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Cripa Poteau County Ok Jail Investigation Findings 4-17-03

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April 17, 2003

Mr. Carroll Rogers
LeFlore County Board of Commissioners
P.O. Box 607
Poteau, OK 74953

Investigation of LeFlore County Jail, Poteau, Oklahoma

Dear Mr. Rogers:
We write to report the findings of our investigation of
conditions of confinement at the LeFlore County Jail (“Jail”) in
Poteau, Oklahoma. On November 8, 2002, we notified you of our
intent to investigate the Jail pursuant to the Civil Rights of
Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997. Our
investigation focused on issues of security and protection from
harm, medical and mental health care, fire safety, environmental
health and safety, opportunities to exercise, and access to the
We conducted tours of the Jail on December 10-12, 2002, and
January 21-22, 2003, 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 Chief Investigator, the Jail
Supervisor, 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, shift logs, and investigative
reports. We also interviewed the community-based health care
provider and reviewed medical records maintained by that
individual. At the end of each tour, our expert consultants
conducted informal exit meetings with the Sheriff in which they
conveyed their preliminary findings.
We commend the Sheriff, Undersheriff, Chief Investigator,
Jail Supervisor, detention officers, and administrative staff of

- 2 
the Sheriff’s Department 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 violate
the constitutional rights of inmates. We find that persons
confined at the Jail risk serious injury from deficiencies in the
following areas: security and protection from harm, access to
medical and mental health care, fire safety, environmental health
and safety, opportunities to exercise, and access to the courts.



The Jail occupies the top floor of the four-story LeFlore
County Courthouse in Poteau, Oklahoma. The Courthouse was built
in 1926 and has been in continuous use ever since. The County
added the Jail to the roof of the Courthouse in the 1930’s. The
County utilizes the basement for storage and floors one, two and
three for offices and courtrooms.
The Jail includes the Jailer’s Office, kitchen, pantry,
women’s cell, trustees’ cell, protective custody cell, “drunk
tank,” and seven congregate cells for men, five of which are
grouped around a central open area, called “the bullpen,” with a
shower at the end. The Jail specifically reserves only 6 beds
for women.
On December 10, 2002, there were approximately 54 inmates
housed at the Jail, including 43 male inmates and 11 female
inmates. On January 21, 2003, the Jail housed 55 inmates,
including 41 male inmates and 14 female inmates. Of those 55
inmates, all but one were pre-trial detainees. Although the Jail
does not track the average length of stay, interviews with
inmates and reviews of daily census forms indicated that the
average length of stay is approximately one month.


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 to the

- 3 U.S. Constitution 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
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 vast 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



Inmates constitutionally are 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.

Classification and Inmate-on-Inmate Violence

The Jail uses only two basic methods of classifying inmates.
First, the Jail separately houses male and female inmates.
Second, the Jail has a policy of housing separately inmates

- 4 
classified as “maximum security” in a congregate cell called the
“hard cell.” Aside from those basic classifications, 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 scale to
identify potentially predatory inmates as well as inmates likely
to be victimized by others. This system minimizes violence in
shared housing units. The failure to use an objective assignment
system places inmates at significant and unnecessary risk of
The Jail Supervisor and detention officers maintained that
there was very little violence at the Jail. Conversations with
current and former inmates revealed, however, numerous, credible
allegations of a pattern of physical violence. Several alleged
incidents, described below, indicate that there is a serious
problem of physical violence at the Jail.
One former female inmate incarcerated at the Jail in 2000
and 2001 informed us that there were “lots of fights” in the
women’s cell. She stated that two female inmates beat the other
inmates in order to have those other inmates removed from the
cell. The inmate reportedly witnessed attacks involving throwing
bleach in another inmate’s eyes, using a toothbrush to stab
another inmate, and beating another inmate’s head against the
radiator in the cell. The former inmate stated that the victims
of the alleged assaults did not receive medical treatment.
Another former female inmate stated that in March 2002 she
was booked into the Jail and, within five minutes of entering the
cell reserved for women, two other inmates attacked her, one
allegedly using a portable fan to beat her in the face. The
female inmate reported that she was removed from the women’s cell
and placed in the protective custody cell with three other women,
all of whom reportedly claimed that they also had been beaten by
other inmates.
A former male inmate incarcerated in 2002 stated that
physical violence was a matter of course at the Jail. He stated
that he regularly saw male inmates physically attack other
inmates. He stated that inmates that were admitted to the Jail
allegedly under the influence of narcotics or alcohol frequently
acted out once placed in a cell and, as a result, were “beaten
down” by other inmates.

- 5 It was impossible to verify the level of inmate-on-inmate
violence as the Jail keeps very little, if any, documentation of
violent incidents. The failure to consistently document these
incidents, or to investigate or to punish the perpetrators,
ensures that violence will continue to occur.


The Jail lacks any space to provide special housing for
inmates who may need it for purposes of disciplinary segregation,
protective custody, or to accommodate medical or mental health
needs. The Jail does have a cell nominally reserved for
“protective custody.” However, Jail administrators and detention
officers routinely utilize that cell to house women in order to
relieve the overcrowding in the lone women’s cell. The failure
to segregate inmates can lead to disastrous consequences. The
following two examples of inmates that were housed in general
population yet needed to be placed in special housing, one of a
man who needed to be protected and another of a woman who needed
to be isolated to protect others, are illustrative.
During our December 2002 tour, detention officers had placed
a man accused of child molestation in one of the congregate cells
that front the open common area called “the bullpen.” Inmates in
the other cells fronting the bullpen were cognizant of the
charges filed against the accused man. We observed a number of
those inmates yelling graphic threats to the accused individual.
According to the accused man, when detention officers released
inmates into the bullpen area, either to use the shower or to
stretch their legs, the officers did not stay in the area to
supervise the inmates. The inmates allegedly reached through the
bars to attack the accused man and threw cleaning fluids and
bodily fluids at him. The individual also informed us that
another inmate in the congregate cell had attacked him the day
before, and that he had previously suffered two other physical
attacks. We observed an open wound behind the man’s ear and were
shown a bloody towel that the man reportedly had used to tend to
his injury. The man had not received any medical attention for
his obvious injury.
During the same tour, we spoke with a female inmate housed
in the four-bunk protective custody cell with three other women
(there were seven women housed in the six-bed women’s cell at the
time). The inmate informed us that when detention officers
attempted to place additional female inmates in the protective

- 6 
custody cell, she would physically attack the new inmates so that
detention officers would be forced to place the inmates in the
already-crowded women’s cell so that she could have the
protective custody cell to herself. When we returned to the Jail
in January 2003, there were 13 women in the women’s cell. The
inmate we spoke with in December was the sole occupant of the
protective custody cell. The inmate informed us, and detention
officers confirmed, that she physically attacked any inmate that
detention officers attempted to place in the protective custody
cell with her. Although the inmate effectively isolated herself,
she did so at the cost of three beds and injuries to other female

Inadequate Supervision

The Jail routinely has inadequate staffing to provide
generally accepted levels of inmate supervision. During the
week, the Jail has three detention officers on duty from 6 a.m.
to 2 p.m. and two detention officers on duty at all other times.
On the weekends, the Jail has one detention officer on duty at
all times and a reserve officer comes in for a few hours on
Sunday to assist with visiting hours. Three detention officers,
let alone the single officer during the weekends, are
insufficient to staff the Jail.
The lack of supervision jeopardizes the safety of inmates.
There have been several credible allegations of male detention
officers engaging in sexual relations with female inmates. The
Jail has failed to provide adequate staffing to ensure that
inmates are safe and secure at all times.
Detention officers informed us that there are times during
the week when all three officers are occupied with either booking
inmates or escorting them to and from court. Further, at nights
and on weekends, it is not unusual for there to be periods of
time when the Jail is left untended. Leaving the Jail
unsupervised creates the possibility for great violence to occur.
The staffing of one officer during the weekend poses other
problems. If a fight or medical emergency occurs, that detention
officer may not open the cell door to break up the fight or
provide medical assistance. Rather, the detention officer must
summon help and wait for that assistance to arrive. Such a delay
could lead to serious injury, if not death.

- 7 Detention officers either do not sufficiently supervise the
inmates or do not document their supervision. Jail policy
requires detention officer to make rounds of the cells each hour.
A review of the Jail’s log indicated that it was not uncommon for
hours to pass without a detention officer making a documented
Our observations confirmed that detention officers do not
sufficiently supervise inmates. We observed that detention
officers often stayed in the Jailer’s Office and did not
frequently venture into the Jail. Detention officers entered the
Jail only to transport prisoners or when trustees alerted
detention officers to a situation that required their attention.
Instead, detention officers relied on trustees to operate the
Jail. Trustees prepared and served all meals without any
supervision. In addition, trustees brought inmate’s verbal
requests for medication or medical attention to the detention
officers. In turn, the trustees then delivered over-the-counter
medication to the inmates. Permitting trustees to perform these
duties inappropriately gave them the power to reward and punish
other inmates. For instance, inmates reported that trustees
sometimes would tell a particular inmate that the inmate's food
had been adulterated.
Finally, the Jail does not consistently have a female jailer
on duty. The Jail must have a female detention officer on duty
when a female is in custody.

Training of Detention Officers

Formal training of detention officers is virtually
non-existent. Only one of the detention officers at the Jail had
completed the state-mandated three-day training course. The Jail
Supervisor had no formal correctional training. Although
Oklahoma State law requires annual in-service training, the Jail
does not provide such training. In addition, only three
detention officers had received CPR certification. One detention
officer on each shift should be CPR certified.
The Jail has a policy and procedure manual that is issued by
the Oklahoma Sheriff’s Association. The manual is not specific
to the Jail and, from our observation, it does not appear that
detention officers follow many of the policies.

Suicide Prevention

- 8 During our December 2002 tour, our expert consultant noted
serious suicide hazards at the Jail and informed the Sheriff of
these hazards. For example, 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. When we returned to the Jail in
January 2003, no measures had been taken to correct the hazards.

Failure to Inform All Inmates of Jail Policies

The Jail does not provide an orientation to new inmates. 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.

Inmate Discipline

Written rules and regulations govern inmate conduct at the
Jail. However, 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 only the
culpable inmates. Such group punishment creates a manifest risk
of retaliatory inmate-on-inmate violence.


The provision of medical services to inmates at the Jail is
seriously deficient and places inmates at risk of harm. Most
fundamentally, the Jail has no on-site medical care provider. In
addition, no medical professionals screen inmates for medical
concerns or supervise or follow-up on outside medical visits.
Further, the Jail fails to maintain any records on the sporadic
health care provided to the inmates in its custody. 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

- 9 
screening process is necessary 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 collect accurate
information to guide future care and fails to provide timely
treatment to those who need it.
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, and enter the inmate’s
responses into a database. The information provided becomes part
of the inmate’s correctional file.
The screening process is severely deficient. The screening
questionnaire has not been approved by a physician, which is
evident as the form does not include any questions concerning
possible exposure to tuberculosis. Although detention officers
record an inmate’s responses to questions concerning medical or
mental health problems, neither a medical professional nor a jail
administrator reviews 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. Detention officers, who themselves
have no medical training, determine when, or if, an inmate
receives medical attention. This is a significant and
unacceptable departure from universally accepted standards of
Even though detention officers conduct intake screenings,
there are no policies clearly delineating situations in which the
Jail will not accept prisoners who exhibit serious medical
problems. For example, the Jail Supervisor and detention
officers stated that they would accept an intoxicated individual
that had lost consciousness. Given that the Jail has no on-site
medical care provider and very few detention officers to monitor
inmates, unconscious individuals should not be accepted.
Detention officers conduct the intake screenings in a
setting which does not ensure confidentiality. The Jailer’s
Office is open to the Jail hallway where inmates, particularly
trustees who are permitted to roam freely in the Jail, can hear
an inmate’s responses to medical questions. The lack of
confidentiality minimizes the likelihood that inmates will
respond truthfully to questions about whether they have serious

- 10 
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
respiratory infections like tuberculosis that spread easily, may
infect the general population.

Health Assessments

Physical examinations, including a medical history, should
be conducted within 14 days of admission to a correctional
facility. Further, inmates should receive a screening test for
tuberculosis at this time. A health assessment serves the
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 is only reactive to emergent crises.

Sick Call

Detention officers collect “Medical Request” forms and, if
the officers consider the reported malady to be of sufficient
severity, they or the Jail Supervisor contact 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, but which would be reviewed regularly by the medical
care provider. This system allows for confidentiality and
reduces concern that detention officers might restrict access to
medical services.
A local registered nurse conducts sick call. Although she
is available at all times by beeper, she has no regular, fixed
schedule for conducting sick call. Further, there are no
arrangements to replace the nurse’s services when she is on
vacation, ill or otherwise unavailable. A physician rarely, if
ever, conducts sick call. In a time period extending from
October 1, 2002 to January 12, 2003, a doctor conducted sick call
one time at the Jail. 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. The nurse is practicing beyond her clinical

- 11 When the nurse conducts sick call, she often utilizes
trustees to assist her in providing services, such as helping her
bandage an inmate’s wound. The use of trustees, who lack any
medical training, is a violation of the inmate’s privacy.
Further, a trustee’s possession of confidential medical
information gives that trustee undue power and influence over
another inmate.
The area used for sick call is wholly inadequate. The nurse
evaluates inmates either in the Jailer’s Office or in the Jail
kitchen. There is no medical equipment in either room.

Medication Storage and Distribution

At the Jail, all prescription medications, including
controlled substances, are stored in a file box in the Dispatch
Office. At the time of our January 2003 tour, the file box was
unlocked at all times and the key was left in the lock.
Controlled substances have the potential for abuse and misuse and
should be stored in a secure environment to which access is
Trustees regularly dispense over-the-counter medications
and, on occasion, distribute prescribed medications to inmates.
Permitting trustees to distribute both prescription and
non-prescription medication is unacceptable. It can create the
potential situation where trustees could either steal the
medication, sell it to another inmate, or exert undue pressure
and power over the intended recipient.
Jail officers also distribute medications at the Jail. They
do so without training or supervision. Finally, a physician
never follows-up with inmates receiving medication to judge the
effectiveness of the medication, to continue the medication or to
determine whether alternative therapy would be appropriate.

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 Jail
does not have a chronic care program. Since the Jail fails to
provide medical oversight of screening, and inmates often are

- 12 
housed at the Jail for a month, it is likely that they do have
inmates requiring chronic care.

Acute Care

The Jail lacks 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.

Infection Control Program

All correctional facilities are at risk of housing inmates
with communicable diseases. Jails should have policies
addressing universal precautions to protect inmates and staff
from possible exposure to blood and bodily fluids. Jails also
should have policies and procedures to detect, isolate and treat
inmates with communicable and infectious diseases. The Jail has
no such policies or procedures. Two examples show the need for
such policies and procedures.
First, during our December 2002 visit, our expert consultant
in environmental health and safety noted that syringes were
stored in an unlocked desk drawer in the Jailer’s Office, that
there were no alcohol wipes available, and that detention
officers or trustees were re-capping syringes after use and then
placing them in the hazardous waste receptacle. Recapping a
syringe possibly exposes an individual to blood-borne pathogens
including HIV and Hepatitis B.
Second, during our January 2003 visit, the women’s cell
housed 14 female inmates in a cell measuring approximately 210
square feet. One of the inmates had a compromised immune system
and another was pregnant. A recently released inmate, who had
been housed in the same cell, stated at intake that she had
tuberculosis. There had been no provision for isolating the
women with tuberculosis. Tuberculosis could have threatened the
life of the pregnant woman and had adverse consequences for her
pregnancy. In addition, medication prescribed to the woman with
a suppressed immune system had run out and no one had taken
measures to ensure that the prescription was renewed. The lack

- 13 of medication and proximity to a tubercular individual
jeopardized the health and life of the inmate with the suppressed
immune system.


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.

Dental Care

The Jail does not contract with a designated dentist to
provide care to inmates. Further, specific policies and
procedures governing the provision of emergency or non-emergency
dental care for inmates do not exist.


The Jail fails to deliver adequate mental health care to its
residents who need such services. The Jail does not provide
inmates with an adequate mental health screen or a mental health
assessment 14 days after admission. In addition, the Jail has
not contracted with a psychiatrist to provide care for the
The experience of one mentally ill inmate illustrates the
lack of mental health services at the Jail. At the time of our
December 2002 visit, we encountered an evidently mentally ill
inmate housed in the “drunk tank” who was yelling and shouting
uncontrollably, frequently calling the female detention officer
on duty “Mama.” The man had not received any mental health care
at the Jail since his incarceration in October 2002. When we
returned to the Jail in January 2003, the same inmate was housed
at the Jail in a congregate cell and still had not received any
mental health care. Our expert medical consultant conducted a
mini-mental health exam that revealed that the inmate was not
oriented to time, date or place. In our interview with the
nurse, we discovered that the nurse had seen the inmate, but only
after one of the inmate’s prescription medications had lapsed
and, suffering withdrawal, the inmate stood in his cell for three
straight days. Detention officers called the nurse to tend to
the swelling in the inmate’s legs, and not for his evident mental
health problems.

- 14 


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 cells are secured by individual padlocks.
This factor makes fire suppression and detection a critical
issue, particularly on the weekend when only one detention
officer is on duty. 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. The
standpipe system extends to the third floor, but not to the Jail.
There are no smoke detection or fire alarm systems installed in
the building. Rather, some of the areas of the Courthouse and
the Jail are equipped with battery operated smoke detectors.
Because the smoke detectors are not part of an integrated
building-wide system, only an alarm in the immediate area of the
smoke or fire would sound. In the event of a fire, an alarm
might go unheeded if detention officers are not in close
proximity to the smoke detectors.

Smoke Exposure

The Jail does not protect residents from dangerous exposure
to smoke. A single staircase rises from the first floor to the
third floor of the Courthouse. A separate staircase connects the
third floor and the Jail. These stairwells are not fully
enclosed with fire-rated enclosures. In addition, an antiquated
elevator shaft runs from the first floor to the Jail floor. In
the event of fire, the stairs and elevator shaft would become
avenues by which heat, smoke, toxic fumes and other products of
combustion could spread unimpeded through the Courthouse and
Jail. The stairs would be impassable and an unreliable means of
The lack of a self contained breathing apparatus (“SCBA”),
for detention officers to use in the evacuation of prisoners,

- 15 
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 safely 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. Although smoking is forbidden at the Jail, inmates
were observed smoking in their cells and cigarettes butts were
observed in the kitchen. 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

Inmates and detention officers have two routes to evacuate
the Jail. Inmates may traverse the internal staircases or they
may exit the Jail through doors on to the roof of the Courthouse
and descend a standing stair attached to the building.
Padlocks secure all cell doors and it requires five 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. In
addition, an “emergency” set of keys is kept in the Dispatch
Office on the first floor and not in the Jail where they would be
Detention officers seemed unaware of evacuation procedures.
Although the detention officers understood the routes to follow
to evacuate the Jail, 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.

- 16 The Jail relies on the local volunteer fire department to
respond to any emergency related to fire. 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 Courthouse, 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.


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 Jail lacks a menu. The trustee that served as head cook
informed us that he orders and cooks food “off the top of his
head.” Inmates that are diabetic or require a medically
prescribed diet are not provided with such foods. Although the
nurse reportedly advises the cook as to a specific inmate’s
dietary needs, the cook stated that he had never received such
instruction. Instead, trustees serve inmates with specific
dietary needs the same food as other inmates and instruct them to
try to adjust the foods they eat according to their medical
Trustees prepare and serve every meal 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
trustees before they are assigned 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 stored improperly 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

- 17 
refrigerated and frozen foods were not kept at temperatures low
enough to inhibit growth of food borne bacteria.
The food storage and service equipment, as well as the
utensils, trays, preparation equipment and pots, tended to be
dirty and covered with dried food. Inmates were not provided
with cups for drinking. Instead, they utilized soda bottles cut
in half, which are never sanitized and are filthy. One female
inmate stated that she shared a soda bottle with another female
inmate as there were not enough makeshift drinking receptacles
for each inmate.
The floors in the kitchen are not properly sealed, which
exposes food to insects and rodents. Broken windows panes in the
kitchen also permit the entry of insects. In particular, we
noticed flying insects in and on food-encrusted utensils in the

Physical Plant

In general, the cells in the Jail are extremely dirty,
odoriferous and poorly maintained. The Jail provides no
ventilation to circulate fresh air and prevent the transmission
of communicable diseases.
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 detention officers to observe what is
going on in the cells, and leaves both the inmates and the
officers at risk. Not a single cell had light levels that met
minimally acceptable levels. One cell had levels of lighting
that measured less than one foot candle of light.
The current state of plumbing at the Jail causes great
concern. The pipes in the plumbing chase behind the cells showed
signs of severe corrosion. Uninsulated overhead pipes in the
women’s cell dripped condensate water on the bunks. The showers
were dirty and mildewed and several were leaking. In addition,
the temperature of the water supplied to the cells was
inadequate. One cell produced water at a temperature too low to
be conducive to good hygiene and three others supplied water at
temperatures high enough to cause skin burns.

- 18 The risk of insect and pest infestation 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. Furthermore, they present an increased fire
risk, as torn and cracked mattresses lose their fire-resistive

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. Further,
while inmates can send their wash to be laundered by trustees,
inmates reported that trustees returned 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.
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 lacks sufficient clothing for the number of inmates
it houses. Female inmates stated that they were not given
replacement clothing when they sent their clothes to be
laundered. Instead, the inmates reported that they were required
to sit in their cells in their undergarments until a trustee
returned the laundered clothing.

- 19 The Jail regularly holds more prisoners than for which it
has beds. Inmates without a bunk sleep on mattresses placed on
the floor. At the time of our January 2003 visit, the women’s
cell housed 13 inmates, six on bunks and seven on mattresses on
the floor. Mattresses must not be placed directly on the floor
because they impede 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. 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
with access to legal materials.
Although the Courthouse has a law library, inmates are
neither permitted access to the materials nor are detention
officers trained or available to assist the inmates in legal
Our review of inmates’ access to legal services 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
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


- 20 1.	

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.


Develop and implement policies, procedures and
practices for the investigation of 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 provide at
least one female detention officer on duty for
each shift.


Provide detention officers with sufficient
training, particularly in-service training.


Develop and implement policies, procedures and
practices to ensure frequent, irregularly timed
and documented rounds.


Provide an adequate orientation to all inmates
entering the Jail.


Develop and implement policies, procedures and
practices for an inmate discipline system.


Develop and implement policies, procedures and
practices to ensure the supervision of trustees.

10.	 Address and remedy the suicide hazards in the


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;

- 21 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.

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 and implement policies, procedures and
practices, that are site-specific, governing the
provision of health care, including medication


Provide for a more confidential environment to
conduct intake screening.


Provide an appropriately clean and confidential
environment, equipped with the appropriate and
necessary equipment, for the nurse or other
medical professional to conduct medical
assessments and examinations.


Develop and implement policies, procedures and
practices to ensure that diabetics and other
inmates who need medically appropriate nutrition
receive an appropriate diet as ordered by a


Develop and implement policies, 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.

10.	 Develop and implement policies, procedures and
practices to ensure that medical information

- 22 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.
11.	 Train booking officers to look for signs of mental
and physical illness in inmates.
12.	 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.
13.	 Validate and continue, if appropriate, current
prescriptions for medications of incoming inmates
within 12 hours of arrival at the facility, or
sooner if appropriate.
14.	 Develop and implement policies, procedures and
practices for proper documentation and accurate,
thorough and legible medical record keeping.
15.	 Develop and implement policies, procedures and
practices for the proper storage and disposal of
medical supplies.
16.	 Train detention officers regarding their role in
securing access to acute and emergent care for
inmates, and provide adequate staff to accomplish
these tasks.
17.	 Ensure that all correctional officers are
certified annually in CPR and equip the Jail with
pocket masks and rubber gloves.
18.	 Staff the Jail with a sufficient number of
detention officers so that inmates requesting
acute and emergent care may be treated timely and
19.	 Establish a chronic care system which includes
gathering information and establishing medication
upon intake into the facility, establishing a

- 23 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.
20.	 Develop and implement policies, procedures and
practices for distribution of prescription and
over-the-counter medication; train detention
officers in the proper mode of medication
distribution; and cease permitting trustees to
distribute any medication.
21.	 Develop and implement policies, procedures and
practices to detect, monitor and isolate inmates
with infectious diseases, where appropriate.
22.	 Train detention officers on universal precautions
to protect inmates and staff from possible
exposure to blood and bodily fluids.
23.	 Develop and implement policies, procedures and
practices governing the provision of emergency or
non-emergency dental care and contract with a
designated dentist to provide care to inmates.
24.	 Provide regularly scheduled sick call to be
conducted by a nurse or physician’s assistant.
25.	 Provide regularly scheduled sick call to be
conducted by a physician.


Provide every inmate with an initial mental health
screening upon arrival at the facility and a
mental status assessment within fourteen days of


Contract with 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

- 24 -



Develop and implement policies, procedures and
practices to ensure that mental health care
records are complete and accurate to maintain
continuity of care, particularly regarding the
administration of medications.


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


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


Develop and implement policies, procedures and
practices to 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 in the Jail.


Use door keys that can be identified without the
benefit of sight, ensure that all keys to doors on
exit routes are readily available, and train staff
in their use.


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.

- 25 9.	

Work with the local fire department to develop
plans for evacuation and fighting fires at the

10.	 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 attempted to establish 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 facility.


Develop and implement policies, procedures and
practices to provide for safe food handling and
storage, 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 ensure that inmates and staff who
work in food service are in proper health to do


Develop and implement policies, procedures and
practices to provide medical diets as prescribed
by a physician and ensure that all food service
menus are reviewed at least annually by a
registered dietician.


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

- 26 6.	

Provide a sufficient number of mattresses and
maintain them in sanitary and fire safety


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


Provide sufficient lighting.


Clean the Jail and implement a system of regular
pest control.

10.	 Provide and maintain water at an appropriate
temperature for good hygiene for all cells.
11.	 Provide sufficient airflow within the Jail.
12.	 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.
13.	 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.


Incorporate all revised forms, practices and
policies concerning each area of Jail operations

- 27 discussed herein in a revised policy and
procedures manual.

Train all staff on revised policies and
procedures; document the training.


Review all policies annually; document the review.


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
and the detention officers at the Jail. We understand that
officials are aware of and acknowledge 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. 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.

/s/ Ralph F. Boyd, Jr.

Ralph F. Boyd, Jr.
Assistant Attorney General

- 28 
cc:	 Mr. Freddie Cox
County Commissioner
LeFlore County Board of Commissioners
Mr. Lance Smith
County Commissioner
LeFlore County Board of Commissioners
Rob Wallace, Esquire
District Attorney
State of Oklahoma - District 16
Mr. Roy D. Gentry


LeFlore County

The Honorable Sheldon J. Sperling
United States Attorney
Eastern District of Oklahoma