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Cripa Wilson County Jail Tn Investigation Findings 8-30-07

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U.S. Department of Justice
Civil Rights Division

Assistant Attorney General
950 Pennsylvania Avenue, NW - RFK
Washington, DC 20530

August 30, 2007

Mayor Robert Dedman
228 E. Main Street
Lebanon, TN 37087

Investigation of the Wilson County Jail

Dear Mayor Dedman:
On April 11, 2006, we notified you of our intent to
investigate conditions at Wilson County Jail (“Wilson” or the
“Jail”), pursuant to the Civil Rights of Institutionalized
Persons Act (“CRIPA”), 42 U.S.C. § 1997. Consistent with our
statutory requirements, we write to report the findings of our
investigation and to recommend remedial measures to ensure that
Wilson meets federal constitutional requirements.
See 42 U.S.C. § 1997b.
Between June 27 and 29, 2006, we conducted an on-site
inspection of Wilson with consultants in the fields of medical
care and correctional management. While on-site, we interviewed
the Sheriff, jail staff, medical care providers, and inmates. We
received and reviewed a large number of documents, including jail
policies and procedures, daily rosters and log books, incident
reports, medical files, inmate intake records, individual inmate
records, and other records.1 Consistent with our commitment to
provide technical assistance and conduct a transparent
investigation, we provided an extensive debriefing at the
conclusion of our inspection, in which our consultants expressed
their initial impressions and concerns. We appreciate the full
cooperation we received from Wilson County (“the County”) and
Jail officials throughout our investigation. We also wish to


We also reviewed a packet that Sheriff Ashe provided to
us at the beginning of our tour, which contained various
correspondence and other information regarding his efforts to
seek funding, among other things, to address a number of
deficiencies at the Jail.

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extend our appreciation to the Sheriff and his staff for their
professional conduct and timely response to our requests.
Having completed the fact-finding stage of our investigation
of Wilson, we conclude that certain conditions at the Jail
violate the constitutional rights of inmates confined there. As
detailed below, we find that Wilson fails to: (1) provide for
inmates’ serious medical and mental health needs; (2) protect
inmates from harm and provide adequate supervision; and (3)
prevent exposure to unsanitary and unsafe environmental


Facility Description

Wilson is located in Lebanon, Tennessee. The Wilson County
Sheriff is responsible for the operation of the Jail. The Jail
is designed to house 106 inmates and has been in use as a jail
for over two decades. The physical plant includes court rooms
and other court administrative offices, as well as the Sheriff’s
In the Jail, inmates are housed in seven pods (which each
contain a central day room) that are two stories high. The pods
are divided into minimum, medium, and maximum security, and a
minimum security pod for inmate trustees. In addition to the
seven pods, the Jail has a central control room, secure outside
recreation yards, kitchen, medical office, visitation room, a
booking area, and administrative offices for corrections and
court staff and some sheriff’s deputies. The sally port for new
admissions was closed during our tour due to construction. The
County is currently building a 300-bed facility adjacent to the
existing Jail that is scheduled for completion in the Fall of
On June 28, 2006, the second day of our tour, Wilson had an
inmate population of 192; there were 159 males and 33 females.
B. General Legal Framework
CRIPA authorizes the Attorney General to investigate and
take appropriate action to enforce the constitutional rights of
inmates. 42 U.S.C. § 1997. The Eighth Amendment places an
affirmative duty on prison officials to provide humane conditions
of confinement and to ensure that inmates receive adequate food,
clothing, shelter, medical care, and are kept safe from harm at
the hands of other prisoners. Farmer v. Brennan, 511 U.S. 825,

- 3 

832-833 (1994). As discussed below, the conditions at Wilson do
not comport with these legal standards.


Medical Care

The Eighth Amendment requires that inmates be provided with
adequate medical care. Id. at 832. Moreover, “[t]he Eighth
Amendment forbids prison officials from ‘unnecessarily and
wantonly inflicting pain’ on an inmate by acting with ‘deliberate
indifference’ toward the inmate’s serious medical needs.”
Blackmore v. Kalamazoo County, et al., 390 F.3d 890, 895
(6th Cir. 2004) (quoting Estelle v. Gamble, 429 U.S. 97, 104
(1976)); Horn v. Madison County Fiscal Court, 22 F.3d 653, 660
(6th Cir. 1994). The Due Process Clause of the Fourteenth
Amendment provides the same protections to pretrial detainees.
Bell v. Wolfish, 441 U.S. 520, 545 (1979). Prison guards
manifest deliberate indifference by intentionally refusing to
provide or delaying access to medical care for a serious medical
condition. Estelle, 429 U.S. at 104.
To establish that a County has denied adequate medical care
to an inmate requires a demonstration of both the objective and
subjective components of deliberate indifference. Farmer, 511
U.S. at 834. The objective component requires the existence of a
“sufficiently serious” medical need and a showing that the inmate
is being incarcerated under conditions posing a substantial risk
of serious harm. Id. A serious medical condition can be
established when the prison fails to treat a condition adequately
or where the affliction is seemingly minor or non-obvious and
medical proof is presented that the delay caused serious medical
injury. Blackmore, 390 F.3d at 899 (citing Napier v. Madison
County, 238 F.3d 739, 742 (6th Cir. 2001)). Additionally, the
objective component can be established when the medical need is
one that has been diagnosed by a physician as mandating treatment
or it is so obvious that a layperson would easily recognize the
necessity for a doctor’s attention. Blackmore, 390 F.3d at 897,
899. In other words, the violation does not necessarily have to
be based upon the detrimental effect of the delay and may be
premised upon the delay alone in providing medical care, thereby
creating a substantial risk of harm. Id.
The subjective component requires a showing that prison
officials have “a sufficiently culpable state of mind in denying
medical care.” Id. The subjective component “should be
determined in light of the prison authorities’ current attitudes
and conduct.” Helling v. McKinney, 509 U.S. 25, 36 (1993).

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Although deliberate indifference "entails something more than
mere negligence,” it can be “satisfied by something less than
acts or omissions for the very purpose of causing harm or with
knowledge that harm will result.” Farmer, 511 U.S. at 835.
Wilson County Jail fails to provide inmates with medical
care that complies with these constitutional requirements. We
found the following deficiencies: 1) deficient intake screening
and lack of routine health assessments; 2) inadequate access to
medical care; 3) lack of sufficient chronic and emergent care for
inmates with serious diseases; 4) inadequate infection control;
5) inadequate medical administration and oversight; and
6) improper administration and control of medications.

Inadequate intake screening and routine health

An adequate intake medical screening, assessment, and
referral process is necessary to ensure that inmates receive
necessary medical care during their incarceration. The Jail’s
intake process is constitutionally inadequate because it does not
attempt to identify inmates’ urgent and/or ongoing health needs.
Compounding this deficiency, the Jail does not provide routine
health assessments to determine the current health status or
chronic health care needs of inmates.
The accepted standard of care in jails requires that all
arrestees receive an initial health screening at the time of
booking. Incoming inmates should have an intake assessment
performed by qualified medical staff who have been trained to
take medical histories, and identify symptoms of drug and alcohol
withdrawal, communicable diseases, acute or chronic illness
(including mental illness), and potential suicide risk.
Standardized intake screening forms or procedures are
critical because they supply medical personnel and jail staff
with critical information regarding the inmate’s medical and
mental health history. And yet, in stark contrast to generally
accepted correctional practice, Wilson has none. Generally
accepted practice also calls for the initial assessment to
include, at a minimum, detailed medical history information such
as medications, alcohol or drug withdrawal, and mental illness,
including suicidal ideation or behavior. The intake screening
form should also prompt questions that when answered in the
affirmative require immediate medical review.

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Another critical component of the correctional intake
process is to ensure that the Jail staff can identify inmates who
are potentially suicidal for appropriate follow-up measures.
Wilson lacks a suicide prevention policy that directs
correctional staff to appropriately employ a preventative
strategy involving senior security staff and medical personnel.
Although we were told by the Jail’s medical assistant that
there is a policy for handling drug withdrawal, we were not
provided with one. Additionally, when our consultant spoke with
an intake officer who was processing an intoxicated inmate during
our tour, he told our consultant that they typically let
intoxicated inmates “sleep it off.” This practice is
unacceptable and fails to recognize the significant dangers
associated with drug and alcohol withdrawal. According to our
medical consultant, the risks involved with an inmate withdrawing
from alcohol or drugs are considerable as there is a 30%
mortality rate associated with untreated alcohol withdrawal.
After a protocol is developed, all personnel who have contact
with intoxicated inmates should be trained in, and aware of, the
Wilson does not give its inmates a full initial health
assessment within a reasonable period after their arrival at the
Jail.2 The accepted standard of care is to conduct a health
assessment within fourteen days of admission to a correctional
facility. Such an assessment typically includes a review of
intake information discussed above, the collection of a complete
medical and mental health history, a physical examination, and
screening for Tuberculosis (“TB”) and sexually transmitted
diseases. Without this assessment, inmates cannot be
appropriately evaluated, and thereby treated for chronic
disorders, communicable disease, and mental illness. The
following inmates were admitted to the Jail 60 days prior to our


To ensure inmates’ serious medical needs are identified
and addressed, facilities must identify inmates with chronic,
acute, or contagious conditions or other serious health care
needs. National standards require that inmates who stay for more
than a few days at a facility be given a detailed health
assessment to detail their current histories and conditions
beyond the limited information collected during intake screening.
These assessments ensure that inmates’ ongoing health care needs
are met and appropriate care provided.

- 6 

tour and each had incomplete health assessments: P.R.3 (admitted
03/11/06), K.B. (admitted 03/22/06), F.T. (admitted 04/29/06),
and L.T. (admitted 04/29/06). Inmate G.A. (admitted 02/14/06) is
HIV positive and had no health assessment completed at all.
Inmates D.G. (admitted 04/02/06) and Q.Y. (admitted 04/12/06)
also did not have health assessments in their records.
A comprehensive health assessment is particularly critical
for the number of inmates who are housed at the Jail for extended
periods of time. In the State of Tennessee, inmates can serve up
to six years at a local jail before transfer to a State facility.
Not only are comprehensive health assessments inconsistently
performed, if at all, when they are performed at the Jail, they
are conducted by a staff member who is not trained or skilled to
perform these types of evaluations. For example, the Jail’s
medical assistant performed a health assessment on inmate W.D.
While she noted in the chart that she heard abnormal lung sounds,
there was no review by a qualified medical professional, no
recommendation for follow-up, and no clinical plan of action for
W.D. This amounts to a failure to provide medical care.
A critical component of the health assessment is
Tuberculosis (“TB”) testing. All inmates should be tested for
exposure to TB within fourteen days of admission to the facility,
to preserve the safety of staff and other inmates from the spread
of communicable diseases. Inmates at Wilson are not currently
tested for TB. The Centers for Disease Control (“CDC”) also
recommends that correctional facilities designate a staff member
to manage TB control.4 Wilson lacks such a designee.
Also problematic is the Jail’s practice of taking inmates
who arrive at the Jail with medications off the medications,
regardless of the medication and its purpose (including chronic
illness or antipsychotic medications), until the inmate provides
documentation regarding their necessity or the Jail is able to
verify their necessity. Although it is an acceptable practice to
confiscate drugs upon an inmate’s arrival, a qualified medical
professional should promptly review the various medications and


To protect inmates’ privacy, throughout the document we
identify inmates by initials other than their own. We will
separately transmit to the County a list that cross references
the initials with inmate names.

CDC, Mortality and Morbidity Weekly Report, June 7,
1996/Vol. 45/no RR-8, Prevention and Control of TB in
Correctional Facilities.

- 7 

make a determination about critical medications that are required
for chronic illnesses, that do not have potential for abuse.

The Jail provides inadequate access to medical

In general, the sick-call process is a fundamental component
of the health care system in a correctional setting because
inmates typically access medical care by completing sick call
forms. The forms are retrieved daily and triaged by a member of
the medical staff, and inmates receive medical care according to
the urgency of their medical needs.
Contrary to generally accepted professional correctional
standards, Wilson does not have an effective system for inmates
to gain timely, basic access to medical care. Based on our
review of documents and discussions with inmates and medical
staff, the manner in which the Jail handles medical requests
(equivalent to sick call forms) and forwards them to the medical
unit is putting inmates at risk. As an initial matter, the
sick-call request system breaches confidentiality because inmate
requests are handed to correctional officers, who are then
supposed to forward them to the medical staff. There is,
however, no record, that this is being done nor whether the
medical staff ever receives these requests. Indeed, inmates
expressed concern that their forms were not received and Jail
staff are unable to refute this concern. In addition, requiring
medical requests to go through Jail staff may create a barrier to
care since it allows staff (who lack medical training) to
arbitrarily decide which requests merit medical attention, and
which do not. For example, in a June 2006 incident, a diabetic
inmate reportedly was placed on lock down for 72 hours for
mouthing off to an officer who refused to check her blood sugar
levels. This is wholly inappropriate. Medical decisions should
not be made by a non-medical provider.
As noted above, access to medical care at Wilson is
constitutionally deficient because care is often administered by
staff not qualified to do so (i.e., medical assistant making
medical decisions regarding x-rays). In instances where inmate
medical requests are successfully received by appropriate medical
staff, the Jail fails to establish a time-frame for the review or
triage of the requests, or for scheduling inmates for medical
appointments. It is standard medical practice for sick call or
medical requests to be reviewed and triaged by a qualified
medical professional within 24 hours. Moreover, generally
accepted correctional professional standards provide that inmates
with more serious or emergent medical issues receive immediate or

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prioritized attention, and that inmates with routine medical
issues be seen within three business days of their request.
According to our review, a number of inmates at the Jail who
submitted medical requests were never seen by any medical staff.
For example, we reviewed the medical requests from inmates C.F.,
N.B., and Y.S., dated the week prior to our visit, and there was
no evidence of them being seen or triaged.5
Also of concern, some inmates indicated that if medical
staff responded to their request at all, they often may receive
medication without being seen by any medical personnel. Indeed,
inmates report that they have learned the “necessary symptoms” to
include in their request forms in order to receive a
prescription. Ordering prescription medication for a patient
based only upon a written complaint and without a face-to-face
evaluation is not only contrary to generally accepted
professional standards, it may also be deadly if an inmate who,
for example, is allergic to a certain drug and is prescribed
medication without an assessment of his or her allergy history.
We identified a similar concern with respect to the Jail’s
provision of psychotropic medications to inmates with mental
illness. Although we identified instances where the Jail’s
physician wrote prescriptions for pyschotropic drugs, he did not
have regular contacts with patients with mental illness and there
is no coordinated or ongoing monitoring of these inmates’ mental
health status, diagnoses, or treatment by a qualified mental
health professional. With respect to inmates with mental
illness, this practice is particularly dangerous in the
psychiatric context because lack of proper monitoring and
assessment of psychotropic prescriptions may lead to
decompensation or lack of proper treatment. Finally, as
described more fully in Section II.B, the Jail’s failure to
maintain proper control over prescription medications exacerbates
the problems described above.
Additionally, the Jail does not provide its female inmates
with pap smears and mammograms, when clinically indicated.
Generally accepted professional correctional standards of care
for women’s health provide that women should receive pap smears
annually, three years after the onset of vaginal intercourse or


Similarly, request forms we reviewed from March and May
2006 for the following inmates: F.L., P.T., A.D., and Z.W.
03/22/06 had incomplete or no documentation recorded regarding a
response to their requests. This lack of a documented response
is an indication that no higher level of review or triage of the
requests, such as by the nurse or physician, was conducted.

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no later than 21 years-of-age, and mammograms annually for women
over forty or otherwise clinically indicated (i.e., family
history). Wilson also has no protocols for women regarding
cervical and breast cancer assessments or for women who enter the
jail pregnant. Pregnancy tests should be included in the initial
intake assessment for all women. Initial pap smears and
mammograms should be performed on women as clinically indicated
in accordance with the national standards outlined above and who
will have or do have longer stays at the Jail, such as after 90
days, and as clinically indicated, thereafter. The Jail should
also implement a tracking system to monitor such diagnostic
procedures for women.
Wilson requires inmates to pay for all medical services.
Although the “fee-for-service” system is not unconstitutional per
se, the practice of charging inmates fees to access medical care
at every level of the medical evaluation process may have the
effect of deterring access to necessary medical care. Contrary
to other correctional facilities’ practices, inmates are charged
comparatively high co-pay fees for every component of the medical
evaluation process. For example, there is a $5.00 charge to see
the nurse, a $10.00 charge to see the physician/dentist, a $25.00
charge for laboratory work and x-rays, a $5.00 charge for each
medication, and $25.00 charge for hospitalization per day and for
an emergency room visit. Generally, there should be one charge
to access the sick-call system, especially when additional care
or follow-up (i.e., laboratory work, x-ray, medication, and/or
referral to a specialist or physician) is deemed necessary at the
initial encounter. It appears from our records review that
inmates are even charged when they are not actually seen by
medical personnel. For example, when medication is dispensed in
response to a sick-call request.

Deficient chronic and emergent care

The Jail fails to address the ongoing medical needs of
inmates with chronic illnesses such as diabetes, heart disease,
asthma, hypertension, seizure disorder, hepatitis, and HIV
disease. Inmates who suffer from chronic medical illnesses must
be regularly monitored by medical professionals to ensure that
their symptoms are under control and their medications are
appropriate based on generally accepted professional standards.
Many chronic illnesses can have significant complications, such
as heart attack, stroke, and/or kidney failure, if they are not
routinely evaluated and treated.
The Jail does not have a chronic illness program that
identifies, tracks, and treats diseases that can be controlled

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when periodic and routine medical encounters take place. Because
the Jail lacks protocols or policies, medical care is often
reactionary, and serious medical conditions or complications are
not brought to the medical staff’s attention until a medical
event occurs which is often preventable. For example, F.L. is a
diabetic inmate who had been housed at the Jail for nearly three
years at the time of our visit. Although diabetics have
increased risks for vision loss and developing kidney and/or
heart diseases, inmate F.L. had not had eye examinations,
vaccinations, or kidney or cholesterol evaluations. In addition,
despite generally accepted professional standards that diabetes
in correctional settings be given hemoglobin A1c checks two to
four times a year to ensure proper control of their disease,
several diabetic inmates stated that they have been taken off
their medications and that their disease is out of control. For
example, F.L., referenced above, has complained that his
medications are not controlling his diabetes. Review of his file
indicates that he has had only two blood tests in the three years
he has been incarceration at Wilson. Both tests indicated that
his hemoglobin A1c was 11.7 and 12.6, respectively. A normal
hemoglobin A1c result is 7.0 or less. Notwithstanding clear
indications from over six months ago that F.L.’s diabetes is
poorly controlled, there was no change or follow-up to his
treatment. P.R. also had a hemoglobin A1c reading of 10.8 in
April 2006, yet the Jail had done nothing to improve the control
of her diabetes at the time of our visit.
The only “program” the Jail follows is to check diabetic
inmates’ glucose levels twice a day and provide a sliding scale
of insulin based on the inmates’ glucose levels. This procedure
is reactive and is typically used only to supplement diabetic
care and is not the accepted primary standard of care for
diabetic treatment. Appropriate care for diabetic inmates
requires annual eye examinations, routine urine tests (critical
to the detection of kidney disease), and monitoring of routine
blood work (so that changes in a diabetic’s worsening status
might be addressed by medication or other steps to prevent
further deterioration).6


In the medical community, there are clearly established
clinical guidelines for monitoring chronic illnesses. Likewise,
generally accepted professional standards of care require, for
example, that diabetics be given hemoglobin A1c checks two to
four times a year, an eye examination annually, blood pressure
checks quarterly, and lipid profiles annually. Failure to provide
these interventions can result in complications such as loss of
vision and stroke. See Harrison, Principles of Internal

- 11 

Additionally, the Jail has a population of HIV positive
inmates. These patients have compromised immune systems and
should be routinely monitored at least every three months. A
failure to provide HIV positive patients with appropriate blood
tests (e.g., CD4 and HIV viral load checks) every three months
could result in opportunistic infection – a major cause of
illness and death in HIV positive patients. Inmate G.A. is HIV
positive and she had to make repeated requests for a viral load
check when she was admitted. Although our review of her records
indicate that her viral load was within normal limits once she
was tested, she was not informed of the results and, at the time
of our tour, she was overdue for another assessment. The results
of necessary laboratory and diagnostic tests should be available
for the clinical encounters. The Sixth Circuit has held that
prison officials who have been alerted to a prisoner’s serious
medical needs are under an obligation to offer medical care to
such a prisoner. Johnson II v. Karnes, 398 F.3d 868, 874 (6th
Cir. 2005).
Further, despite initial reports to the contrary, the Jail
fails to provide a medically appropriate diet for inmates with
conditions that require such diets. In addition to a lack of
documentation, our discussions with kitchen staff confirmed that
medical diets are not provided.
The Jail also fails to provide reasonable medical treatment
to inmates with serious or potentially serious acute medical
conditions. Although the Jail has a physician under contract,
and he reports that he is “available” for on-call consultation
and emergencies, it appears that he is rarely called or consulted
for emergency situations. The Jail made this decision with
little to no input from the physician. Wilson’s failure to
provide adequate care to inmates with acute conditions is
exacerbated by the Jail’s limited amount of standard emergency
equipment. Although the Jail has an Automatic External
Defibrillator (“AED”), the nurse indicated that she does not know
how to use the AED. In addition, there are no standard protocols
for medical and security staff responding to medical emergencies.
This failing is illustrated by the January 2006 death of inmate
S.R., who was jailed at Wilson after swallowing a large bag of
cocaine. After he started to have a seizure, the nurse responded
without any medical equipment and made a medical assessment that
his medical crisis symptoms were feigned. She reached this
conclusion despite pleas from correctional staff who had to

Medicine, 15th Edition, McGraw-Hill.

- 12 

ultimately call 911 for help. It is possible that the resultant
delay in S.R. receiving medical treatment resulted in his death.
In providing her account about this incident, the nurse
unapologetically reported that she lacks knowledge of the
symptoms of drug induced distress because she doesn’t have any
friends or family members with those types of problems.7

Inadequate Infection Control

The Jail fails to take reasonable steps to prevent the
spread of potentially contagious diseases. As outlined above in
the intake assessments section, inmates are not tested or
evaluated for TB. TB is a potentially lethal respiratory disease
commonly found in correctional facilities, and whose transmission
to other inmates and jail staff can be prevented or controlled.8
On intake, inmates with signs and symptoms of TB disease can be
identified and isolated until TB is ruled out.9 Wilson does not
administer TB tests to inmates. As a result, inmates and staff
risk exposure to TB.
The Jail has no formal written plan to prevent exposure of
inmates and staff to an inmate who has any contagious disease.
The crowded conditions at the Jail and the constant exposure of
inmates to each other and Jail staff present a serious risk of
the spread of infectious respiratory diseases. For example,
during our tour, E.F. returned from the hospital after an
emergency room visit and was placed into one of the “isolation”
cells.10 The nurse indicated that she placed the inmate there


While S.R.’s death cannot be directly linked to the
nurse’s actions that day, procedures for handling medical crises
should be standardized and all security and medical staff should
be trained in those protocols so that critical response is not
left to Jail staff’s personal experience or guess work.

A TB control plan provides guidelines for the
identification, treatment, and prevention of TB transmission to
inmates, staff, and the general public.

Active and inactive TB can be identified by a skin
test. If the skin test is positive, a chest x-ray is performed
to rule out active TB. Meanwhile, the inmate can be isolated to
prevent potential spread of the disease.

Although the Jail has a cell designated for isolating
inmates for medical reasons, this cell is not designed to have a

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because she was “not sure what type of pneumonia” the inmate had.
The inmate had not been assessed by the nurse and information
regarding her status was limited. After we requested that the
nurse call the physician to ascertain additional information, the
doctor released the inmate to general population over the
telephone. Not only was a potentially contagious inmate returned
to the Jail with little information, but there was no routine
procedure in place or performed for evaluating an inmate who had
returned from an emergency room visit.
Similarly, the Jail fails to adequately manage transmission
of infections. At the time of our tour, the Jail had an outbreak
of a contagious skin infection, known as Methicillin-Resistant
Staphylococcus Aureus (“MRSA”), and the Jail failed to be
aggressive in treating it.11 During our tour, we were told that
inmates on Pod E were recently moved there prior to our arrival
because it was suspected that infection existed among those
inmates. Although isolation may be necessary in cases where an
inmate has open wounds which cannot be managed by appropriate
medical dressing, a number of inmates on Pod E did not appear to
require isolation. Important to the control of MRSA infection
and contamination is prompt and thorough responses to medical
requests that indicate a MRSA infection.12 Prompt and aggressive
treatment of MRSA with antibiotics is necessary to resolve the
infection and contain contamination to others. In addition, the
hasty placement of inmates in Pod E represents the lack of

reverse airflow or negative pressure, thus making it ineffectual
for isolating persons with suspected TB or other airborne

MRSA is a bacteria resistant to certain common
antibiotics, such as methicillin, oxacillin, penicillin, and
amoxicillin. Centers for Disease Control and Prevention, at MRSA
manifests itself as a boil or skin sore and is spread through
contact with an infected person or a surface the person has
touched. Id. In some cases, MRSA can have serious medical
consequences, such as causing surgical wound infections,
bloodstream infections, and pneumonia. Id.

Generally accepted medical care standards dictate that
a jail adopt a skin infection control plan to guide the
prevention of transmission of skin infections, including drug
resistant infections such as MRSA. An effective control plan
would outline a course of care to prevent the spread of

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coordination between sick-call, medication administration, and
medical follow-up by the physician. For example, Inmate DI was
placed in Pod E, but his infection had been resolved and he was
no longer on any medication; while another inmate on Pod E, W.D.,
had an open wound and was no longer receiving any antibiotics.

Access to Medical Care is Inhibited by Limited
Policies and Procedures and Inadequate Oversight
of Medical Care Services

The Jail lacks adequate policies and procedures and a
sufficient oversight system to ensure that health staff provide
appropriate services. As a result, staff often are unaware of
evolving inmate medical problems, or simply fail to implement
appropriate remedies. Policies and procedures are needed to
ensure consistency and to communicate appropriate standards of
care at a correctional facility. With a few exceptions (noted
below), the Jail does not have adequate written policies to
govern the provision of medical services. Most, if not all, of
the delivery of medical care at the Jail is ad-hoc and piecemeal.
For example, the Jail has a total of two pages of substantive
medical care and services policies to guide the limited number of
medical personnel regarding medical care delivery at the Jail.13
Lack of training and/or policies regarding serious medical
conditions may also be considered in the deliberate indifference
determination. Blackmore, 390 F.3d at 899 (reversing district
court’s grant of summary judgment to prison officials because the
serious medical condition was obvious and issues of fact remained
regarding the lack of policies, practices, and adequate
Nurses are often the first health professional an inmate
encounters for access to care for both routine sick-call and
emergency complaints. At Wilson, the Jail’s nurse provides the
primary medical services at the facility. Accordingly, nursing
protocols are critical for a jail, such as Wilson, that uses
nurses as the initial triage point for access to health care.
The Jail, however, does not have nursing protocols to direct
nurses in the treatment of illnesses and in making medical


The Jail does not have, and needs, policies, protocols,
and procedures in the following fundamental health areas: intake
screening, infection control, sick-call, chronic illness,
comprehensive health assessments, medication administration,
mental health, suicide prevention, detoxification, women’s
health, quality improvement, and emergent response.

- 15 

assessments.14 The Jail should develop and implement appropriate
nursing protocols (typically by the physician), and thereafter
the physician and/or the health authority should conduct periodic
reviews of the nurse’s records, assessments, and physician
referrals in order to ensure adherence to the protocols.
Additionally, the Jail should hire another nurse to actually
conduct medical encounters with inmates. At present, the one
nurse has little clinical contact with inmates and functions more
as a clinical administrator.
The Jail does not have an individual who serves as the
health authority and has responsibility overseeing the health
care program (and ensuring adherence to policies) at the Jail.15
The primary site physician reported that he does not consider
himself the health authority at the Jail, and nor could he serve
in that capacity with his current schedule of only two hours per
week at the Jail. Given the deficiencies in care and other
problems identified in this letter, additional physician
supervision at the Jail is necessary. At a minimum, the Jail
should increase the physician assistant or physician time spent
at the Jail to 20 hours per week, in order to accommodate the
current population and to provide adequate supervision of other
medical staff.
As a result of the Jail’s lack of policies and procedures
and supervisory oversight, various medical staff and personnel
are performing duties and responsibilities outside the scope of
their licensure and training. For example, the Jail’s medical
assistant – who is well-meaning – often dispenses medical care


Nursing protocols provide important and detailed
guidance to nurses regarding treatment guidelines and standards
for management of a specific disorder or clinical situation.

The Jail’s current medical staff consists of a
part-time physician, Dr. Scott Giles; one full-time nurse,
Ms. Cathy Dillard, LPN; a full-time medical assistant, Ms. Lisa
Smith; and three physician assistants who rotate through the
facility. Dr. Giles averages about two hours a week at the Jail
and one of the physician assistants spends another two hours per
week at the Jail, for a total of half a day per week of Advance
Level Provider time at the Jail. Advance Level Providers are
generally licensed nurse practitioners (RNs with an advanced
degree) or physician assistants, or other professionals who are
licensed and qualified to examine, diagnose and treat patients
and order prescription medication - tasks an RN or Licensed
Practical Nurses may not perform.

- 16 

outside her area of expertise. She performs physical
examinations, independently evaluates inmates’ various medical
complaints, and orders tests and x-rays without any clinical
supervision or review. The night before our investigatory tour,
a female inmate D.G. was beat up by other inmates. Reportedly,
her head was slammed repeatedly into the concrete floor.
Following the beating, she complained to the medical assistant of
headaches and nausea. The medical assistant ordered a skull
x-ray. Notably, the type of x-ray ordered was not appropriate to
rule out the serious risk of injuries as presented by the
inmate’s symptoms. We found no record that follow-up was
conducted or that the nurse or physician was even informed about
this medical decision. In fact, there was no documentation in
the medical record at all that the medical assistant evaluated
the inmate and ordered the x-ray. Both the inmate and the
medical assistant informed us verbally that she had ordered the
x-ray. The medical assistant’s duties and responsibilities at
the Jail are contrary to generally accepted professional
standards because a medical assistant serves, at most, to support
the nurse or physician, but not as the sole individual who
conducts medical examinations and makes medical decisions.
Allowing the medical assistant to function in this capacity
places the inmates at unnecessary risk of mis-diagnosis and
potential for harm and even death.

Improper administration and control of medications

In addition to the lack of any clear policies or protocols
regarding medication administration, we observed serious lapses
in the Jail’s current procedure for medication administration and
Contrary to generally accepted standards, numerous
medication administration records were not completed or signed as
medication was distributed. Moreover, records we reviewed
routinely did not indicate the duration for which the medication
was to be dispensed. For example, W.D. was being treated for a
MRSA infection but his medication record did not indicate whether
he was to continue to receive antibiotics or whether he completed
the necessary treatment. We also observed problems with
distribution of medication in a medication call we observed
within a housing unit; it was disorganized, i.e., with several
inmates crowding around the medication cart. Also problematic
was the failure of staff dispensing the medication to document,
and perhaps control, the medication that it distributed to
inmates. For example, an officer was provided Tylenol to
distribute to inmates. Reportedly, he distributed the Tylenol
but half of the supply was later found missing. When our

- 17 

consultant raised this issue with the nurse, she indicated that
she has been unsuccessful in her attempts to get officers who are
dispensing medications to complete the appropriate documentation.
Additionally, fundamental principles of medical
administration are not followed at the Jail. Inmates’ medical
records were disorganized, had papers not in chronological order,
and had little, if any, documentation regarding the clinical
encounter or plan of care. Critical and basic health care
information, such as vital signs were also missing. All
doctor/inmate medical encounters should have documentation that
includes the standard SOAP format that is routinely used in the
medical community.16
The Jail also distributes a number of controlled substances.
However, it fails to limit access or maintain the substances
under locked conditions. During our tour, a narcotic, Percocet,
was missing from the medication cart. After several hours, and
after our repeated inquiries emphasizing the seriousness of the
missing narcotics, we were told by staff that the Percocet was
given to an inmate who was prescribed the Percocet and had been
recently released from the Jail. However, there was no
documentation to confirm this and staff readily admitted they
couldn’t be certain this indeed occurred. If Wilson employed
proper procedures for controlled substances, including requiring
the documented accounting for controlled substances at the end of
each shift and proper release records, this error could have been
avoided and/or promptly identified.
As discussed above in the section regarding inmate intake
and assessments, the Jail’s current practice of confiscating
and/or discontinuing medications upon inmates’ arrival to the
Jail is also haphazard and dangerous. For example, inmate O.J.
has a history of seizures and reportedly has made repeated
requests for his seizure medications. We reviewed his medical
request form, dated May 24, 2006, which stated that his
medication must be verified before starting him on the
medication. At the time of our tour, it had yet to be verified,
and his medication had not been started. It is critical that
inmates with certain disease processes receive continuous
medication, such as Type 1 Diabetes and seizures. An


SOAP is a standard diagnostic assessment tool used by
doctors. It stands for: Subjective (e.g., complaints from the
patient), Objective (e.g., visible signs of injury), Assessment
(e.g., diagnosis), and Plan (e.g., antibiotics).

- 18 

interruption in medication for certain chronic illnesses may
cause an inmate’s chronic condition to worsen. Diabetics for
whom treatment or medications are delayed may, for example,
suffer diabetic comas and possibly even death.

Mental Health Care

Jail officials violate the Eighth Amendment when they
exhibit deliberate indifference to inmates’ serious mental health
needs. Perez v. Oakland County, 466 F.3d 413 (6th Cir. 2006)
(citing Estelle, 429 U.S. at 103-104 (1976)). Deliberate
indifference may include intentionally denying or delaying access
to care, or intentionally interfering with treatment or
medication that has been prescribed.
Wilson fails to meet this constitutional minimum standard
because it does not provide adequate mental health care for its
inmates. There is no qualified mental health professional who
routinely treats inmates at the Jail. The sole mental health
provider is a counselor at a local mental health hospital,
Cumberland Mental Health Facility (“CMHF”), who comes to the Jail
once a week to meet with inmates that are identified for him by
the Jail’s nurse. The counselor does not routinely see inmates
who are on suicide watch or who have just returned from the
hospital after a suicide attempt. Although the counselor
undoubtedly provides an important service to the Jail, he is not
a qualified mental health professional as he possesses only a
Master’s level degree in divinity.17
Wilson does not conduct mental health evaluations of the
larger inmate population. Such outreach is necessary to identify
inmates with mental health concerns before those concerns
escalate to crises that require intensive intervention and
threaten the health and safety of inmates and staff alike.


Notwithstanding the weekly visits by the mental health
counselor to the Jail and Wilson’s arrangement with two local
agencies (CMHF and Middle Tennessee Mental Health Institute
(“MTMHI”)) to receive Jail inmates in mental health crises, the
Jail does not provide adequate mental health care for the inmate
population at the Jail. At a minimum, the Jail should have the
services of a full-time master’s level psychologist on staff at
the Jail, and psychiatric services, either on site at the Jail or
at a local mental health center, at least eight hours per week.
The Jail also should have a designated psychiatrist to assist
with overseeing the mental health care and clinical activity at
the Jail.

- 19 

However, no designated mental health staff review sick call
requests to identify inmates with emerging mental health
concerns. Outreach by mental health staff is particularly
important because correctional staff at the Jail demonstrate
little training in, or understanding of, the needs of inmates
with mental illness or suicidal tendencies.
For those inmates who are identified as suicidal or who are
suffering from acute mental illness, the Jail fails to provide
reasonable care. The Jail relies entirely on MTMHI for inpatient
care. Inmates are transferred to MTMHI when they attempt suicide
or have acute episodes of psychotic behavior. According to the
mental health counselor and our review of records, it is typical
for suicidal inmates who are referred to MTMHI to have to wait
over twelve hours before they are transferred to MTMHI. The
Jail’s current policy requires inmates to be medically cleared by
the contract physician and for blood work/toxicology screens to
be completed before they can leave the Jail, which oftentimes
delays emergency medical attention. It is unacceptable to
require acutely suicidal inmates to remain at the Jail for
prolonged periods of time without any mental health intervention.
See Gray v. City of Detroit, 399 F.3d 612, 616 (6th Cir. 2005).
Our review indicates (as illustrated by the following
examples) that the Jail is failing to adequately monitor,
supervise, and intervene with suicidal inmates.

On January 31, 2006, an inmate informed officers that a
fellow inmate was trying to hang himself. When officers
went into his cell, they observed him hanging from an air
vent using a piece of stripped clothing. The inmate was
placed in a paper gown. It is not clear from our record
review what, if any, other precautions were taken with this
inmate, or whether the medical staff or the mobile crisis
unit was called.


On March 2, 2006, officers were attempting to put a paper
gown on an inmate who was refusing to undress. During the
encounter, the inmate reportedly banged his head against the
wall. The written report on the incident also indicates the
inmate was violently resisting. One officer sprayed the
inmate with pepper spray. It is generally inappropriate to
spray a suicidal inmate without conferring with medical or
mental health staff. Further, there is no indication that
the inmate was ever decontaminated or that medical staff or
the mobile crisis unit was called.

- 20 


On June 8, 2006, inmates alerted staff to an inmate found
sitting in his cell with blood dripping from his right wrist
and a pencil in his left hand. Although the mobile crisis
unit from MTMHI was called after he was cleaned up by a
nurse and put in a paper gown, this incident is illustrative
of inconsistent practice (regarding monitoring and allowable
cell items) followed by Jail staff.


On June 19, 2006, an inmate reportedly alerted a corrections
officer that another inmate was cutting himself. The
officer found the inmate cutting his stomach and both
forearms. When the inmate refused to give the officer the
pencil he had been using to cut himself, the officer sprayed
him in the face with pepper spray and then handcuffed him.
The inmate was then placed in a paper gown and allegedly
monitored through the night by correctional staff. There’s
no indication that the inmate was monitored or seen by
medical staff or that either MTMHI or CMHF was called.

Even when Wilson manages to avert suicides, the following
incidents amplify that the staff is following inconsistent
practice and policy in handling suicidal inmates:

On February 13, 2006, a corrections officer encountered an
inmate he noted as being “upset” according to an incident
report we reviewed. The corrections officer asked the
inmate if he was suicidal, and the inmate reportedly told
the officer that he was not. The officer alleges that he
checked on the inmate twice during medication runs and the
inmate told him he was fine. The officer reports learning
the next day that the inmate tried to hang himself. The
significance of this incident report is that despite the
inmate’s entreaties that he was not suicidal, the officer
was apparently concerned enough to continue to check on him.
However, the officer, beyond completion of the incident
report, apparently failed to inform staff on duty or in the
control center, and failed to alert anyone on the medical
staff of his concerns. This apparent lack of communication
is symptomatic of a lack of training and inadequate policies
and procedures regarding suicidal inmates.


On February 14, 2006, an inmate reported to an officer
handing out inmate medications that he was having suicidal
thoughts and wanted to harm himself. The officer
appropriately placed the inmate on suicide watch, and
ultimately he was deemed eligible for inpatient admission to
the mobile crisis unit. While the officer’s vigilance
averted potential disaster on this occasion, it is

- 21 

significant to note that the inmate had previously indicated
that he had thoughts of hurting himself and had reported
being suicidal upon admission. He also indicated when he
was first admitted that he had cut his wrists prior to being
arrested. If the Jail had adequate protocols in place, he
would have been identified and monitored as potentially
Many inmates with mental illnesses require medication to
maintain their stability. Missing doses of certain psychotropic
drugs, coupled with the stress of incarceration, could lead to
unnecessary decompensation and increased risk of suicide gestures
or attempts. As noted above, Wilson routinely takes psychotropic
medications from inmates upon intake until and unless proper
verification is conducted. Wilson lacks a protocol for ensuring
that inmates’ medications are resumed in a timely fashion. We
learned of a number of disturbing accounts from inmates who
reported that they resorted to attempting suicide in order to get
medical attention/treatment for their mental illness. For
example, inmates L.T., K.L., E.O., and A.D. all attempted
suicide, reportedly as a last resort to get medical attention.
L.T. attempted suicide on April 6, 2006. After he was returned
from MTMHI, he attempted suicide again on May 24, 2006.
A related concern is Wilson’s lack of a system to ensure the
continuity of psychotropic medications for its inmates who are
mentally ill, without adequate medical justification. For
example, inmate, T.Z. who was bipolar and who was taking lithium
to control his mental illness, had his lithium stopped at some
point during his incarceration. When we asked the nurse about
this inmate, she stated that he “refused” to take his medication.
However, there was no documentation of the refusal or that the
inmate was advised of the risks and benefits of his decision.
After further inquiry, it was determined that T.Z. had not
refused the medication, but that CMHF sent a limited amount of
the drug to the Jail and although he was scheduled for a return
visit to CMHF, the Jail never transported T.Z. to his
As the foregoing illustrates, the Jail fails to
appropriately identify inmates with serious mental health needs
at the intake process or to adequately provide mental health
needs during their confinement. These deficiencies contribute to
unsafe conditions and unnecessary suffering. It is not uncommon
for inmates with mental illness to get into altercations with
security staff or other inmates and to be subjected to uses of
force by security staff. For example, as discussed above, during
our tour, one inmate, who by all accounts was actively psychotic,

- 22 

instigated a fight with the three other inmates because she had
not received her medications and wanted to get off the cell
block. Staff and inmates alike reported that prior to the fight
- in which she repeatedly slammed the head of another inmate into
the cement floor - the mentally ill inmate had been demanding her
medication, was very aggressive and did not seem to be able to
function well in the pod.
Finally, the existing physical structure of the medical
clinic has no private areas to ensure appropriate correctional
confidentiality and privacy during medical assessment.18 Nor
does the Jail have “safe cells” for suicidal inmates and inmates
undergoing alcohol or drug withdrawal. Currently, when a
suicidal inmate is placed on suicide watch, the Jail utilizes a
room in the intake area where incoming inmates are held until
they are processed. This is insufficient because this room does
not allow for constant observation and it is not free of suicide
hazards. In fact, during our tour, we were told that one female
inmate was placed in the general intake holding cell for suicide
watch and while she was on suicide watch, she attempted to commit
suicide by hanging herself with her undergarment. Although the
Jail is soon scheduled to move into a new facility, the Jail
should address the current deficiencies in the present physical
structure, as well as ensure that future construction will meet
the demands of the medical operation.

Protection from Harm

The Eighth Amendment provides that inmates be protected from
the unnecessary and wanton infliction of pain by correctional
officers, Whitley v. Albers, 475 U.S. 312, 319 (1986).
Correctional officers may use force reasonably in a good faith
effort to maintain or restore discipline, but force is not to be
used maliciously and sadistically to cause harm. Hudson v.
McMillan, 503 U.S. 1, 6 (1992); see Webb v. Bunch, No. 93-5258,
1994 WL 36854, at *4 (6th Cir. Feb. 8, 1994). The Eighth
Amendment likewise imposes a duty on prison officials “to protect
prisoners from violence at the hands of other prisoners.” Farmer
v. Brennan, 511 U.S. 825, 833 (1994). Prison officials must also
take reasonable measures to ensure inmates’ safety. Id. at 832;
Curry v. Scott, 249 F.3d 493, 506 (6th Cir. 2001).


This may inhibit inmates from being candid in revealing
their personal and confidential health concerns.

- 23 


Use of Force

We believe that there is a pattern or practice of the use of
excessive force by Wilson correctional officers. In early 2006,
the Criminal Section of the Civil Rights Division and the United
States Attorney’s Office for the Middle District of Tennessee
concluded their federal investigation and prosecutions of two of
the Jail’s former correctional officers.19 In January 2003,
officers at the jail fatally beat inmate Walter S. Kuntz. In
addition to his fatal wounds, the officers caused severe head
injuries and three broken ribs. The ringleader of the beating
was a supervisor at the Jail; in 2006 he received a sentence of
life in federal prison without the possibility of parole.
According to published news accounts, a federal investigation
revealed that 11 beatings occurred at the Jail between July 2001
and January 2003. Sometimes, the beatings resulted in inmates
losing consciousness.
In addition, several former inmates have filed civil
lawsuits, and one of those suits is still pending. News reports
indicate that the County has paid at least $840,000 in
settlements, including $400,000 to the Kuntz family and $95,000
to another inmate who alleged that correctional officers beat him
after his arrest in April 2002.
Former inmates and correctional officers have testified that
Wilson officers routinely cover up incidents of abuse by filing
false use of force incident reports. They also report that some
Wilson supervisors had tacit knowledge of the assaults and either
knew or should have known abuse and staff misconduct had taken
place. Although we cannot corroborate the testimony of these
former inmates and correctional officers, in interviews that we
conducted at the Jail, particularly of the male inmates, we found
that they were extremely reluctant to talk to us about staff
abuse (even the well known and well documented incidents
mentioned above) or any other protection from harm issues for
fear of retaliation.
Despite the successful criminal convictions of officers at
the facility, Wilson’s lack of system reform and oversight to
prevent the re-occurrence of excessive use of force give us


Seven other correctional officers were convicted of
civil rights violations ranging from assault to conspiracy.
Another officer, who was acquitted of charges, was still employed
at the Jail at the time of our visit.

- 24 

little confidence that inmates are presently safe from ongoing
abuse by officers. In fact, as our review of facility records at
the time of our tour indicate, use of force remains a problem at
the facility. For example, we reviewed a January 2006 use of
force report in which a sergeant writes that an inmate complained
that a corrections officer pushed and shoved him in the throat,
causing his neck to pop and leaving him in extreme pain. We
reviewed an April 2006 incident in which an officer acknowledged
grabbing an inmate and forcibly placing him in his cell after the
inmate addressed the officer in a loud manner, following the
conclusion of the inmate’s altercation with another inmate.

Inadequate Management Review of Use of Force

Inadequate management review and investigation of use of
force contributed to the high number of excessive force incidents
that occurred at Wilson between 2001 and 2003. The purpose of a
management review and investigation of each use of force is to
ensure that no criminal conduct has occurred, that facility
procedures have been followed, that no remedial training is
necessary, and that no review or change in policies is required.
There is no indication that the Jail administrator conducts his
own review of uses of force. Our review indicated that Wilson’s
policies and practices have not been reformed as a result of the
problematic examples of excessive force mentioned herein. As a
result, obvious uses of force are not identified. For example,
the sergeant (mentioned above) who wrote in a January 22, 2006
use of force report about an inmate who complained that a
corrections officer pushed and shoved him in the throat causing
his neck to pop and leaving him in extreme pain, failed to
adequately investigate the allegations. Although the sergeant
wrote in his report that officers involved in the incident were
preparing incident reports, no such reports were attached to the
sergeant’s report in the information that we received. In
addition, while the sergeant’s report indicates that the inmate
received a spinal x-ray, we did not see any results from the
x-rays or evidence that any sort of investigation into the
incident took place.


Supervision in the Living Units

Wilson fails to adequately supervise its inmates. The
physical layout of Wilson combined with the current placement of
correctional staff in the control center and throughout the Jail
prevent direct supervision of the housing pods, thereby
increasing the risk of harm to inmates and staff. Additionally,

- 25 

the Jail’s supervisory failures promote staff abuse,
inmate-on-inmate violence, the introduction of contraband, and
the increased risk of inmate suicide, each of which place both
inmates and staff at risk of serious harm.
The inmate living pods are clustered around a control center
located one story above the floor of the pods. Although all of
the pods can been viewed from the control center (except the
female pod as discussed below), staff can only observe inmates
who are out in the common area or dayroom, and cannot see inside
inmate cells. Inmates inside a pod freely enter and exit their
own and other’s cells at will.20 Wilson mans the control center
with a single staff person, whose sole shift responsibility is
the operation of the control center. If someone wishes to access
the control center or if the assigned staff person wishes to go
to the bathroom, s/he must walk down a narrow spiral staircase to
the lower floor to exit – leaving the control center unmanned.
We were told that a relief person is called to relieve the staff
person. Nevertheless, the functionality of this process leaves
periods of time in which no one is watching the pods. We
observed that no one was monitoring the inmates on at least one
occasion during our visit. It is evident from inmate reports
that the pods are not consistently monitored from the control
center. Inmates reported fights, especially in E Pod, which are
not timely observed by control center staff. Inmates also
reported, and staff confirmed, that inmates must holler or throw
shoes at the control center window in order to get the attention
of correctional staff.
The following incidents illustrate that the poor physical
layout of the Jail, as well as the Jail’s inadequate supervision,
facilitate inmate-on-inmate violence at Wilson. As detailed
above in our medical and supervision discussions, on the evening
prior to our visit three female inmates were involved in an
altercation. The female inmate that was beaten was allegedly
actively psychotic and probably should not have been residing at
Wilson. Staff have reported several inmate altercations due to
racial animosity. In June 2006, a white inmate was attacked by
several black inmates without any correctional officer
intervention. In May 2006, a white inmate was assaulted by
several black inmates in the booking area. The officer explained
to the injured inmate that he could file formal charges against
the black inmates. The officer provided no other intermediate


Wilson also utilizes several video monitors to monitor
other parts of the Jail, such as the sally port and hallways
leading into the pods.

- 26 

options. The inmate decided not to file formal charges against
the inmates out of fear of retaliation, and nothing further was
done as a result of the incident.
Finally, in a January 2006 incident, an inmate was overheard
telling a correctional officer that he wanted to be removed from
his current pod because of all of the “Ns” (apparently referring
to a racial epithet) in the pod. After the correctional officer
left the pod, the inmate was jumped by approximately 12 black
inmates until a white inmate intervened. Apparently, no staff
observed the fight or was made aware of it until the following
day when the inmate’s mother called the Jail stating that her son
needed medical care. The inmate had suffered a broken jaw.
Wilson’s failure to properly supervise and classify its inmates
has resulted in inmate-on-inmate violence. Such incidents create
risks of harm to inmates and staff who are responsible for
intervening in inmate altercations.
Wilson employs two unsafe security practices which put the
safety of inmates and staff in the pods at risk. First, we noted
that staff did not spend time in the pods other than to
distribute meals and medication. As noted above, Wilson’s
failure to provide more consistent supervision results in inmate
fights in which there is often untimely intervention. There
should be two staff assigned to the control room who switch
duties from watching the monitors to observing inmate and staff
activities in the pods. Second, we observed that the female pod
is obscured by blinds. This practice appears to be Wilson’s
attempt to maintain sight separation between the male and female
inmates. We were told various reasons for this practice, e.g.,
to keep male correctional officers from looking at the females,
and to obscure the view of the male inmates in the other pods
from looking into the reflection of the glass in the control
center into the female pod. While Wilson’s use of the blinds to
preserve some privacy in the female pod may be well-intentioned,
it effectively poses a security risk to the inmates and staff
because it prevents the control room staff from being able to
visually observe activity in the female pod.

Supervision in the Food Service Area

Inmates/trustees are not properly supervised in the kitchen
at Wilson. For example, we observed an unsupervised inmate in
the kitchen office where the kitchen knives are kept unlocked and
un-inventoried on top of the desk. Because they are unsecured,
an inmate could easily walk back into the housing units with
these utensils that can be used as weapons. We were informed
that the office is supposed to be off-limits to inmates.

- 27 

Regardless, knives and other metal utensils should be kept under
lock and key and managed by one kitchen staff person on each
shift. Additionally, inventory should be taken at the beginning
and end of each day, and inmates who serve as trustees should be
searched upon their entry and exit to the building to ensure that
the introduction of contraband into the facility is limited or

Classification of Inmates

The classification system at Wilson contributes to its
safety and security deficiencies. Generally accepted
classification systems separate problematic inmates from those
who cause fewer problems or who are vulnerable to violence or
abuse. Wilson’s failure to do so makes supervision more
difficult and increases the risk of harm to both staff and
inmates. We learned that Wilson initially places inmates in
housing assignments based on two criteria: by sex and available
bed space. After a period of residency, some inmates earn
“trustee” status and are permitted to transfer to the less
restrictive environment of the trustee pod. This option,
however, is not available to the female inmates. We also found
that inmates in protective custody were placed with inmates who
were supposed to be isolated for medical reasons. In fact, in
one of the pods, not only were protective custody inmates housed
with inmates with active staph infection, but they were also
housed with inmates who were on temporary disciplinary
Wilson officials blame the lack of a classification system
on overcrowding, but crowded conditions that place the Jail in
legal jeopardy do not trump sound corrections management
procedures. A jail’s classification system used must meet sound
professional and penological principles. Specifically, a good
classification system should ensure that inmates are timely
classified and housed appropriately for security and safety.
Additionally, an effective system includes consideration of an
inmate’s security level, suicide risk, and past behavior. It
should also have the capability to effectively track inmates
throughout their incarceration, provide quality control
information, identify inmates by gang affiliation or special
inmate needs (e.g., mental health or medical, protective
segregation, and administrative segregation needs), and assign
inmates to housing units within facilities which are appropriate
and safe given their classification status.

- 28 

Finally, there should be classification policies and
procedures which classify inmates in accordance with the level of
custody (i.e., level of inmate supervision and custodial
management issues) and the level of security (i.e., dangerousness
and nature of offense) required to ensure safety.

Control of Contraband

The safety of staff and inmates is also dependent upon a
jail’s ability to restrict contraband, i.e., items banned or
prohibited by the jail, such as cell phones or cigarettes,
because they might pose a security risk. Wilson fails to
adequately limit contraband items from entering the Jail. We
found that inmates are not properly searched, incoming mail is
not properly inspected, and professional visitors (e.g., lawyers
and social workers, and correctional staff are not searched).
Both staff and inmates confirmed that inmate access to cigarettes
(both store bought and hand made) is problematic because the
trade and barter of such items increases the number of fights and
shake downs by fellow inmates looking to obtain contraband.
Staff and inmates also admitted that inmates have access to
lighters and matches to smoke the cigarettes. We found that
inmates also use exposed electric wires in the pods to create a
spark to light their cigarettes. Exposed electrical wires are a
clear security risk and must be secured and repaired immediately.
Additionally, inmates reported having over-the-counter and
prescription medications hidden in their cells. We were told,
and reviewed incident reports that indicated, illegal medications
served as inmate currency to purchase items such as cigarettes
and to obtain extra food from other inmates.
The Jail also allows inmates to have coffee pots, hot
burners, compact disc (CD) players, etc. in their cells/living
pods. Although these items are not contraband, these items could
easily become fire safety and general security problems. In
fact, during our tour, we observed a number of inmates creating
“hootch”21 with their coffee pots and hot burners. In addition
to the potential fire hazards from coffee pots and hot burners,
if they are used for the production of alcohol, they should be
confiscated and prohibited.


“Hootch” is a colloquial term for alcohol that is
created by fermenting bread or fruits for long periods of time.
The hot pots are used in this fermenting process.

- 29

Lack of Quality Control of Chemical and Mechanical

Wilson suffers from a lack of quality control mechanisms for
the distribution and usage of its chemical agents and hard
restraints, such as waist chains and handcuffs. First, although
Wilson has a policy regarding the use of chemical agents, they
lack a policy regarding the storage and distribution of chemical
agents. According to Wilson’s policy, the chemical agent
“Freeze” (“Oleoresin Capsicum” or “OC” spray) is its
less-than-lethal method to manage “out-of-control” inmates. The
Jail stores canisters of Freeze in an office attached to the
Jail’s training room, which also serves as an area where officers
eat their meals. Both correctional officers and sheriff’s
deputies have access to the office where the spray is located and
stored. A lieutenant told us that corrections officers and
sheriff’s deputies are allowed to get a new can of spray whenever
they need to. We observed the spray canisters in a small
cardboard box sitting on top of a cabinet. The canisters were
unsecured, and no inventory was kept regarding current stock or
the expiration dates of the canisters, nor does Wilson monitor
which officers obtain spray, or measure the length of time before
an officer requires another canister. It appears possible that
an officer or anyone who wanders into that office can take
several canisters and they would not be missed. In the absence
of such controls, Wilson cannot ensure its staff is properly
using spray in its interventions with inmates. Furthermore, we
saw no evidence that staff received annual training regarding the
usage of OC spray, nor any training on appropriate
decontamination procedures when it is used.
Second, Wilson’s handcuffs and leg and waist chains are
stored unlocked in the booking area of the Jail. Our consultant
found it troubling that no inventory list is kept for this
equipment and that handcuffs are distributed to the correctional
officers and the sheriff’s deputies without being tracked. This
is problematic because no one is required to sign for the
equipment and no one is held accountable for how long or for what
purpose the equipment is being used.
All chemical agents, handcuffs, chains, and any other
security devices should be kept under lock and key and
inventoried. Both correctional and law enforcement officers
should be required to sign for all of the security and restraint
equipment when it is checked out and returned so an accurate
record of the equipment is maintained and reviewed by a

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There is no operational grievance process at Wilson because
inmates are either confused about how it works, unaware the
process exists, or, more commonly, do not trust the process.
Grievances are initiated by the inmate completing a “Wilson
County Jail Inmate Request” form. As the title of the document
would suggest, inmates do not treat this document as an
opportunity to grieve issues, concerns, or complaints, but use it
to make requests, such as switching from one pod to another.
Several inmates who allegedly attempted to write grievances
claimed that they were told by staff to stop writing grievances.
Some inmates reported that they have seen correctional officers
throw the forms away. An adequate grievance process is an
integral part of every jail program and should be designed to
ensure that there is an administrative means for the expression
and resolution of inmate concerns and can serve as a source of
information to ensure safety and security. An adequate process
includes a written form that is completed by the inmate, an
opportunity for staff to investigate and resolve the inmate
complaint, and an appeal process within a specific time frame.

Due Process

Inmates are routinely locked down for disciplinary reasons
without due process. Every inmate confined to their cells for
disciplinary reasons should be provided with a written statement
of the charges and investigation of the charges as soon as
possible, but no later than 24 hours after the offense occurs. A
disciplinary hearing, conducted by staff trained specifically for
this purpose, should be conducted and the inmate should receive a
copy of their findings. In cases where the hearing determines
the inmate’s innocence, all records pertaining to the incident
should be stricken from the inmate’s file.
However, at Wilson, we found that inmates can be locked in
their cells for up to 72 hours with one hour of out of cell time
per day without a process for administrative review. We learned
that a supervisor arbitrarily determines the length of the lock
down. One inmate who had been at the Jail for a period of time
reported that lock down typically will be for either 24, 48, or
72 hours; however, we did not find any lock down that was less
than 72 hours. As previously mentioned, four black inmates were
accused by a white inmate of assaulting him. The four black
inmates were placed on lock down for 72 hours in June 2006. No
disciplinary hearing was provided to examine the circumstances

- 31 

surrounding the incident. As previously mentioned, we reviewed a
June 2006 incident in which a diabetic inmate reportedly was
placed on lock down for 72 hours for “mouthing off” to an officer
who refused to check her blood sugar levels. Finally, we
reviewed an incident that occurred in April 2006 where an officer
broke up a verbal confrontation between two inmates. According
to the incident report, the inmate “got very loud.” When another
officer tried to quiet him down, the inmate refused and the
officer allegedly grabbed the inmate and placed him in his cell.
The inmate allegedly resisted and the officer stated that he was
forced to use a take down technique and spray the inmate with OC
spray. The inmate was placed on lock down for 72 hours without a
Inmates had only recently been given rule books prior to our
visit and reported that staff arbitrarily choose which rules to
enforce and create rules to suit their needs. We were provided a
copy of the rule book, which is only available in English. We
encountered at least one non-English speaking inmate during our
visit. In addition, there is no mechanism in place to assist
inmates who either cannot read, or who have very poor
comprehension skills.

Life Safety and Sanitation

Fire Safety

We observed during a fire drill that Wilson’s fire
prevention procedures are substandard and threaten the safety and
security of its inmates and staff. The control center houses a
series of monitors, a fire annunciator board22 and other pieces
of security equipment. Once the alarm went off during the drill,
the annunciator board malfunctioned. The fire horn did not sound
in all of the pods and many of the fire alarm lights
malfunctioned. Fire alarms and all fire-related apparatus need
to be regularly inspected and certified to be in working
condition. More disturbing, staff did not know how to shut off
the warning horn or the annunciator. The maintenance man was
called in from home to shut the systems off. Although all of the
pods were monitored by staff during the drill, some staff
appeared confused about their responsibilities. Inmates ignored

An annunciator board is an electronic display which
monitors the status of the fire alarm system. In the case of
Wilson, it is located in the control center.

- 32 

the alarm (which they did not know was a drill) completely by
continuing to watch television or remaining asleep on their cots
in the open areas of the pod, while staff simply walked past the
inmates making no effort to alert them to emergency protocols.
One inmate told us, “We don’t really know what to do if there was
a fire.” Staff could not answer basic questions concerning
scenarios such as how to respond if a fire causes a cell door to
swell and an inmate is trapped inside. In addition, staff could
not readily identify keys that open critical exit points in the
Jail. All staff and inmates must be knowledgeable of fire
evacuation plans and must participate in drills.
Although no flammable, toxic or caustic materials were found
inside of the Jail, they were openly stored under a stairwell
immediately next to the front entrance of it. Gas powered tools
were also stored there. This area is easily accessible to
visitors and anyone walking around the open perimeter of the
Jail. All flammable equipment should be inventoried and kept
under lock and key outside of the building in a well ventilated
storage shed or compartment.
Furthermore, as noted above, Wilson allows inmates to have
coffee pots, hot burners, and compact disc players in the pods
and in their cells. There is no policy governing the control and
use of these items. Allowing inmates to possess and use such
items without policies and the strict adherence to them is a
security risk for the Jail, as well as a potential fire hazard.


Prison officials must ensure that inmates are protected from
harm and receive adequate food, clothing, and shelter, Farmer v.
Brennan, 511 U.S. 825, 832 (1994). Officials must also ensure
that prisoners are not “deprive[d] . . . of the minimal civilized
measure of life’s necessities.” Rhodes v. Chapman, 452 U.S. 337,
347 (1981).
When we observed a male inmate sorting the laundry, we
noticed an inventory of underwear for the male inmates, but
nothing similar for female inmates. When we asked the inmate
where the inventory for the underclothing for female inmates was
located he responded that there was none. An officer quickly
responded that female inmates were “allowed” to wear their own
underwear but the male inmates must wear only facility clothing.

- 33 

The Jail must acquire sufficient stock of female personal
clothing items for female inmates to wear when their own
underwear is not available, such as when personal items are being
Everywhere we walked in the pods, we observed mattresses
that with frayed and/or cracked vinyl coverings as well as open
tears. Inmates reported using these worn mattresses to hide
contraband, which makes them a security risk in addition to a
sanitation concern. Worn, unsanitary mattresses easily promote
the spread of infection. All worn mattresses should be replaced
as often as necessary.
In order to address the constitutional deficiencies
identified above and protect the constitutional rights of
inmates, Wilson should implement, at a minimum, the following

Medical Care

Designate a health authority who is a licensed and
trained medical professional and qualified to perform
the following duties and responsibilities: supervising
all medical care rendered to inmates; monitoring care
of serious and/or chronic conditions; ensuring that all
inmates receive a health assessment within fourteen
days of intake; conducting clinical encounters with
inmates as appropriate; reviewing and approving all
prescription medication dispensed at the Jail;
approving revised medical intake screening forms and
processes, including confiscated medications upon
arrival; and annually reviewing all policies and
procedures concerning medical or mental health
screening and/or the provision of care.


Increase the services of a physician and/or physician
assistant to an appropriate number of hours per week to
ensure adequate clinical contacts and oversight of the
medical care and services at the Jail. Increase the
nursing staff to ensure that appropriate medical
encounters with the inmates are taking place, are
documented, and properly referred for secondary level
review as appropriate.

- 34 


Develop and implement policies, procedures, protocols
for all medical care and services at the Jail,
including, but not limited to, nursing job description,
medical assistant job description, documentation and
record-keeping, medical triage and physician review,
intake screening, infection control, sick-call, chronic
illness, comprehensive health assessments, medication
administration, mental health, suicide prevention,
detoxification, women's health, quality improvement,
and emergent response.


Develop and implement a program to train all security
staff and medical personnel regarding all policies,
procedures, protocols, and use of emergency equipment.


Develop and implement an appropriate medical intake

screening instrument that identifies observable and

non-observable medical needs, including infectious

diseases, and ensure timely access to the physician

when presenting symptoms requiring such care.


Develop and implement a chronic care program that
ensures timely identifying, tracking and monitoring of
chronic illnesses.


Revise the sick-call system to ensure confidentiality,
prompt delivery and review by medical staff, and
appropriate triage. Remove the disincentives to an
inmate's seeking and receiving necessary medical care
for chronic, pre-existing and/or life-threatening


Develop and implement a formal written plan to prevent
exposure of inmates and staff to contagious diseases,
including, but not limited to TB and MRSA.


Develop and implement a system for monitoring and
reviewing the administration and control of
medications, including documentation and distribution.

- 35 



Mental Health Care

Retain the services of a licensed mental health
provider or community mental health clinic whose
responsibilities will include supervising and providing
mental health care for inmates at the Jail.


Develop and implement an appropriate intake screening
instrument that identifies inmates’ mental health needs
and risks of suicide behavior and ensures timely access
to the mental health professional when presenting
symptoms require such care.


Ensure that all staff are regularly trained regarding
suicide and suicide prevention and that the shift
supervisors take an active role in ensuring that
inmates on suicide watch are adequately monitored.

Protection from Harm

Ensure that inmates and trustees are supervised in the
pods and the food service area with appropriate and
adequate staffing levels.


Develop and implement policies and procedures requiring
all tools, utensils, equipment, flammable materials,
etc. are inventoried and locked down at all times.


Develop and implement policies and procedures requiring
all staff involved in a use of force to write a timely
report regarding the incident.


Develop and implement policies and procedures for
supervisory and/or management review and investigation
for all uses of force to determine whether force was
appropriately used, whether a referral should be made
to a local law enforcement agency or county attorney
for possible criminal action, whether remedial training
is necessary, or whether facility policies should be


Develop a process to track all incidents of use of
force that at a minimum includes the following
information: the inmate(s) name, housing assignment,
date and type of incident, primary and secondary staff

- 36
directly involved, reviewing supervisor, external
reviews and results (if applicable), remedy taken (if
appropriate) and administrative sign-off.

Ensure that all staff are regularly trained regarding
the facility’s use of force policy.


Develop and implement policies and procedures for an
objective classification system that separates inmates
in housing units by classification levels.


Establish a procedure to ensure that inmates do not
possess or have access to contraband.


Secure and repair all exposed electrical wires in the

10.	 Develop and implement policies and procedures for the
effective and accurate maintenance, inventory, and
assignment of chemical and mechanical restraints.
11.	 Develop and implement policies and procedures to ensure
inmates have access to an adequate grievance process.
12.	 Ensure that inmates placed in lock down status are
provided with appropriate due process that has been
developed and implemented in policies and procedures.

Life Safety and Sanitation

Develop and implement adequate policies and procedures
regarding fire prevention including emergency planning
and drills.


Regularly inspect all fire and life safety equipment to
ensure they are in working order.


Inventory and store all flammable, toxic, and caustic
materials in a well ventilated, but locked compartment.

- 37 


Ensure that there is an inventory of underclothing
available for female inmates so that they can at a
minimum have a change of clothing when their personal
items are being laundered.


Inspect and replace as often as needed all frayed and
cracked mattresses.







Please note that this findings letter is a public document.
It will be posted on the Civil Rights Division’s website. While
we will provide a copy of this letter to any individual or entity
upon request, as a matter of courtesy, we will not post this
letter on the Civil Rights Division’s website until ten calendar
days from the date of this letter.
We hope to work with the County in an amicable and
cooperative fashion to resolve our outstanding concerns regarding
Wilson. Assuming there is a spirit of cooperation from the
County and Wilson, we also would be willing to send our expert
consultants’ evaluations of the facility under separate cover.
Although the experts consultants’ evaluations and work do not
necessarily reflect the official conclusions of the Department of
Justice, their observations, analysis, and recommendations
provide further elaboration of the issues discussed in this
letter and offer practical, technical assistance in addressing
We are obligated by statute to advise you that, in the
unexpected event that we are unable to reach a resolution
regarding our concerns, the Attorney General may institute a
lawsuit pursuant to CRIPA 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 are confident that we will be able
to do so in this case. The lawyers assigned to this
investigation will be contacting the facility’s attorney to
discuss this matter in further detail. If you have any questions

- 38 

regarding this letter, please call Shanetta Y. Cutlar, Chief of
the Civil Rights Division’s Special Litigation Section, at (202)
/s/ Wan J. Kim
Wan J. Kim
Assistant Attorney General
cc:	 Mike Jennings, Esq., Wilson County Attorney
Terry Ashe, Wilson County Sheriff
Paul M. O’Brien, United States Attorney,
Middle District of Tennessee