
at least annually, without regard to whether the
care is provided on or off-site.


Ensure that nurses provide medical care within the
scope of their training and licensure.


Develop and implement policies, procedures and
practices to ensure that medical information
received at booking, as well as treatment
information and documentation, becomes part of an
inmate’s medical record separate from the inmate’s
correctional file.

10.	 Train booking officers to look for signs of mental
and physical illness in inmates.
11.	 Develop and implement policies, procedures and
practices to ensure that inmates reporting or
exhibiting possible signs of significant medical
or mental health problems at booking are seen
promptly by a medical professional and receive
appropriate follow-up care.

- 23 12.	 Validate and continue, if appropriate, current
prescriptions for medications of incoming inmates
within 12 hours of arrival at the facility, or
sooner if appropriate.
13.	 Develop and implement policy, procedures and
practice for proper documentation and accurate,
thorough and legible medical record keeping.
14.	 Properly store and dispose of medical supplies;
dispose of expired medical supplies.
15.	 Train detention officers regarding their role in
securing access to acute and emergent care for
inmates, and provide adequate staff to accomplish
these tasks.
16.	 Ensure that all correctional officers are
certified annually in CPR and equip the Jail with
pocket masks and rubber gloves.
17.	 Staff the Jail with a sufficient number of
detention officers so that inmates requesting
acute and emergent care may be treated timely and
18.	 Provide a clean and private environment, equipped
with the appropriate and necessary equipment, for
the nurse or other medical professional to conduct
medical assessments and examinations.
19.	 Develop and implement policies, procedures and
practices for a chronic care system which includes
gathering information and establishing medication
upon intake into the facility, establishing a
system of care of inmates with chronic diseases at
established intervals, standardizing the
information gathered at treatment visits, and
devoting sufficient attention to inmates whose
uncontrolled conditions must be stabilized.


Provide every inmate with an initial mental health
screening upon arrival at the facility and a

- 24 mental status assessment within fourteen days of



Retain a psychiatrist to meet the serious mental
health needs of the Jail’s population.


Develop comprehensive site-specific mental health
care policies and procedures, including medication


Ensure that mental health care records are
complete and accurate to maintain continuity of
care, particularly regarding the administration of


Develop and implement policies, procedures and
practices to ensure that staff respond to sick
call mental health requests in a timely manner.


Develop and implement policies, procedures and
practices for a system to ensure that inmates
receive all necessary mental health medications in
a timely manner.


Develop and implement policies, procedures and
practices to properly store food, including
maintaining food temperatures that avoid the
growth of harmful bacteria.


Develop and implement policies, procedures and
practices to ensure that food storage, preparation
and service systems are washed and maintained in a
sanitary manner.


Develop and implement policies, procedures and
practices to provide for safe food handling and
storage, including proper handwashing.


Ensure that inmates and staff who work in food
service are in proper health to do so.


Ensure that all food service menus are reviewed at
least annually by a registered dietician.

- 25 6.	

Provide sufficient bunks or portable sleeping
surfaces so that inmates are not required to sleep
on the floor.


Maintain all mattresses and pillows in sanitary


Develop and implement policies, procedures and
practices to ensure that the facility follows
nationally accepted standards for infection
control and hygiene.


Provide sufficient lighting.

10.	 Clean the Jail and implement a system of regular
pest control.
11.	 Provide and maintain water at an appropriate
temperature for good hygiene for all cells.
12.	 Ensure that airflow is not impeded.
13.	 Develop and implement policies, procedures and
practices to ensure that toilets, sinks, showers
and drains are maintained in sufficient quantity,
clean and in proper working order.
14.	 Provide adequate exchanges of sanitized bedding,
clothing and undergarments.



Develop and implement policies, procedures and
practices to provide inmates with regular
opportunities for exercise.


Develop and implement policies, procedures and
practices to provide access to the law library or
legal assistance sufficient to enable inmates to
prepare their defense and to challenge the
conditions of their confinement.

- 26 


Incorporate all revised forms, practices and
policies concerning each area of Jail operations
discussed herein in a revised policy and
procedures manual.


Train all staff on revised policies and
procedures; the training must be documented.


Review all policies annually; the review must be


Develop and implement a quality improvement system
that monitors and improves deficiencies identified
in this findings letter.
# # #

We appreciate the cooperative approach taken by the Sheriff,
the Undersheriff, the Jail Administrator and the detention
officers at the Jail. We understand that officials recognize
many of the problems discussed in this letter. In anticipation
of continuing cooperation toward a shared goal of achieving
compliance with constitutional requirements, we will forward our
consultants’ reports under separate cover. Although the reports
are their work and do not necessarily reflect the official
conclusions of the Department of Justice, their observations,
analyses and recommendations provide further elaboration of the
issues discussed above, and offer practical assistance in
addressing them.
In the unexpected event that the parties are unable to reach
a resolution regarding our concerns, we are obligated to advise
you that 49 days after receipt of this letter, the Attorney
General may institute a lawsuit pursuant to CRIPA to correct the
noted deficiencies. 42 U.S.C. Section 1997b(a)(1). Accordingly,
we will soon contact County officials to discuss in more detail
the measures that the County and Sheriff must take to address the
deficiencies identified herein.

- 27 Sincerely,
/s/ Ralph F. Boyd, Jr.

Ralph F. Boyd, Jr.
Assistant Attorney General
cc: 	 Mr. Steve Hobson
Vice Chairman
Garfield County Board of Commissioners
Mr. Scott Savage


Garfield County Board of Commissioners

Cathy L. Stocker, Esq.

District Attorney - District Four

State of Oklahoma

Mr. Bill Winchester


Garfield County

The Honorable Robert G. McCampbell

United States Attorney for the

Western District of Oklahoma