March 6, 2003
Mr. Jack Sullivan
County Commission Chairman
102 Grant Avenue
Santa Fe, NM 87501
Re: 	 Santa Fe County Adult Detention Center
(Formerly the Santa Fe County Correctional Facility)
Dear Mr. Sullivan:
We write to report the findings of our investigation of
conditions at the Santa Fe County Adult Detention Center
("Detention Center," formerly the Santa Fe County Correctional
Facility). On March 20, 2002, we notified you of our intent to
investigate the Detention Center pursuant to the Civil Rights of
Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997.
On May 7-10 and 29-31, 2002, we conducted on-site
inspections of the facility with expert consultants in
corrections, medical care, mental health care, and sexual
misconduct/gender issues. While at the Detention Center, we
interviewed correctional and administrative staff, inmates,
medical and mental health care providers, and programming,
training, safety, food service and sanitation personnel. Before,
during and after our visit we reviewed an extensive number of
documents, including policies and procedures, incident reports,
medical and mental health records, inmate grievances, use of
force records, and investigative reports.
We commend the staff of the facility and the County for
their helpful and professional conduct throughout the course of
the investigation. The staff have cooperated fully with our
investigation and have provided us with substantial assistance.
Consistent with the statutory requirements of CRIPA, we
write to advise you of the results of this investigation. As
described more fully below, we conclude that certain conditions
at the Detention Center violate the constitutional rights of
inmates. We find that persons confined suffer harm or the risk

- 2 ­


of serious harm from deficiencies in the facility’s
medical and mental health care, suicide prevention,
inmates from harm, fire safety, and sanitation. In
facility fails to provide inmates sufficient access
and opportunity to seek redress of grievances.
I.
A.

provision of
protection of
addition, the
to the courts

BACKGROUND

FACILITY DESCRIPTION

Santa Fe County opened the Detention Center in 1998.
Management and Training Corporation (“MTC”), a private
corporation, has managed and operated the facility by contract
with the County since October 2001. The facility has a housing
capacity of approximately 672 inmates. On the first day of our
visits to the facility, the total inmate population was 598.
There were 532 adult male and 66 adult female inmates. At the
time of our visits, the Detention Center housed inmates from
nineteen jurisdictions, including federal inmates by agreement
with the Bureau of Indian Affairs and the United States Marshals
Service. Since that time, the facility has entered into a
contract to house a large number of inmates from the State of New
Mexico Department of Corrections, as well.
Inmate housing includes double cells and dormitories. Some
inmates are singly housed in double cells. Housing is divided
into four housing unit pods of six areas each, centrally managed
by a unit control center. The Detention Center also has
administrative areas, classrooms, a booking and intake area, four
outdoor recreation yards, food service, laundry and medical
facilities. Physicians Network Associates (“PNA”) provides the
medical care at the facility by subcontract with MTC.
B.

LEGAL BACKGROUND

CRIPA gives the Department of Justice authority to
investigate and take appropriate action to enforce the
constitutional rights of inmates in jails and prisons. 42 U.S.C.
§ 1997.
With regard to sentenced inmates, the Eighth Amendment’s ban
on cruel and unusual punishment "imposes duties on [prison]
officials, who must provide humane conditions of confinement;
prison officials must ensure that inmates receive adequate food,
clothing, shelter, and medical care." Farmer v. Brennan, 511

- 3 -

U.S. 825, 832 (1994). Prison officials have a further duty "to
protect prisoners from violence at the hands of other prisoners."
Id. at 833. 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). It also forbids excessive physical force against
prisoners. Hudson v. McMillian, 503 U.S. 1 (1992). Medical
needs which must be met include not only physical health needs,
but mental health needs as well. 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).
With regard to pre-trial detainees, the Fourteenth Amendment
prohibits imposing conditions or practices on detainees not
reasonably related to the legitimate governmental objectives of
safety, order, and security. Bell v. Wolfish, 441 U.S. 520
(1979). The Fourteenth Amendment also requires that inmates have
access to the courts, sufficient to challenge their sentences and
the conditions of their confinement. Bounds v. Smith, 430 U.S.
817 (1977); Lewis v. Casey, 518 U.S. 343 (1996).
II.
A.

FINDINGS

MEDICAL CARE

The Detention Center provides medical services through a
subcontract between MTC and Physicians Network Associates
(“PNA”). The Detention Center, through PNA, provides inadequate
medical services in the following areas: intake, screening, and
referral; acute care; emergent care; chronic and prenatal care;
and medication administration and management. As a result,
inmates at the Detention Center with serious medical needs are at
risk for harm.
1.

Intake, Screening, and Referral

PNA’s intake medical screening, assessment, and referral
process is insufficient to ensure that inmates receive necessary
medical care during their incarceration.
According to PNA policy and in keeping with the standard of
care in jails, all arrestees should receive an initial health
screening at the time of booking. At the Detention Center,
screenings are completed by a Licensed Practical Nurse (“LPN”)
following a three-page form, and include a physical, mental, and

- 4 ­

dental health screen. The intake process is intended to ensure
that inmates who suffer from chronic conditions or otherwise need
prompt medical attention are referred to the Health Services Unit
for needed follow-up care and given appropriate housing.

Review of a random sample of medical records of inmates
admitted during the month of April 2002, revealed that 20 percent
did not have the documented initial health screening described
above. Without this screening, incoming inmates suffering from
chronic and/or contagious disease may not be referred for followup care, which heightens the risk that their illnesses will
continue and their conditions will deteriorate. Furthermore,
incoming inmates whose illnesses go undiscovered and untreated
may be housed with the general population, placing other inmates
and staff at risk for disease.
Moreover, even when PNA staff identify inmates with serious
medical needs during the intake process, they fail to refer them
for appropriate care. Chart review revealed that of those
inmates in our sample who did receive the initial health
screening, none were referred to the Health Services Unit for the
medical attention they needed. For example, inmates reporting
histories of hypertension and depression who claimed to be on
prescription medication at the time of their incarceration should
have been promptly referred to the Health Services Unit for
assessment, decisions about continuity of medication(s), and
appropriate medical care. Interruption of hypertension
medication can lead to heart ailments and strokes, and
interruption of antidepressant medication can lead to mental
health crisis as well as resulting in physical withdrawal
symptoms such as headache, disturbed sleep and loss of appetite.
Failure to refer for medical follow-up inmates who have chronic
or acute conditions may result in the interruption of treatment
and medication, which may in turn lead to deterioration or loss
of function.
Subject to reasonable security needs, screening interviews
must be conducted privately, to ensure that the inmate feels
comfortable enough to disclose any physical or mental health
problems she or he may be experiencing. During our visit, we
observed breaches of confidentiality of inmate medical and mental
health information. Two different male corrections officers, on

- 5 ­

separate occasions, entered the room where a newly admitted
female inmate was completing the initial health screening and
observed parts of the process. One of the male officers
handcuffed the inmate. The officers’ presence and the imposition
of unneeded restraints on a cooperating inmate decreases the
likelihood that the inmate will provide reliable information
during the screening. Accurate medical history is critical to
the provision of appropriate care and protection of other
residents and staff from communicable diseases.

To provide for inmates' serious medical needs, facilities
must identify inmates with chronic, acute or contagious
conditions or other serious needs so that appropriate care may be
provided. Accordingly, inmates who stay more than a few days at
a facility must have a detailed assessment of their health
histories and current conditions beyond the limited information
provided in the intake health screening. Such steps are
necessary so that plans for inmates' ongoing care may be
established. The facility fails to conduct timely histories and
physicals to ensure that medical providers have adequate
information to meet inmates' serious medical needs.
Our review indicated that only 37 percent of the inmates
received a full health appraisal within 14 days of arrival at the
facility. Only 50 percent of the records in our sample contained
documentation that the health appraisal or the skin test for
tuberculosis were completed within 18 days of admission. In some
files in which a health appraisal was recorded, documentation was
incomplete, and failed to include information on the inmate’s
history, a review of symptoms and/or a record of the physical
examination. In some cases we reviewed, PNA staff failed to
respond appropriately to information received from inmates during
the 14-day evaluation, including information which indicated a
serious medical need. The nurses conducting these examinations
have no formal training in physical assessment.
For example, one inmate reported during his 14-day physical
that he had tested positive for glaucoma at the facility from
which he was being transferred. Although a note was placed in
his chart to procure the records of this test, PNA failed to
follow through and staff never obtained the records. The inmate
complained about his condition again nearly two months later, but
still did not receive an eye examination. Another four months
passed between the inmate’s second request and our site visit to
the Detention Center, at which point our expert reviewed this

- 6 -

inmate’s medical record and reported his concern to the staff.
Nearly one month after our visit, the patient finally received an
eye examination. However, there was still no report of an ocular
pressure determination or any other test to detect glaucoma. If
this inmate has glaucoma, he may become blind unless he receives
treatment. As of our last review of his chart, it had been eight
months since he originally reported this condition during the
initial health screening, and his record still did not reflect an
appropriate assessment to determine what care he needed.
PNA does not test for sexually transmitted diseases
(“STDs”). STDs are prevalent in jail populations. Left
untreated, STDs can cause brain and organ damage and damage to
fetuses. PNA’s failure to screen for STDs places the inmates and
the community at risk.
2.

Acute Care

PNA fails to provide timely access to appropriate medical
care for inmates when they develop acute medical needs. Medical
care is unreasonably and unnecessarily delayed and, even when
provided, often inadequate.
Inmates access medical care by completing sick call forms,
which are filed in boxes on the housing pods. A designated
member of the Health Services Unit staff retrieves the sick call
forms daily. PNA policy provides that the requests will be
“triaged,” and inmates will receive medical care according to the
urgency of their medical needs. The Health Services Unit calls
for the inmate if a visit to the Unit is deemed necessary.
Our review of inmate sick call requests revealed that
inmates experience delays in responses to their requests for
care, putting them at risk for worsening conditions. For
example, one inmate filed a sick call request stating that he was
suffering from alcohol and narcotic withdrawal symptoms,
including cold sweats and vomiting. PNA policy states that an
inmate exhibiting symptoms of withdrawal such as sweating and
vomiting will be evaluated by a Health Services staff person as
soon as possible. This inmate was not seen for four days, even
though withdrawal from alcohol can be life-threatening.
Even once inmates succeed in getting to the Health Services
Unit, they frequently receive substandard care. We reviewed the
medical records of ten inmates seen for primary care by the nurse
practitioner within a one-month period. Six of the ten inmates
received substandard care. For example, two inmates had abnormal

- 7 ­

skin tests for tuberculosis, one of whom was recently infected,
but neither was offered treatment. The consequences of failing
to treat new latent tuberculosis infection can be severe, as
recently infected individuals are at a high risk of developing
contagious tuberculosis. This risk can be significantly reduced
with prophylactic treatment. The nurse failed to recognize
abnormal heart rhythm in one inmate, and in a second inmate,
identified abnormal heart rhythm but failed to refer that inmate
to a specialist for appropriate examination.
Additional chart reviews confirmed PNA’s failure to respond
to inmates’ acute medical needs. For example, one inmate
reported breast lumps and lumps in her armpit, chest pain, and
swelling in her legs and feet. Although a mammogram was ordered
in October 2001, it had not been done by the time of our visit to
the Detention Center seven months later. In addition, by that

time the swelling in this inmate’s legs was so severe that when
pressed, her tissue stayed depressed, resembling “silly putty.”
This condition is known as “pitting edema” and, as our expert
reported to the PNA staff, requires urgent medical care.
Pursuant to our recommendation, this inmate was subsequently seen
by a physician. However, the physician did an incomplete
evaluation of her swollen legs and did not document whether he
conducted an evaluation of her breast or armpit lumps.
Another inmate who had heart disease and a history of
positive skin testing for tuberculosis complained of chest pain.
The nurse practitioner treated him with nitroglycerin. After two
months, the inmate was sent to the emergency room, where the
physician recommended a chest x-ray, a stress test, and treatment
with long-acting pain medication, none of which the inmate
received. Three months later, the inmate developed fever, chills
and an elevated respiratory rate. The nurse practitioner did not
examine the inmate or order a chest x-ray, which would be the
standard of care for a patient with a positive skin test for
tuberculosis complaining of these symptoms. Instead, the nurse
practitioner diagnosed the inmate with pneumonia and prescribed
antibiotics through a telephone call with health services staff,
which is inconsistent with accepted standards of care. She did
not see the inmate until three days later. The failure to
diagnose and treat this inmate in an appropriate manner on a
timely basis, despite the fact that he could have had
tuberculosis, placed the inmate at serious risk. Furthermore,
the failure to place this inmate in respiratory isolation based

- 8 ­

on the possibility that he was infected with tuberculosis placed
the inmates and staff at risk for contracting the disease.
The grievance system does not provide an avenue for
resolving problems of access to health services. The grievances
we reviewed included a complaint from one inmate who was supposed
to have an x-ray, but had received no response from the Health
Services Unit despite having filed two grievances in three weeks.
This complaint was not reviewed for eight days after it was
filed, and no resolution to the grievance is documented. Another
inmate filed a grievance complaining that he had not received his
medication and that his condition was worsening. According to
the response record, the matter was not resolved for eight days.
The nurse practitioner’s personnel file included a memo from
the Vice President of Operations of PNA instructing her to see
one patient for each five minutes of scheduled clinical time.
Many inmates, particularly those with acute or chronic
conditions, require significantly more clinical attention to
ensure that their needs are adequately addressed. This arbitrary
time limit places extreme pressure on the nurse practitioner and
necessarily affects the care she is able to provide. It also
increases the likelihood that the nurse practitioner will fail to
diagnose, will incorrectly diagnose, and/or will fail to provide
appropriate treatment and prescribe correct medications to
inmates with medical needs.
At the time of our visit, the only physician providing
supervision or care at the Detention Center was the doctor who is
the Chief Executive Officer (CEO) of PNA and is based in Lubbock,
Texas. As the CEO of PNA, this doctor has numerous
responsibilities, including supervising the medical care at each
of the facilities at which PNA provides care throughout the south
and southwestern United States. This physician was visiting the
Detention Center an average of once every six weeks, and saw only
a few patients during each visit. While he is available by
telephone for consultation, he does not visit the Detention
Center frequently enough to provide adequate supervision. Given
the deficiencies in care and other problems identified in this
letter, additional physician supervision at the Detention Center
is necessary.
3.

Emergent Care

PNA fails to provide appropriate and timely care to inmates

- 9 ­

with emergent medical needs.
One case we reviewed involved an inmate who was referred to
the Health Services Unit because he had bleeding from the ear
following trauma. Bleeding from the ear typically indicates
either a perforated ear drum or a basilar skull fracture. The
nurse never provided or referred the inmate for a full ear
examination or a neurological examination, and instead prescribed
an addictive narcotic pain reliever which is an inappropriate
treatment for these symptoms.
Another inmate entered the Detention Center with high blood
pressure and diabetes. He reported sudden loss of vision on
February 20, 2002. Diabetics are at an increased risk for
disease of the retina and bleeding into the retina. Sudden loss
of vision, particularly in the case of a known diabetic,
constitutes a medical emergency, and the inmate should have been
immediately referred for emergency care. He was referred to an
optometrist, who measures eyes for eyeglasses, as opposed to an
ophthalmologist, who specializes in diseases of the eye. The
inmate was finally seen by an ophthalmologist on April 1, 2002,
nearly six weeks after he lost his vision. Although the
ophthalmologist immediately referred him to a retina surgeon, the
Detention Center did not transport him to the retina surgeon for
nearly two more weeks. After examining the inmate, the surgeon
identified the inmate’s condition as a medical emergency and
called the Detention Center for permission to operate
immediately. Nonetheless, the inmate did not receive the surgery
for another ten days. Although this inmate’s blindness could
have been prevented had he received appropriate care, the delay
in treatment caused him to lose his vision permanently.
Another inmate, also with severe symptoms, was similarly
unable to access appropriate care when he experienced a medical
emergency. This inmate, who reported a history of head trauma at
intake, became disoriented on his third day at the Detention
Center. Three days later he experienced bowel and bladder
dysfunction, exhibited abnormal movement in his extremities, and
had difficulty balancing. After another three days, he became
incontinent, was disoriented and experienced weakness in his left
side. The facility finally sent him to the emergency room at
this point. Head trauma can cause serious seizure disorders.
Despite this inmate’s history of head trauma and his serious
symptoms, neither the nurse practitioner nor the physician at the
Detention Center ever examined him. This denial of treatment

- 10 resulted in the worsening of the inmate’s condition.
4.

Chronic Illness and Prenatal Care

Individuals suffering from chronic illnesses such as
diabetes, hypertension, asthma, and HIV must be regularly
monitored by medical professionals to ensure that their symptoms
are under control and their medications are appropriate. PNA’s
policies recognize its obligation to provide appropriate medical
care for inmates with chronic diseases. Nevertheless, our review
of the medical records of fourteen inmates known to have one of
the four chronic diseases mentioned above revealed that PNA fails
to provide adequate medical care to inmates with chronic
diseases.
For example, appropriate care for individuals with
hypertension requires that the individual’s blood pressure be
brought under control by diet and prescribed medication. The
medical records we reviewed, however, indicated that only
50 percent of the inmates with hypertension received such care at
the Detention Center. The standard of care for individuals
suffering from asthma requires the performance of a baseline peak
flow measurement and, for those with persistent asthma, treatment
with inhaled control medication and the provision of rescue
medication. We reviewed medical records for four inmates with
moderate persistent asthma. Of these four, only one had a
documented measurement of peak flow. None of the inmates had
appropriate medication with inhaled steroids. Without this care,
these inmates are at risk for persistent wheezing,
bronchopneumonia, and life-threatening health crises. Of the
five diabetic inmates whose charts we reviewed, none had
documented measurements of A1C hemoglobin. This measurement is
the only way to assess long term control of the disease.
Furthermore, none of the diabetics had documented retinal
examinations, which should be done annually. Such an examination
might have prevented the loss of vision experienced by the
diabetic inmate discussed in the preceding section.
The Detention Center fails to provide a medically
appropriate diet for inmates with conditions that require the
inmates to receive special diets. For example, the “heart
healthy diet” provided to diabetics at the Detention Center
contains approximately 30 percent more calories and fat than
recommended for diabetics.

- 11 PNA fails to provide adequate prenatal care for pregnant
inmates. Of the four pregnant women at the Detention Center at
the time of our visit, none had any prenatal visit with an OB/GYN
during their incarceration documented, despite the fact that two
of the women were in their third trimester of pregnancy and near
term. While the pregnant inmates may have been seen by the nurse
practitioner, they were not screened for diseases that can
severely impact maternal and fetal health.
We reviewed the chart of one inmate who was within days of
delivery at the time of our visit. This inmate reported a
history of spontaneous miscarriages. She was within six weeks of
delivery when she arrived at the Detention Center, and the nurse
practitioner advised that she should be transferred to another
facility better equipped to handle inmates with high risk
pregnancies. This transfer never took place. Despite the nurse
practitioner’s recognition of this inmate’s serious medical
needs, the inmate was not scheduled for a prenatal visit with an
OB/GYN until our expert reviewed her chart and advised the
Detention Center staff that she needed additional prenatal care
immediately. She was scheduled for a visit with an OB/GYN that
week, and delivered one week later. This delay of care was
deficient and placed the woman and her child at risk for serious
harm.

5.

Special Needs Care by Outside Providers

As discussed in the chronic care section above, Section
A(4), the Detention Center fails to ensure that inmates receive
timely referral to outside care providers when specialized care
is medically necessary. In addition, our review indicates that
approximately one in three outside care appointments that are
arranged by medical staff are postponed or cancelled because of
lack of available transportation officers.
Furthermore, the Detention Center fails to ensure that the
recommendations of outside specialists, once consulted, are
carried out upon the inmate’s return to the facility. We
reviewed the charts of several inmates sent for outside care, and
found no indication that PNA staff sought written documentation
of results of the referrals or the recommendations and findings

- 12 
of the outside care providers. PNA does not employ any tracking
method to follow the care received by inmates who are referred
for outside specialty care. Without this information, the PNA
providers cannot implement treatment recommendations made by the
specialized care provider.
6.

Medication Administration and Management

PNA fails to provide inmates with needed medications in a
timely manner, and fails to monitor medication in inmates with
serious medical needs.
The Detention Center fails to provide for continuity of
medications for inmates upon arrival at the facility. Several
files we reviewed revealed that the nurse practitioner does not
continue the same medications for inmates that were prescribed
for them prior to their incarceration. Sometimes the nurse
practitioner simply discontinues the medication, and sometimes
she changes the inmate’s prescription to older, less expensive
medications which are significantly less effective. For example,
inmates who entered the Detention Center with credible histories
of taking medication such as Prozac and Wellbutrin were
disadvantageously changed to doxepin, amitryptilyne and
nortriptyline, which are significantly less effective than Prozac
and Wellbutrin and have significantly more adverse side effects.
One inmate arrived at the facility with Navane in her
possession. She reported that she has “psychotic features,” but
had been stable for five years on low doses of Navane, an
antipsychotic. Despite the fact that she arrived at the facility
with her medication on her person, she did not receive the

medication for her first five days in the facility. She was
switched to Mellaril, a non-equivalent drug, which the Federal
Drug Administration has determined is not a first line
antipsychotic. Because Mellaril is known to cause potentially
fatal heartbeat irregularities, it is usually prescribed only
when other antipsychotics have been tried and failed. Her
treatment was not being monitored by the nurse practitioner or
the counselor. Her cellmates confirmed that she frequently
seemed distraught, and would cry, scream, and talk to herself.
Failure to provide this inmate with her prescribed medication and
to monitor her treatment on a different medication placed her at
risk for psychotic relapse.

- 13 PNA also fails to provide reliable access to medications
that have been prescribed or continued by the nurse practitioner.
Several inmates complained that they had not received prescribed
medications despite repeated requests. Our chart reviews
substantiated these complaints. For example, one HIV-positive
inmate did not get his medication at the Detention Center for six
weeks. The inconsistent use of medication contributes to the
emergence of drug resistant diseases, which place both the
individual and the community at risk.
Inmates also complained that they frequently missed their
doses because they were not in their cells or did not hear the
medication call. A review of the medication administration
records revealed that approximately 25 percent of the entries
were blank. PNA attributed these missed doses to inmate
noncompliance. PNA policy requires that every refusal of
medication will be documented in the inmate’s medication
administration record (MAR), and after three refusals or
no/shows, the medical staff will discuss non-compliance
consequences with the inmate and document this counseling in the
health record. Based on the charts we reviewed, PNA does not
appear to be following its policy.
When certain medications are prescribed, such as
anti-epileptic medications, it is necessary to check blood levels
of these medications at regular intervals to ensure the inmate’s
health is not at risk from either too high or too low a dosage.
We found several instances in which PNA failed to monitor inmates
on these types of medications, even when inmates reported
experiencing side effects.
Even when staff did monitor medication levels, they failed
to respond to indications that an inmate’s dosage was
inappropriate. For example, an inmate had been prescribed a
medication for his seizure disorder, in addition to several other
medications, and his blood levels of the seizure medication had
been measured. Although the laboratory results showed that the
amount of this drug in his system was not enough to achieve the
intended therapeutic effect, there was no reference to this
finding anywhere else in his medical record. Moreover, staff
failed to respond appropriately, such as adjusting his
medication. Seven days later, the inmate attempted suicide by
cutting his wrists, then suffered a seizure. Even with all the
attention from medical staff due to his suicide attempt, his
seizure medication blood level was not measured until four days

- 14 
after his suicide attempt, at which point it was still well below
the therapeutic range. Even then, staff did not address this
deficiency for another three days, when his medication was
finally adjusted.
Our review revealed that the Detention Center uses protocols
to guide nurses in the treatment of illnesses that include some
standardized orders for prescription of medications. This
includes a protocol for treatment of inmates experiencing
substance abuse withdrawal. Allowing nurses administer the
medications to inmates without review by the nurse practitioner
or physician and without an evaluation of the inmate’s particular
medical needs is unsafe.
PNA’s formulary does not contain effective medication for
inmates with serious medical needs such as hypertension, heart
failure and diabetes. In addition, the formulary includes many
less expensive, less effective medications than are currently
available for the treatment of some diseases.
The facility claims that there is a waiver process in place
by which medical practitioners can prescribe medications off the
formulary, but the medical staff was unable to provide us with
policies or forms providing for such waiver. Approval from
corporate headquarters is necessary to prescribe an off-formulary
medication. This cumbersome and unstandardized process combined
with the severe understaffing at the facility make it less likely
that overburdened staff will make the effort to prescribe a drug
off-formulary. Although we did note that some inmates were
receiving off-formulary medications, they were few and far
between. Some inmates at the Detention Center are currently
provided with less effective medications with greater side
effects than they had received prior to incarceration, which can
lead to deterioration in inmates with mental illness and endorgan damage in inmates with diseases such as hypertension and
diabetes.

At the time of our visit, all medications, including
psychotropic medications, were prescribed by the nurse
practitioner. As the only person on the medical staff with the
ability to prescribe medication, the nurse practitioner is
overburdened. She frequently prescribes, adjusts or terminates
psychotropic medication on the recommendation of the mental
health counselor, sometimes without examining or even seeing the

- 15 
inmate. Neither the counselor nor the nurse practitioner is
trained to manage medication of inmates with complex mental
health diagnoses, such as schizophrenia and bipolar disorder.
Furthermore, the counselor has made it widely known that he is
personally opposed to the use of psychotropic medication.
Several inmates with credible histories of stabilization on
psychotropic medications reported that the counselor told them
they did not need medications and that they should take control
over their own problems. The counselor is not trained nor
licensed to make medical prescription decisions. Allowing him to
function in this capacity increases the risk that inmates with
mental health needs will not receive needed medication. We
understand that shortly after our visits, the facility retained
the part-time services of a psychiatrist, which may have
alleviated some of this problem.
B.

MENTAL HEALTH CARE

The Detention Center fails to provide adequate mental health
services to inmates who need this care. Specifically, the
Detention Center fails to provide appropriate intake screening
and referral and access to mental health care.
1.

Intake Screening and Referral

PNA’s initial health screening process, which is discussed
in detail in section A(1) above, includes a brief mental health
assessment. Nurses ask inmates questions concerning their mental
health treatment history, medication, and mental health status.
This assessment may result in a referral for either a routine
mental health evaluation or an immediate evaluation by the mental
health practitioner and determination whether the inmate will
receive follow-up mental health care.
Our review indicates that PNA does not identify
appropriately inmates who may need an immediate mental health
evaluation and mental health services. For example, one inmate
answered several of the initial mental health suicide screening
questions in the affirmative, including that he had recently
experienced a significant loss, that he felt that he had nothing

to look forward to, and that he “just didn’t care.” He reported
that he had been diagnosed with Post Traumatic Stress Disorder
and that he was taking an antidepressant for this condition. He
also stated that he felt that he needed to see a psychologist.

- 16 
Despite these indicators, the screening nurse concluded that the
inmate needed only a routine mental health referral, as opposed
to an immediate mental health evaluation and determination
whether mental health services were necessary. This inmate’s
suicide two weeks later is discussed in greater detail in the
section on suicide prevention, below.
As this inmate’s experience illustrates, PNA’s failure to
identify and refer appropriately inmates with immediate mental
health needs may be partially attributed to the fact that the
threshold for triggering such a referral is too high. The form
used to guide the nurses requires too many indicators to be
present before directing referral. Inmates reporting suicidal
ideation, a history of recent suicide attempts, psychiatric
hospitalization, and/or recent or current use of psychotropic
medication should be referred for a mental health assessment when
booking is completed. However, chart reviews indicate that
inmates reporting these symptoms during the initial health
screening are not consistently referred for immediate assessment
by a mental health professional.
Moreover, some inmates reporting significant mental health
histories do not receive referrals for mental health services at
all. For example, one inmate arrived at the facility on a mood
stabilizing medication and an antidepressant. These medications
were verified at intake. During the initial health screening,
the inmate reported a two-year history of mental health problems,
including a suicide attempt. Despite her verified medications
and her mental health history, the intake nurse did not refer
this inmate for mental health services.
Other inmates who receive a routine mental health referral
are not seen by a mental health practitioner in a timely manner.
Inmates reported a significant time lag between the referral and
their first visit with the mental health services provider.
Chart review confirmed these reports. Inmates who received
routine mental health referrals might wait two weeks or more to
see a provider after the initial referral was made.
Some inmates may develop symptoms of mental illness
following incarceration, but not seek care. The 14-day physical
examination is an opportunity for nurses to detect inmate mental
health needs that have arisen since the time of admission.
However, nurses conduct no mental health assessment at the 14-day
physical.
The mental health evaluations conducted at the facility do

- 17 
not incorporate development of a diagnosis or treatment plan, and
are therefore inadequate. The form which guides this evaluation
fails to provide for an ultimate determination that an inmate has
a mental disorder, and contains no reference to a diagnosis of
the disorder. This information is important because it forms the
basis for the provider’s decision to place the inmate on the
mental health roster for services. It also functions as the
basis upon which a treatment plan may be developed for the
inmate. In the absence of such documentation, it is difficult to
assess whether some inmates referred for mental health care are
receiving appropriate care. The facility does not engage in
discharge planning for inmates receiving mental health services.
2.

Access to Adequate Care

The mental health care provided at the Detention Center is
inadequate to meet the needs of inmates with serious mental
health conditions. At the time of our visit, mental health
services at the facility were provided by a master’s level
counselor, who is not trained to diagnose psychiatric illness nor
licensed to prescribe medication. The facility’s problems with
medication management are outlined above in section A(5).
One chart we reviewed contained a particularly severe
example of the potential consequences of failing to provide
access to adequately trained mental health staff and appropriate
mental health care. This inmate arrived at the facility with a
documented history of prior treatment at the Detention Center for
bipolar disorder and depression. The facility’s former staff
psychiatrist had diagnosed the inmate with depression during a
previous period of incarceration and treated her with
medications. Review of her chart indicates that shortly after
MTC/PNA took over management of the Detention Center, the inmate
was taken off some of her medications based on the counselor’s
note that “she and I decided she didn’t want to take the Paxil
and vistorel.” The counselor’s written notes document that this
inmate subsequently declined over a period of the next three
months, including banging on the metal portion of her bed and
singing along aloud; destroying her mattress with a razor blade;
and flooding her cell with water. She was placed in
administrative segregation several times during this period.
Both the counselor’s notes and the inmate’s sick call requests
document that throughout this period, the inmate repeatedly
requested a return to her previous medications, but the counselor
denied her requests. The inmate’s decline ultimately resulted in
a suicide attempt.

- 18 During subsequent periods of incarceration the counselor
noted that this inmate “attempted to convince [him]” that she
needed medication for her “alleged” bipolar disorder but
“unfortunately she wasn’t able to convince [him].” He denied her
repeated requests for medication without consulting with any
practitioner trained and licensed to make such decisions. Thus,
this inmate who had been treated by a psychiatrist with
psychotropic medications for many months was forced to attempt to
conform her behavior in a jail environment without any aid from
medication. She experienced continued headaches, anxiety,
depression, and sleep disturbance, and frequently found herself
in segregation.
Other inmates reported that this counselor instructed them
to “Go smoke dope and you will be O.K.” and made other
inappropriate comments in the course of counseling sessions.
Such comments alienated some inmates, who had nowhere else to
turn for counseling services. Furthermore, the facility had no
mental health professional trained and skilled to provide
services to victims of sexual assault. When we raised this issue
during our exit conference, the County took immediate action and
reports that inmates will now be transported to the Rape Crisis
Center for services as needed.
C.

SUICIDE PREVENTION

The Detention Center suicide prevention policies and
practices are seriously deficient and suicidal inmates are at
grave risk of harming themselves as a result. As of the time of
our visit, during the seven months since MTC assumed management
of the facility, there had been one completed suicide and seven
attempted suicides. A review of these incidents reveals that
the Detention Center staff fail to respond appropriately to
inmates’ indications of mental health crises and possible
suicidality.
The standard of care for suicide prevention requires timely
identification of risk; adequate assessment of risk; monitoring
high risk inmates, in special housing units if indicated; and
referral to appropriate providers for needed care. Because
identification and assessment are addressed in preceding sections
of this letter, this section will focus primarily on the
Detention Center’s provision of monitoring and appropriate
housing to suicidal inmates, and referral for crisis mental
health care.

- 19 
-

Our review indicates that the Detention Center fails to
provide adequate monitoring for inmates who have been identified
as suicidal. An illustrative example is the completed suicide
that occurred at the facility in January 2002. Upon arrival at
the facility, this inmate expressed feelings that there was
nothing to look forward to in the future as well as other signs
of suicidality. He asked to see a mental health professional,
but was given only a routine referral and not put on any type of
suicide precautions. Two days later, while the inmate awaited
his first visit with a mental health professional, staff learned
that he had written a last will and testament in his cell, and
placed him on suicide watch. While he saw a counselor during his
time on suicide watch, once he was released from the watch three
days later, he received no mental health services for nine days,
until he attempted to cut himself with a razor. He was seen by
medical and mental health staff and placed on a suicide watch in
the booking area. Orders were for a five-minute watch, but staff
only checked the inmate every 15 minutes.
While on watch, the inmate made explicit statements and
other indicators that he continued to have active plans to end
his life. Statements and observations included: observation
that the inmate attempted to hang himself with a sock
(appropriately, staff did remove his clothes after this attempt);
a statement to a crisis response counselor that he would hurt
himself on an exposed nail in his cell in the booking area;
threats to the nurse practitioner that he would “pull out his
jugular;” observations by a nurse that he attempted to remove
sutures to the cut he had inflicted on his neck; a staff member
note that the inmate’s food tray contained chunks of padding from
the foam wall (he ultimately created a foothold for himself to
climb up to hang himself); observations that he was tearing up
his suicide blanket; and a statement that he was “very
claustrophobic. I’ll lose my mind in this cell.” Despite these
indicators, the facility did not adjust either the frequency of
or the location of the watch, or take other security measures to
address the situation presented. Furthermore, the crisis
response counselor who saw the inmate the day before his suicide
determined that the booking area was not an appropriate location
for this inmate and recommended that he be moved, but the
facility did not follow this recommendation.
The watch log ended at 18:45 the night before the inmate’s

- 20 
death, and did not resume until the following day at 6:00 a.m.,
nearly twelve hours later. That entry was followed by a second
entry at 6:15 a.m., and the log ended again, until a 9:40 entry
in which the inmate is quoted as saying to staff, “if I find
something I will do myself in.” The inmate committed suicide by
hanging himself from a sprinkler head with a strip of his suicide
blanket at approximately 9:50 a.m.
Another inmate attempted to communicate to a supervising
officer his intention to kill himself by holding a note up to his
segregation cell door. Despite this clear manifestation of his
need for intervention, the officer did not respond and the inmate
was later found trying to hang himself with a sheet. These
incidents as well as staff interviews at the facility indicate
that staff are insufficiently prepared to identify the signs of
suicidality and respond appropriately.
The Detention Center lacks an appropriate location for
housing high risk suicidal inmates. The inmate who completed his
suicide was being held in an isolation room in the facility’s
booking area at the time of his death. These cells are
inappropriate for inmates in mental health crisis because it is
impossible to provide sufficient supervision of such inmates.
The cells have solid doors with small windows. There are no
panic buttons or intercoms and no video surveillance in any of
the cells. Furthermore, the padded room was not designed to
deter inmate suicide. As noted above, an inmate was able to pull
large chunks of foam from the padded wall, and an exposed
sprinkler head provided a hanging opportunity.
The medical area, with its current staffing, is equally
insufficient. An inmate placed on watch status in a medical unit
cell for his own safety due to mental illness and seizure
disorder was able to cut both of his wrists with a razor blade
within 5 minutes of his arrival in that cell. The only way that
staff knew that the event had occurred was when blood began
running down the floor from his cell. This example also
illustrates that staff lacked the skills to search the inmate
adequately and make appropriate decisions about what he should
have in his possession prior to placing him in that cell.
Some suicide attempts by cutting occurred in the housing
units. Staff learned of these incidents only through inmates
reporting the emergencies on the intercom. At the time of our
visit, several of the intercoms from the housing units to staff
in the control room were broken. If inmates are unable to get
the attention of staff quickly in an emergency, the response of

- 21 rescue personnel could be delayed.
Staff have not been provided with the training or resources
to respond properly to suicide attempts. In the booking area,
where newly arrived inmates are housed, there was no tool to cut
down a hanging inmate, despite the fact that the completed
suicide had occurred in this area. In addition, only 27 staff
members had received training in CPR and First Aid at the time of
our visit. As the likely first responders to suicide attempts
and other health crises, all staff should be trained and provided
with appropriate equipment to respond to such emergencies while
awaiting medical staff.
Our review also indicates that inmates on suicide watch are
not consistently seen by the mental health provider in a timely
manner and are sometimes released from suicide watch without any
evaluation or mental health clearance. For example, one inmate
reported that he had cut himself. Staff placed him in the Health
Services Unit for treatment of his lacerations and kept him there
on suicide watch. He stayed in the Health Services Unit, on
suicide watch, for nine days without once being seen by the
mental health provider. On the tenth day, he was released back
to administrative segregation, still without having seen a mental
health provider or receiving mental health clearance to return to
administrative segregation. The failure to respond to this
inmate’s mental health crisis, and the subsequent release of this
inmate from suicide watch without a mental health evaluation,
placed the inmate at risk for continued crisis and/or another
suicide attempt.
Another incident involved an inmate who cut her wrists with
a razor and was placed on a 15-minute suicide watch in the
medical unit. According to the subsequent investigation of the
incident, the inmate was upset because her medications were
stopped. Although she had been seeing the mental health provider
every two weeks for counseling, the counselor’s records contained
no notes or information concerning her attempted suicide. The
inmate was treated for lacerations to her wrists and released
from suicide watch without ever receiving a mental health
evaluation or mental health clearance. Absent appropriate
evaluation and intervention, this inmate remained a risk to
herself.
The Detention Center has the ability to refuse admission to
inmates who present at booking in a severe mental health crisis,

- 22 and also has a protocol for referring inmates with emergent
mental health needs to the local hospital for appropriate care
when the inmate’s needs exceed the facility’s capabilities. Our
review indicates that the Detention Center underutilizes these
options and fails to refer inmates to outside care when
necessary.
Completed suicides and incidents of attempted suicide should
be thoroughly reviewed to identify gaps and inadequacies in the
provision of care. Information gained through morbidity and
mortality reviews plays a critical role in preventing future
incidents. PNA’s policy is to initiate a mortality review
following the death of an inmate. However, our review of the
mortality review PNA conducted following the suicide of the
inmate described above, revealed that PNA failed to assess
critically the care and treatment of this inmate prior to his
death. The mortality review provided a chronological history of
the events leading up to his death but lacked a self-critical
analysis of treatment failures.
D.

PROTECTION FROM HARM
1.

Booking Area

The booking area includes a small group of cells that are
used to house inmates who have arrived recently, as well as some
inmates on administrative or punitive segregation, some
experiencing mental health or medical problems, or in protective
custody. In this area there are 14 cells, one of which is padded
and has no plumbing. Four of the larger cells (“the holding
cells”) are used to house inmates until staff screen and place
them in the general population. Except for one of the cells
designed for disabled inmates, none of the holding cells has beds
or other furnishings other than the toilet and sink and some
narrow movable benches.
The booking cells, and especially the holding cells, are
hot, stuffy, have poor circulation, have a foul smell and are
unsanitary. The holding cells at times have too many inmates to
allow for their safety and health, particularly since inmates are
kept in these cells for up to five days before they are placed in
the general population. We saw some cells with inmates lying on
mattresses on the floor from wall to wall, and occupying all
available space on benches. Two of the holding cells and one of
the smaller cells had no light at all, neither natural nor

- 23 
artificial. Each cell has a narrow window that provides minimal
light from the hallway. It was difficult to observe the inmates
in those cells, creating an unsafe condition in which inmates
could be victimized without staff being able to see anything
through the doors. Because there is insufficient staff assigned
to this area, staff cannot open doors frequently enough for
proper surveillance, to compensate for the poor visibility
through the windows. As an illustration of the difficulty staff
have properly supervising these cells, on one occasion inmates
got into a dispute which inmates were smoking in the cell, which
is prohibited. The inmates eventually set off the sprinkler.
The smoking, the dispute and the sprinkler tampering all occurred
before an officer noticed and intervened.

Conditions in these cells lend themselves to inmate unrest.
In one incident, two inmates were forcing others to move from
where they were sleeping to give them the preferred spaces. An
altercation broke out, and an inmate who refused to move from his
spot sustained injuries. Furthermore, mixing sometimes agitated,
intoxicated inmates with the rest of the newly arrived inmates is
a recipe for conflict in these poorly ventilated, tight quarters,
and sometimes leads to violence.
In another troubling incident, an older female inmate with a
history of victimization was housed in a segregation cell in the
booking area with another female inmate. Both women report that
one of the male porters (an inmate with cleaning duties)
repeatedly harassed her, making sexually explicit comments,
threatening to find her in the shower and assault her. At one
point he showed his exposed penis to her through the window of
her cell. Several days after the incident, when we interviewed
this woman, she was still traumatized by the experience. She
reported that following these incidents she refused to shower
during her five days in segregation because she believed that
officers would not protect her.
In fact, there is insufficient staffing in the booking area
to keep inmates safe. Only one officer is assigned to do rounds
of the cells, admit and release inmates from the area, respond to
other inmate needs and take inmates out for showers. The shower
areas are around the corner, so an officer cannot provide
supervision both in the showers and cells at the same time.
Inmate porters move about the area without supervision. Use of
this area for medical, protective, disciplinary and

- 24 
administrative segregation is inappropriate. The area is busy
with incoming and outgoing inmates, which leaves staff unable to
respond to the needs of inmates on special status. As described
above in the suicide prevention section (C), the staffing is so
thin that an inmate in this area was able to complete a suicide
in one of the booking cells before staff noticed.
The jail appears to have trouble processing inmates into
general population with appropriate speed. One woman returned to
the facility after a medical furlough for shoulder surgery.
Despite her discomfort she was kept for three days in the holding
cells without a bed or appropriate follow-up medical attention
before being allowed back into general population.
Furthermore, the jail is responsible for detaining a number
of offenders brought in under the New Mexico Detoxification Act
following disorderly behavior, for the purpose of “protective
custody” to detoxify from alcohol or drugs.1/ The jail does not
process these inmates into the general population, but rather
leaves them in the booking area. Despite the high frequency with
which inmates who have abused alcohol or drugs are received in
the booking area, the staff in that area were unaware of signs
and symptoms of withdrawal. Officers are insufficiently trained
in the detection and handling of intoxicated inmates. This puts
inmates at risk that serious and sometimes life-threatening
withdrawal symptoms may not receive prompt response.
2.

Sexual Misconduct and Privacy Concerns

As part of our investigation, we reviewed the circumstances
for women housed at the Detention Center. Our review revealed
serious concerns regarding past sexual misconduct under the
previous management and insufficient prevention efforts under the
new management. Staff provided anecdotal evidence of sexual
relationships between staff and inmates under the previous
management, as well as at least one incident in which male
inmates were allowed into the female housing areas for several
hours. Under the new management, one inmate became pregnant,
although investigation did not reveal whether the father was an
inmate or staff. The reporting and investigative system at the
jail is flawed, which may have contributed to a lack of
information available regarding this and other occurrences at the
facility. While we did not determine that there is an ongoing

1

/See New Mexico Statutes Annotated 1978, §§43-2-2 through 

43-2-22.


- 25 pattern or practice of sexual misconduct that violates the
constitution under the new management, we do recommend that the
new management make more concerted efforts to guide and train
staff, avoid leaving female inmates isolated and vulnerable, and
improve the system of reporting, investigation and
accountability. We have provided technical assistance aimed at
addressing our concerns. In addition, we also have provided
technical assistance regarding ways to address the lack of
privacy for women inmates during times when they are housed in
the medical unit and are undressed.
E.

LIFE SAFETY AND SANITATION
1.

Fire Safety

Inadequate fire safety measures at the Detention Center
compromise residents’ safety. The facility does have sprinkler
and alarm systems, self-contained breathing apparatus for staff
to use in an emergency, and up-to-date fire extinguishers
throughout the building. However, systems for fire drills,
emergency evacuation and fire prevention are inadequate.
Absence of a reliable fire drill program risks harm to
inmates. During our on-site visit, we asked the facility to
conduct a fire drill. Administrative staff determined which unit
to drill and which staff to use. Even under these controlled
circumstances, security staff only evacuated one of the six
sections of the housing unit. Staff were reluctant to evacuate
the entire unit because they did not believe that they had safe
evacuation routes and holding areas to do so. This demonstrates
that facility staff do not have faith in their emergency
evacuation procedures and are unprepared for evacuation should
the need arise. Furthermore, most staff we questioned, many of
whom had been working at the facility for seven months or longer,
had never participated in a fire drill.
During a test of emergency keys, the Key Control Manager had
a difficult time identifying keys needed to exit the facility.
Keys were grouped with as many as 16 on a ring, and it was
necessary to cross match them against numbers on a clipboard to
find the right key for every door. In the case of a fire or
other evacuation emergency, such a system would be too slow and
cumbersome to evacuate inmates and staff safely. In addition,
the facility’s fire plan has not been approved by the State Fire
Marshal, and the facility is not conducting fire safety

- 26 inspection rounds.
2.

Food Service

The food service operation at The Detention Center does not
meet sanitation requirements and puts residents at risk of
developing food borne illness. We encountered food service and
preparation equipment that was not properly cleaned. Some foods
were stored in unsanitary containers or locations. In addition,
several practices suggest a lack of sufficient concern for
maintaining food at safe temperatures. We encountered bulk foods
that required refrigeration sitting in a hallway next to a dry
storage area following a delivery, with no staff attempting to
refrigerate them. Furthermore, one of the facility’s
refrigerators had been showing temperatures well above an
acceptable safe temperature for some time without being repaired.
In addition, foods, once prepared, were not maintained at safe
temperatures until service.
Food service workers were not screened properly for health
problems before being permitted to prepare food. Only half of
the food service workers had been cleared by Health Services
staff to ensure they were healthy enough to work in the kitchen.
Furthermore, the supervisor was conducting daily visual health
checks of workers only after they had begun working with food for
the day, and without asking them any questions about their
health. We noticed an inmate with visible open wounds on his
wrists slicing watermelon with bare hands, instead of plastic
gloves. The supervisor had not noticed this condition,
determined whether the inmate should be working, or provided
close enough supervision to ensure that he was using proper
protective practices.
3.

Clothing and Mattresses

Laundry at the Detention Center is conducted with
insufficient frequency to maintain proper hygiene. In addition,
insufficient underwear is provided to inmates. We encountered
inmates who had been at the facility for two or three weeks
without being given a pair of underwear. Some had one pair of
their own, and others were forced to wear the uniforms without
underwear. Furthermore, the facility launders inmates’ clothing
with insufficient frequency for adequate personal hygiene.
Many of the facility’s mattresses were old and cracked, and
some were torn, exposing the inner stuffing. Mattresses in this

- 27 
condition cannot be properly sanitized. By the time of our
second visit, the facility had purchased 200 new mattresses,
which should at least partially address the problem.
In the booking area, where inmates sometimes stay for up to
five nights in rooms without beds with up to 17 people (see
above, Section D(1)), we encountered some inmates who could not
get sheets to use with the torn mattresses. As a result, inmates
are forced to sleep directly on the mattresses, which they place
either on the bare floor or on narrow benches. Some inmates
staying overnight in booking had not even been provided with
mattresses.
4.

Infection Control, Hygiene and Public Health

The Detention Center fails to take reasonable steps to
prevent the spread of airborne pathogens. For example, chart
reviews revealed that it takes as long as one to three weeks for
inmates with positive skin tests for tuberculosis to receive
chest x-rays. The Detention Center has no respiratory protection
program, and inmates with positive skin tests are not isolated,
as they should be, until their chest x-rays are returned and
confirmed to be negative for tuberculosis. Accordingly, inmates
and staff are at risk for exposure and transmission of
tuberculosis.
The Detention Center also fails to take reasonable steps to
prevent the spread of blood borne pathogens. Staff and inmate
workers are not consistently trained in universal precautions,
and the Detention Center has no plan or training for how staff
should handle high risk exposures to blood, such as needle stick
injuries. One hazardous waste container we observed was not
lined with a red plastic biohazard bag, and the container was
half-filled with loose trash.
Staff at the Detention Center also fail to adhere to
appropriate hygiene standards. For example, we found urine
stored in a container in a medication refrigerator. In addition,
several of the areas in which medical staff would be expected to
wash their hands regularly lacked the proper plumbing fixtures or
supplies to do so. Inmates reported having trouble getting
toilet paper when they needed it.
F.

ACCESS TO COURTS AND OPPORTUNITY TO REDRESS GRIEVANCES

- 28 The County has a responsibility to provide its inmates with
reasonable access to the courts to challenge their sentences,
directly or collaterally, and the conditions of their
confinement. The County is not providing inmates the tools
needed for such access through a law library, legal assistance,
forms system or otherwise.
The grievance system at the Detention Center is not
providing a meaningful path for redress of inmate complaints.
While the facility has a grievance coordinator who processes
grievances, the facility fails to document its actions in
response to inmates’ complaints and fails to let the inmate know
how it has responded. The management frequently rejects inmate
grievances that are formally incomplete, despite the fact that
they include sufficient information to process them meaningfully.
Furthermore, the grievance system requires that inmates
confront staff and attempt to resolve problems before filing a
grievance. Given the power difference between inmates and staff,
this requirement makes it even less likely that the grievance
system will be a realistic avenue for reporting staff misconduct.
In addition, when we were visiting the housing units, there were
no grievance forms available in some units. Even after we
brought this to the attention of staff, when we checked again
there were still no forms available. No grievance forms were
available in Spanish, despite the sizeable population at the
facility that speaks and/or reads only Spanish.

III.

REMEDIAL MEASURES

In order to rectify the identified deficiencies and to
protect the constitutional rights of the facility’s inmates, the
County should implement, at a minimum, the following measures:
A.

MEDICAL CARE

1)

Provide for a more confidential environment in which to
conduct medical and mental health booking screenings,
recognizing legitimate security concerns.

2)

Revise and implement policy, procedures and practices to
ensure that all inmates receive the initial health
screening in a timely fashion.

- 29 3)

Revise and implement policy, procedures and practices to
ensure that inmates reporting or exhibiting possible
signs of serious medical or mental health needs at
booking are referred promptly to the Health Services Unit
and receive appropriate follow-up care.

4)

Revise and implement policy, procedures and practices to
ensure that inmates receive a comprehensive medical
history and physical examination, performed by
appropriately trained, licensed and, if appropriate,
supervised personnel, within 14 days of their arrival at
the facility.

5)

Screen all incoming inmates for syphilis. Assess inmate
risk for other sexually transmitted diseases, such as
chlamydia and gonorrhea, and screen high risk inmates
using modern laboratory methods.

6)

Revise and implement policy, procedures and practices for
addressing drug and alcohol withdrawal to ensure that all
inmates are screened and/or treated appropriately if they
report or exhibit signs of drug or alcohol withdrawal.

7)

Develop and implement policy, procedures and practices to
ensure timely referral for evaluation and treatment of
inmates who exhibit signs and symptoms of mental illness.

8)

Develop and implement policy, procedures and practices
for validating and continuing, if appropriate, current
prescriptions for medications of incoming inmates.

9)

Ensure appropriate staffing for the Health Services Unit
by retaining intermediate and advanced practitioners who
are able to provide adequate treatment and monitoring of
inmates with serious medical needs, in a timely fashion,
without practicing beyond the scope of their licensure.

10)

Establish policy, procedures and practices for evaluating
and improving responsiveness to inmate sick call
requests.

11)

Establish a chronic care system that 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

- 30 visits, devoting sufficient attention to inmates whose
uncontrolled conditions must be stabilized, and ensuring
that inmates with chronic medications have access to
those medications when appropriate.
12)

Improve morbidity and mortality review process to ensure
that deaths are thoroughly and effectively evaluated and
any problems with care or access to care that are
revealed through that process are resolved.

13)

Revise and implement policies, procedures and practices
to ensure that diabetics and other inmates who need
medically appropriate nutrition receive an appropriate
diet.

14)

Develop and implement policy, procedure and practices to
ensure that pregnant inmates receive prenatal care from
appropriately trained and experienced medical
professionals on a timely basis.

15)

Develop and implement policies, procedures and practices
to ensure that inmates whose medical needs require
specialized care are promptly scheduled for and
transported to outside care appointments.

16)

Develop and implement policies, procedures and practices
to ensure that the findings and recommendations of
outside care providers are documented in the medical
chart of each inmate referred for outside care, and that
treatment recommendations are followed once the inmate
returns to the facility.

17)

Eliminate the practice of using protocols with medication
orders except for life-threatening emergencies.

18)

Develop and implement policy, practices and procedures to
ensure that inmates are prescribed medications only after
a physical examination by the prescribing clinician.

19)

Institute a medication management program which ensures
continuity for ordered medication, and includes a
requirement that the reason for every missed dosage of
medication will be documented and a nurse will confer
with any inmate who misses three or more doses for any
reason. Revise the formulary to include at least one

- 31 medication for elevated blood lipids, a proton pump
inhibitor, an ACE inhibitor, an SSRI antidepressant, and
birth control pills, and develop and implement a simple
and efficient waiver protocol for use when off-formulary
medications are needed.
20)	

Implement a schedule for measuring blood levels of
medication for medications which require such monitoring.

21)	

Revise and implement procedures to document the reason
for every missed dosage of prescribed medication. Adhere
to stated PNA policy of conferring with any inmate who
misses three or more doses for any reason.

22)	

Develop and implement a quality improvement system that
monitors and improves deficiencies in medical care and
access, including but not limited to reviewing medication
prescribing patterns and monitoring medication usage to
assure appropriateness and continuity, and physician
review and supervision of nursing.

B.	

MENTAL HEALTH CARE

23)	

Provide sufficient mental health professional staffing to
meet the serious mental health needs of the jail’s
population, including staff qualified and trained to
diagnosis and treat the seriously mentally ill.

24)	

Develop and implement policies, procedures and practices
to ensure that every inmate receives an initial mental
health screening upon arrival at the facility and a
mental status assessment within fourteen days of arrival.

25)	

Modify the comprehensive mental health evaluation to
ensure that mental health practitioners diagnose their
patients and create treatment plans.

26)

Develop and implement policies, procedures, and practices
to ensure that a mental health caseload roster is
developed and regularly updated to reflect intakes and
discharges, and that the provision of mental health
services to inmates is tracked by the facility through an
effective management information system.

- 32 
27)

Develop and implement policies, procedures and practices
to ensure that staff respond to sick call mental health
requests in a timely manner and provide adequate ongoing
care to inmates determined to need such care.

28)

Institute a more thorough quality improvement system that
covers all mental health professionals.

C.

SUICIDE PREVENTION

29)

Develop and implement appropriate suicide prevention
policies, procedures and practices, including but not
limited to reducing the threshold required to trigger an
immediate mental health evaluation.

30)

Develop appropriate housing for inmates on suicide watch,
and ensure that cells in the booking area are not used
for this purpose.

31)

Develop and implement policies, procedures and practices
to ensure that inmates initially placed on suicide watch
are placed on continuous watch, and that the watch is
reduced only upon the recommendation of a mental health
professional following a suicide risk assessment.

32)

Revise and implement effective policy, procedures and
practices to ensure proper supervision of suicidal
inmates, logging of supervision, and availability of cutdown tools for hangings.

33)

Ensure that inmates have means to communicate with staff
when necessary, through working intercoms or other
effective means of communication.

34)

Train staff to understand the signs, symptoms and
appropriate responses to potentially suicidal inmates,
including when and how to seek mental health follow-up.

35)

Develop and implement policies, procedures and practices
to ensure that inmates whose level of suicidality cannot
be properly handled at the facility are promptly
transferred elsewhere for appropriate care.

36)

Revise and implement policies, procedures and practices
to ensure that high risk inmates are placed in areas that
lessen the likelihood of completed suicide, by requiring

- 33 that all inmates are thoroughly searched before they are
placed on watch, and that admission medical/mental health
orders are written in the inmate’s chart and document
allowable clothing, property, utensils, and diet.
37)	

Develop and implement appropriate policies, procedures
and practices to ensure that inmates on suicide watch are
monitored sufficiently by mental health professionals and
are not released from suicide watch without clearance
from a mental health professional, and that appropriate
discharge orders are written upon release, including
treatment recommendations and required follow-up care.

38)	

Develop and implement policies, procedures and practices
to ensure that thorough, self-critical mortality reviews
are conducted following the suicide or attempted suicide
of an inmate, and integrate knowledge gained from such
reviews into suicide prevention protocols.

D.	

PROTECTION FROM HARM

39)	

Staff the booking area sufficiently to provide reasonable
safety to inmates.

40)	

Cease using the booking area for inmates on segregation,
protective, medical, mental health or other special
status.

41)	

Develop and implement policies, procedures and practices
to ensure the safe and proper housing of inmates
experiencing withdrawal from drugs or alcohol. Properly
train staff to identify signs and symptoms of withdrawal
and respond appropriately.

42)	

House inmates in the booking area for only brief periods
of time.

E.	

LIFE SAFETY AND SANITATION

43)	

Develop and implement policies, procedures and practices
to ensure that staff conduct adequate fire drills for all
shifts, covering all institutional areas.

44)

Develop and implement policies, procedures and practices

- 34 to ensure that staff conduct adequate fire safety
inspections.
45)

Revise the emergency key system to ensure that keys are
readily identifiable and available to those who need
them.

46)

Develop and implement policy, procedures and practices to
ensure that the facility’s fire safety systems are
maintained in order and operable.

47)

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

48)

Develop and implement policies, procedures and practices
to ensure that inmates and staff who work in food service
are in proper health to do so.

49)

Provide all inmates with properly cleaned and adequate
bedding and clothing. Ensure access to needed hygiene
supplies.

50)

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

E.

ACCESS TO COURTS AND OPPORTUNITY TO REDRESS GRIEVANCES

51)

Develop and implement policies, practices and procedures
to ensure that inmates have adequate access to the
courts.

52)

Reform the grievance system so that grievances are
processed and legitimate grievances addressed and
remedied in a timely manner, responses are documented and
communicated to inmates, inmates need not confront staff
prior to filing grievances about them, inmates may file
grievances confidentially, and grievance forms are
available on all units. Ensure that grievance forms are
available in Spanish.

- 35 
-

53)	

Develop and implement a quality assurance plan to address
all deficiencies identified in this letter.
*

*

*

*

In light of the County’s cooperation in this matter, under
separate cover we will send you our experts’ reports. Although
the experts’ reports and work 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.
Pursuant to CRIPA, the Attorney General may institute a
lawsuit to correct deficiencies of the kind identified in this
letter forty-nine days after appropriate officials have been
notified of them. 42 U.S.C. § 1997b(a)(1). We would prefer,
however, to resolve this matter by working cooperatively with
you, and we have every confidence that we will be able to do so.
Sincerely,
/s/ Ralph F. Boyd, Jr.

Ralph F. Boyd, Jr.
Assistant Attorney General
cc: 	 Steven Kopelman, Esq.
Santa Fe County Attorney
Mr. Cody Graham 

Warden

Santa Fe County Correctional Facility

David C. Iglesias, Esq.

United States Attorney

District of New Mexico

Mr. Robert Ecoffey

Director

Office of Law Enforcement

Bureau of Indian Affairs 

Mr. William McClure

- 36 Detention Specialist

Office of Law Enforcement

Bureau of Indian Affairs


William Myers, Esq.

Solicitor

United States Department of the Interior

Ms. Edith Blackwell

Acting Associate Solicitor

Division of Indian Affairs

United States Department of the Interior

Ms. Kathleen Hawk Sawyer

Director

United States Bureau of Prisons

Mr. Michael B. Cooksey

Assistant Director 

Correctional Programs Division

United States Bureau of Prisons

Ms. Loren Grayer

Senior Deputy Assistant Director

Community Corrections & Detention

Chris Erlewine, Esq.

General Counsel

Office of the General Counsel

United States Bureau of Prisons

Mr. Benigno G. Reyna

Director

United States Marshals Service

Ms. Lydia Blakey

Acting Assistant Director 

Prisoner Services Division

United States Marshals Service

Gerald
Acting
Office
United

Auerbach, Esq.

General Counsel

of the General Counsel

States Marshals Service