South Carolina Lee Corr Inst Site Visit Report Mental Health 2008
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LLP Re: South Carolina Department of Corrections Lee Correctional Institution Dear Mr. Westbrook During September 15, 16, 2008 we site visited the Lee Correctional Institution (Lee CI) along with Steve Martin, Esq. We received a tour of general population housing units, programming areas (e.g. educational building, gym, dining area etc.), health services unit and the special management unit (which included a "superrnax" section consisting of two wings (four cells per wing). We also had the opportunity to interview M.D. During this site visit Jeffrey L. Metzner M.D. interviewed 12 inmates within the special management unit (SMU) as well as reviewing their mental health records contained in the automated medical records (also known as the CRT). Dr. Metzner also reviewed selected paper records of these inmates. Appendix [ provides a summary of these inmate interviews and data that provided the basis for various findings summarized later in this report. In addition, during this site VISlt, Raymond F. Patterson, M.D., interviewed and/or reviewed the records on an additional inmates housed in general population or crisis cells. Appendix II provides a summary of Dr. Patterson's inmate interviews and record 6. 7. I Institution Health 2 of 14 to use 1. mental health policy, SCDC policy, 3. SCDC intervention policy, 4. SCDC use of torce policy, 5. SCDC inmate classitication policy, 6. SCDC disciplinary policy, 7. SCDC SMU policy, 8. organizational chart for Lee cr, 9. internal audits, 10. job description of Human Services Coordinator I, 11. a document listing the length of stays in the SMU tor inmates at Lee CI and Leiber CI, 12. a January 31, 2007 report entitled" Mission Critical Funding Needs" from the Director of SCDe. 13. the 2006-2007 Agency Accountability Report (September 14,2007). Overview Lee Correctional Institution, which is a level III prison, was opened during 1993. The total inmate count during our site visit was approximately 1740 inmates with 226 inmates receiving mental health services, which represented 13% of the total inmate population. Each of the general population housing units had a capacity of about 256 inmates. The Kershaw housing unit housed 35% of all mental health caseload inmates. The next largest concentration of caseload inmates was in the special management unit where 52 the 248 on the mental health case load. These SMU inmates and 21 all SMU inmates. 1 a room near the did not an unobstructed t'f\l"rf'.C'T r\t1'1('~'" Within the SMU were varIOUS otlice settings that could be used for meeting with caseload inmates. During our exit from the SMU, we briefly talked with two nursing staff entering the SMU They indicated that the morning pill pass usually occurs for the morning pill between 8:30 a.m.-IO a.m., the next pill pass between 2-3 p.m. and the last pill pass after 7:30 p.m. Other Areas We toured the health services unit which does house medically ill inmates on a 24-hour basis, but did not house inmates whose primary problems were mental health related. The health services building also contained otlices for the mental health clinicians, which were used for meeting with case load inmates. We also toured the educational building, recreational building and the Kershaw housing unit. The Kershaw housing unit had a capacity of 256 inmates. Each side of this housing unit had 64 cells. Kershaw Housing Unit The Kershaw Housing Unit is called a "dormitory" as are the other housing units at Lee Correctional Institution but is comprised of two sides designated the North and South side with 64 cells on each side comprised of cells on the lower tier and 32 cells on the upper tier. The majority these cells housed two inmates; however, some these cells only one inmate because of medical disabilities. Although it was reported there is than 1 Services units. on side with on the upper celled but had designation housing with sexual misconduct and found guilty of those offenses and required to wear pink/red jumpsuits. There were approximately inmates housed in this dormitory who were of that designation and several were interviewed during the course of the site visit. Inmates in this dormitory also reported that the East side of the campus was a more chaotic environment in which they had to be careful because there had been inmate on inmate and inmate on statT violence as well as thetts of property. Interview with Janet Woolery, M.D. Dr. During the morning of September 15, 2008 we interviewed has been working at Lee Correctional Institution since January 2008. She works eight hours on Mondays and four hours on Wednesdays. She reported that Dr. provides mental health services as needed, which apparently involved monthly visits to Lee CI. Dr. estimated that she sees 15-17 inmates during Mondays and 8-9 inmates during Wednesdays. Initial sessions generally require about 30 minutes. Follow-up sessions range from 15-30 minutes. She reported that trequency of her visits was as clinically indicated, although all visits were at least once every 90 days. Dr. thought that most visits were once every 90 days. Dr. reported access to the automated medical records during her sessions with inmates. She did not access the paper medical records, which is the only source of the treatment team developed treatment plan, records from Gilliam Psychiatric Hospital and mental health providers the community. I Dr. sees an office with a door open with a correctional nearby. which does not provide for sound privacy. Although she thought this would have an impact on interactions with the inmates, she has not discussed such an impact with them. Dr. has not been in the SMU housing units. She also had minimal involvement with the inmates in the crisis intervention cells within the SMU. Informed consent forms are not used by Dr. She indicated that she does obtain verbal informed consent. She was not aware of any heat plan in place. In fact, Dr. was not familiar with any mental health policies and procedures at Lee CI. It was estimated by Dr. that 80-90% of her caseload inmates meet criteria for a serious mental illness (SMI). She thought that 50-60% of these inmates were receiving antipsychotic medications and another 70-80% receiving mood stabilizing medications. Approximately 60% of these inmates have a coexisting intermittent explosive disorder. ADHD is generally treated with Wellbutrin and Strattera. Dr. estimated that 40 to 50% of the caseload inmates in the SMU were exhibiting psychotic symptoms. Dr. indicated that the MARs are available when she assesses inmates. She was not familiar with any quality improvement process. Dr.' was not involved with any management or policy making roles within the mental health system at Lee CI. She was not involved with either training of correctional officers or supervision of mental health counselors. Dr. reported that she refers 0 to 1 inmate per month to the Gilliam Psychiatric Hospital. She not make referrals to the intermediate care unit. She has visited GPH but not the ICS. She, at will make a referral to the cutters unit. 1 Re: Correctional Institution Health '''''rutf','''' 6 of 14 Dr. In at 4 a.m., noon Findings Significant problems in the mental health system at Lee CI were apparent based on our site visit and review of relevant discovery documents. This report will provide a summary of these problems. The psychiatrist staffing allocation is inadequate. Dr. provided 12 hours per week of psychiatrists' time which translates into a .3 FTE position. It was unclear how based on intormation received from Dr. much time is provided by Dr. Assuming that Dr. provides eight hours of psychiatric services per month, the total FTE psychiatrist time would be increased by only 0.05 FTE to .35 FTE. A task force report by the American Psychiatric Association (American Psychiatric Association. Psychiatric Services in Jails and Prisons. 2nd edition. Washington, D.C.: American Psychiatric Association, 2000) recommends 1.0 FTE psychiatrist for every ISO inmates prescribed psychotropic medications. It is likely that at least 180 inmates at Lee CI were prescribed psychotropic medications. Unfortunately the exact number was not obtainable during our site visit related to the lack of an adequate management intormation system at Lee CI. In addition, there are problems associated with the use of the psychiatrist, which may be related to the staffing allocation issue. These problems include the psychiatrist's lack of familiarity with relevant policies and procedures, lack of input into pertinent policy decisions, minimal involvement with the treatment planning process, lack of significant involvement with inmates on crisis intervention status and use of the automated medical records exclusively in contrast to supplementing its use with the paper medical record that includes relevant information from providers including the Gilliam Psychiatric Hospital and various community mental health ", .."."n when the in the SMU was used for clinical contacts, as was almost always , adequate sound privacy was absent due to the close proximity the case with Dr. of the correctional otlicers with the door open, which clearly had a negative effect from the perspective of inmates being willing to discuss sensitive and/or confidential information with the psychiatrist. Such a concern \vas uniformly expressed by the inmates interviewed in the SMU. There was an excessive use of torce (e.g., pepper spray and the restraint chair) on inmates with mental illness in the SMU, which is summarized in the report by Steve Martin, Esq. The lack of a mental health policy and procedure relevant to the use of restraints for inmates with mental illness as well as the lack of interventions as clinically appropriate is below the standard of care tor a correetional mental health system. Crisis Intervention Cells SCDC policy/procedure HS 19.01 (placement of inmates in crisis intervention status) (November 1, 2007) was reviewed, which included the following provisions: In order to provide for the safe and humane treatment and care of inmates, the SCDC will develop and implement procedures whereby inmates who appear to be suffering from a mental health disorder or problem may be separated from the general population and placed in Crisis Intervention (CI) status evaluation or in appropriate inpatient facilities .... 1 as C[ status can only are apparently not as reports occasionally forms, although she reported no knovvledge of how forms are used, policy requirements, or formal Treatment Team meetings with the counselors or inmates. The policy further requires inmates be placed in a suicide gown and given a suicide blanket; however, we were informed there is a subsequent Further, SCDC policy that prohibits provision of paper gowns to inmates. policy/procedure HS-19.03 entitled "Inmate Suicide Prevention and Intervention" requires inmates who are potentially suicidal "will be immediately referred to mental health staff. .. " This policy also states that when an inmate is determined as clearly a danger to him/herseIt: medical statT will initiate an inpatient admission and if no beds are available at the appropriate inpatient psychiatric facility, the inmate will be admitted to the designated Intirmary on crisis intervention status. The policy continues that if no beds are available at the inpatient psychiatric facility or the designated intirmary, the inmate will be transferred to an area designated tor crisis intervention. This policy also requires provision of the paper gown to the inmate. Further, it provides that the type of suicide watch (continuous observation or IS-minute \vatch) will be determined at the discretion of the Clinical Correctional Counselor or protessional healthcare staff The requirements of these policies are not being met, and the designation of Clinical Correctional Counselor to determine types of suicide watch exceeds their training and credentials. Neither policy requires direct participation of the psychiatrist in these determinations. Although mental health staff reportedly was required to see inmates on crisis intervention status on a daily basis, inmates reported that they were not seen daily Monday through Friday, which appeared to be confirmed by a review of various medical records of on such status. Finally, the had little to no involvement with inmates placed on intervention status. so, or more. was placed in chair fur is minimal mental health staff been comacted or have interviewed inmate to determine the appropriateness what appears to a punitive practice without regard for the inmate's mental status at the time. The Disciplinary Hearing Officer (DHO) responsible for reviewing the charges placed against inmates sometimes is provided with a mental health assessment of whether the inmate's mental state had any relevance to the charges and opinion as to whether or not the inmate should be held responsible for the behavior resulting in the charges. Based on discussion with statl and inmates, and review of the records, this practice appears to be inconsistent and the assessments provided by the counselors do not include a direct examination of the inmate pertaining to the specific charge. Several inmates who have received various charges were in active mental health treatment, including prescribed medications (which they mayor may not have been receiving) at the time of the charge. Once again, the psychiatrist is not involved in this process. An additional disciplinary practice is the requirement for inmates who have been found guilty of sexual misconduct to wear pink jumpsuits. There were approximately 25 inmates in this category at the time of the site visit Discussion with statl and inmates and review of the records revealed that none of these inmates were formally assessed for the presence of a mental illness or disorder that may have contributed to their sexually inappropriate behaviors, and none have received specific treatment to address these behaviors. Treatment Planning Population medical, which includes the inmate as Lee Correctional Institution. The population inmates is through the staff request can be dropped into the staff request box which is a UH",,-.n,,,, were many of which appeared to have recently been ,,,,try,,,.,-n andlor updated in anticipation of onr site visit. Unfortunately, these treatment plans were not individualized and clinically were not very meaningfuL The psychiatrist was not part the team treatment planning meetings and was not even aware of the treatment planning form that was present in the paper medical record. Diagnostic Issues Contributing to the lack of meaningful treatment plans was inaccurate diagnoses and significant in without adequate documentation, both of which aot)earea to be to multiple causes included the following: 1. Correctional Institution Mental Services 11 14 It was also significant that despite inmates diagnosed with Appendix I). their treatment plans did not list issues associated with this problem list or formulate appropriate interventions. Ul~'OLJlVJ.1J l'vfedication iHanagement Issues Inmates clearly reported, and review of medication administration records confirmed, the presence of medication management issues that included gaps in medication administration (i.e., days when they are not administered for reasons that we could not discern based on record review) and medication non-adherence not being addressed in a timely manner. In addition, despite Dr. 's perception that she has clinical contacts with mental health case load inmates receiving psychotropic medications at least every 90 days, it was clear from review of records and inmate interviews that such was not the case. In other words, it was not ditlicult to identify inmates who were not receiving timely follow-up by the psychiatrist. Quality Improvement The lack of any quality improvement process at Lee CI is very concerning but, in part, explains some of the deficiencies in the mental health system. This problem is exacerbated by the absence of an adequate management information system as evidenced by the representation from Will Davidson, Esq that the Lee Correctional Institution was unable to produce a list in a timely manner of all caseload inmates sorted by housing location, let alone by diagnoses or psychotropic medication use. Without such a much more dit1icult to evaluate both mental health management tool, it processes and outcomes. It is not that in two days we were able to identify were not if can answer 1 Lee Correctional Institution Re: Mental Health Services Page 12 ofI4 Jeffrey L. Metzner, M.D. Raymond Patterson, M.D. 1 I Correctional Institution Re: Mental Health Services 14 14 II 1 at Special Management Unit L Inmate I reported is seen at the cell front his mental health counselor, whom not Hnd to be helpful related to his background as a correctional officer prior to being a mental health counselor. He reported that he has been in the SMU tor years and in the supermax section for about the past three months. Inmate I stated that he does not have access to showers or recreational yard. He reported that he and another inmate were recently "cleaned up" by the correctional staff prior to our site visit. The healthcare record of this inmate was briefly reviewed. Dr. last saw this inmate during May 21, 2008. Her note included the following: "I'm doing better with the meds. I would like my Tegretol back." Inmate 1 was noted to be in lockup related to sexual charges. His diagnosis was intermittent explosive disorder. Medications included thioridazine, Zoloft and Cogentin. He has not been seen by Dr. since May 2008. He has been seen on a monthly basis by mental health counselor His previous visit with a psychiatrist was August 29,2006 A July 30, 2008 note by Mr. indicated that the session focused on medication compliance, expected behaviors and necessary changes. He was seen at the ceUtront Inmate 1 had a history of prior treatment at the Gilliam Psychiatric HospitaL He reported a history of physical altercations with correctional officers. Diagnoses at GPH included schizoaffective disorder, bipolar type, alcohol abuse, cannabis abuse and moderate mental retardation. Inmate 1 reported being able to read and vvrite. history included special education and completion of the eighth grade. SMU at Lee CI 2. Inmate 2 behavior Medications include and Tegretol, which he reported taking due to hyperactivity and He thought the medications were somewhat helpful. Inmate 2 estimated that he saw the psychiatrist about 90 days in an office setting that did not allow for sound privacy. He meets with his mental health counselor at the cellfront for 10-15 minutes on about a monthly basis. Inmate 2 reported infrequent access to the recreational yard. Access to showers reportedly ranged from weekly to three times per week depending on various factors. Inmate 2 reported issues with medication continuity. He stated that about two months ago he was without Zoloft for one week because the institution ran out of this medication. He also indicated that periodically medications are not delivered related to various yard disturbances. The healthcare record of this inmate was reviewed. An August 25, 2008 note by Dr. contlrmed his history that he had refused to come to a scheduled appointment. He was rescheduled to see Dr. His previous appointment with Dr. was during March 3, 2008. Inmate 2 reported at that time that he was not receiving his medications on a consistent basis. He appeared disheveled in appearance and was very loud and aggressive in his presentation. Tegretol, Zoloft and Inderal were restarted. He was to be seen again in 90 days. The last documented counseling session with his mental health counselor was dated August 19, 2008, when he was seen in the supermax area within SMU. note dated July 2008 indicated the intermittent I with Page 3 of 18 Inmates at Lee CI The healthcare record of this inmate was reviewed. His last meeting with Dr. was during August 2008, when he reported getting gassed due to outbursts of on the door. He was described as feeling agitated and was noted to be pacing. His presentation was reported to be consistent with an intermittent explosive disorder and a cognitive disorder NOS. His current medications were discontinued and he was started on a trial of Tegretol, Risperdal and Cogentin. A CBC and LFTs were ordered as was a Tegretollevel. The plan was to see him again in 3-4 weeks. The previous session with Dr. was during June 2008. He reported having muscle spasms related to the medication. His Cogentin was increased and Geodon was started. Prolixin was to be decreased and he was to be seen again in four weeks. Dr. met with Inmate 3 during June 1 I, 2008. He was described as a 30-year-old man who was in a crisis cell was after chewing a razor blade. He was not suicidal and did not appear psychotic. His presentation was consistent with an antisocial personality disorder and mental retardation. Prolixin was started. A June 12, 2008 treatment plan included the following: Objective: inmate to become 100% compliant with taking his prescribed medication. Approach: daily medication administration by nursing staff Objective: inmate to refrain from assaultive behaviors Approach: 1: 1 counseling and case management by CCC pm 1 at health counselor were at sound were not present in his medical ,..,,,nr,,,,, Assessment: The discrepancies between his diagnoses were not addressed in any progress notes in his medical record. His conditions of confinement have clearly resulted in periods of exacerbation of his mental health problems, especially when placed on crisis intervention status. 4. Inmate 4 Inmate 4 was a 29-year-old man who has been in prison for eight years and in the SMU tor about 44 days following a tight at Kirkland CI in the ICS. He reported having received treatment in the ICS for about six months. [nmate 4 was being released back to the general population yard during the day of this interview. He was concerned that he would not be able to make it in the yard and wanted to go back to the ICS at Kirkland CI. However, Inmate 4 was told that he will not be able to return to the ICS. Inmate 4 indicated that he has not had access to the recreational yard because he has either been asleep or too tired to stand during count time. He also has not been showering until very recently due to a reaction (I.e., itching) his body has to the available state soap. His lack of showering was consistent with a September 10, 2008 progress note. The healthcare record of this inmate was reviewed. A March 21, 2008 counseling note indicated a diagnosis of schizophrenia, unditlerentiated. Medication compliance was to be continuously monitored. Dr. renewed Risperdal 1 mg po hs during March 31, 2008. He attended a "living with schizophrenia" group during April 2008. II Appendix I with SMU Inmates at Lee CI 18 "'1H'\1'<O VHUl",",'" During 2008 to out of the ICS. pled to ofa 4 was evaluated by upon his transfer to CI 2008. He reported medications at ICS with He wanted to retum the ICS but was advised that he was not likely to return due to the behavioral problems he had caused. September 9, 2008 note indicated that he was due for his Risperdal Consta shot but Kirkland CI had not sent his medication with him to Lee CI. This medication was renewed that same day. He eventually received this injection during September 1 2008. A September 11, 2008 treatment team review indicated the diagnosis of schizophrenia, undifferentiated, by history and intermittent explosive disorder by history. Assessment: This inmate's history was consistent with a diagnosis of a chronic schizophrenia, which appeared to have responded reasonably well to treatment in an ICS environment. His current treatment plan was not adequate. Inmate 4 has experienced some medication continuity disruption following his transfer to Lee CI and has not yet met with a psychiatrist. 5. Inmate 5 [nmate 5 was a 39-year-old man who reported that he has been in the SMU for about 14 days. He cut himself today (September 15, 2008) because he was unsuccessful in his attempts to obtain a Bible. He reported that he has Hepatitis C but was not receiving treatment for Hepatitis C because his length of incarceration was reportedly too short to be eligible for such treatment. roommate a A July 11, 2008 note indicated that two 1 Appendix I withSMU 18 at CI note a 2008. 5's was with an intennittent disorder. His medications were continued and doxepin added. However. BuSpar was ordered in contrast to doxepin. Dr. met with Inmate 5 during March 24, 2008. His presentation was consistent with a borderline personality disorder, dependent personality disorder and history of polysubstance abuse. Seroquel 400 mg po qd was prescribed. lIe was to be seen again in 90 days by the psychiatrist. during December 28, 2007. Meds were refilled (Risperdal and Seroquel) by Dr. Other meds prescribed during the past year have included Dilantin and Depakote. Liver function tests were ordered during January 29, 2008. Inmate 5 also reported medication continuity problems. Specitically, he reported two days last week he did not receive this evening dosage of Seroquel, which was continned by review of the MAR. He reported lack of access to yard or showers for the past 15 days. Review of a May 9, 2001 discharge summary from Gilliam Psychiatric Hospital indicated discharge diagnoses of bipolar disorder not otherwise specified, alcohol dependence and antisocial personality disorder. Assessment: Inmate 5's presentation was fairly confusing based on a review of his healthcare record although it to be consistent with a diagnosis of borderline He medical problems \\hich are 1 Appendix I with SMU Inmates at 18 He the as to him. The record inmate was 6 had been transterred from Gilliam Psychiatric Hospital to CI during August 2008. He initially was transterred to GPH during February 2008 after cutting his abdomen in an attempt to kill himself. The most recent mental health counseling note was dated September 11, 2008, which was a treatment team review. His diagnosis was psychotic disorder NOS due to ecstasy use. Medications prescribed included Remeron and Invega. The treatment plan, which was reviewed, was not specified in the CRT. The most recent note by a psychiatrist was written by M.D. during August 1 2008. The note indicated that he had stopped taking medications when he came to Lee CI. He reportedly had trouble dealing with his lite sentence and could not sleep because he did not have a mattress. Auditory and visual hallucinations were present. He was encouraged to take his medications. Review of the paper chart revealed the presence of a medical screening torm upon admission that included questions relevant to suicide and medications. A September 10, 2008 treatment plan was revievved that included the following: Objective: Inmate to be evaluated by the psychiatrist. Approach: Inmate to see psychiatrist pm Inmate to retrain trom any drug use. Approach: 1: 1 counseling and case management A July 14, 2008 discharge summary from Gilliam Psychiatric Hospital was reviewed. summary included psychotic disorder due to malingering, personality disorder and narcissistic personality disorder. His self... mutilation to to 7 Appendix I at CI the Youthful This was prescribed Tegretol for problems, which he thought was somewhat helpful. Inmate 7 reported seeing a psychiatrist in a private office setting about 30 days but did not think he was seeing a mental health counselor. The healthcare record of this inmate was reviewed. The most recent appointments with the psychiatrists were during April 21 and July 28, 2008. His presentation was consistent with an intermittent explosive disorder. Dr. prescribed carbamazepine. Results of a carbamazepine blood level were reported during July 28, 2008. His last session with a mental health counselor was dated November 29, 2007. Assessment: It is unclear why he has not been seen on a regular basis by mental health counselor. Inmate 7 reported that he is put in request to seek counsel without results. 8. Inmate 8 This inmate is a 33-year-old Caucasian man who has been incarcerated for the past 13 years and in the SMU for nine months. He initially was transferred to the SMU following a fist fight but his received more time related to problems with the correctional officers. He has been prescribed Paxil since meeting for the tirst and only time with a psychiatrist during June 2008. He reported a family history of bipolar disorder and a past history of posttraumatic stress disorder. \DDlenOlx I at CI 2008 note was consistent with this report of discontinuing An his medication. In addition to his diagnosis he was noted to be extremely antisocial. An 19,2008 note indicates that his August MAR was checked for compliance which indicated that he accepted all doses. Inmate 8 indicated that he was accepting the medications but not taking them. He stated that he eventually would throw these medications away. A September 2, 2008 progress note included the following: Hwhen asked about his refusal to see psych M.D. & if he was willing to continue mental health follow-up-he never gave a straight ans\ver. CCC discussed at length his med compliance and compliance with treatment as well as behavioral problems. Inmate was receptive .... " The treatment plan included a psychiatric consultation as well as potential discharge for mental health serVIces. Assessment: It is unclear why he has not been seen by psychiatrist either per the June 2008 plan or related to his medication noncompliance. He has not been receiving timely follow-up by the psychiatrist. 9. Inmate 9 Inmate 9 was a 25-year-old man who has been in prison for two years and in the SMU for one year. He had been any supermax section for 3.5 months until July 2008. He has been receiving Seroquel tor a sleep disturbance and agitation. Inmate 9 also reported that this medication helps his tendency to "flip out real fast." 1 at CI IHUl\.aLvu a past March 2007 Inmate 9 was placed in the SMU following a verbal confrontation with unit He was described as being upset and during April to, 2007, which appeared to be related to his lockup status. His diagnosis remained unchanged during April 1 2007. Psychological testing was scheduled during April 17, 2007. Haldol continued to be prescribed during April 2007. He was scheduled to be released back to general population during April 26, 2007. At his request Haldol was being tapered during May 2007. Malingering was also considered at that time. A note dated May 22, 2007 indicated that his Haldol had been discontinued. Malingering was now considered to be the likely diagnosis by M.D. However, there was no supportive documentation concerning such a diagnosis. Mild mental retardation was also diagnosed. It appears that he was seen during June 20, 2007 in order to consider discharge from the behavioral mental health services. Psychological testing yielded an IQ range of 57-64. Additional charges were described during July 23, 2007. The diagnosis of intermittent explosive disorder was made and a trial ofTegretol was started. Inmate 9 was placed back on the mental health caseload during August 2007. Information obtained from a DDSN caseworker indicated that he had been diagnosed as having schizophrenia at a community mental health center. However, an August 2007 note indicated no evidence of symptoms consistent with this diagnosis during his current incarceration. were I Appendix I 1111""'-''' at Lee CI March 31, 2008 note indicated that his constant behavioral problems resulted in to the supermax section. He reported he had cups of urine, feces and milk threatening to throw on officers. Dr. evaluated this inmate during April 1 2008. She noted a history of psychosis and current diagnosis of intermittent explosive disorder. He was again seen by Dr. during July 7, 2008. Little change was noted. He was continued on Seroquel. Pepper spray was again used during August 3, 2008. During August 12,2008 he was no longer in the supermax section of the SMU. He had been disciplinary free for almost 5 months. A CCC treatment team note, which was dated August 15, 2008, indicated that his diagnosis was intermittent explosive disorder. Seroquel continue to be prescribed. Inmate 9 was receiving an outpatient mental health level of care. The treatment plan listed intermittent explosive disorder as his only problem with the clinical objective being discontinue sexually inappropriate behavior and the approach being psychiatric clinic p.r.n. and daily medication as given by nursing statf as well as 1: 1 counseling and case management. This inmate's paper medical record was reviewed, which included a June 2005 discharge summary from the Columbia Care Center, Just Care. Following a hospitalization of about included schizophrenia, difIerentiated type, 1 at CI as included Depakote, Inmate 10 reported that his cellfront meetings with his mental health counselor were not helpful due to lack of adequate privacy. He has better privacy, but still not adequate sound privacy, during his clinical contacts with the psychiatrist. The healthcare record of this inmate was reviewed. A December 28, 2005 progress note indicated a history of bipolar I disorder and antisocial personality disorder. He was referred to the Seneca area mental health center. Inmate 10 was scheduled for release from SCDC during January 2006. A January 10, 2008 progress note at Kirkland CI indicated a past history of anger issues and bipolar disorder. He had been treated in the past with Ritalin related to behavioral problems at school. M.D. \vho diagnosed Seroquel was started during March 25, 2008 by borderline personality disorder, attention deficit hyperactivity disorder, and a history of marijuana abuse. An intake assessment at Lee CI was performed during April 4, 2008. His past history with anger problems was noted. His diagnosis was unchanged. An April 11, 2008 initial treatment team note was consistent with the previous progress note. The treatment plan, contained in the paper medical record, included the following: Objective: inmate to remain 1 psychotropic medication. compliant with taking his prescribed 1 Appendix I with 18 at Lee CI to see a counselor were to his mental Inmate 10 indicated he was in the crisis cells tor two weeks but only seen by a mental health counselor on two occasions. Inmate 10 also reported that he was no clothes or blankets or a mattress tor the first two days in the crisis celL However, a progress note 2008. in the CRT indicated that he was discharged from the crisis cell during July Review of the paper medical record indicated that crisis intervention status was discontinued during July 3, 2008 and his personal belongings were to be returned. Subsequent progress notes \vere consistent with Inmate 10 telling statT that he was concerned about his surroundings and that he again received a charge for refusing to obey an order. During August 7, 2008 Inmate 10 requested to see the psychiatrist due to problems with his medications. He also requested transfer to the intermediate care services program but was told that he was too high functioning to be sent to this program. An appointment with the psychiatrist was to be scheduled. M.D. evaluated Inmate 10 during August 12,2008. His presentation was consistent with a mood disorder NOS. Navane was discontinued and Prolixin and Paxil started. Laboratory studies were ordered but were refused by the Inmate 10. Inmate 10 stated he did not refuse to have his blood drawn. Dr. his again saw this inmate during September 16, 2008. Labs were reordered and continued. 11. Inmate 11 11 at nrc)lzram was was ,""V"hW"'''~ was tapered at that time. in the MOd,rt"" magm)SlS during May 17,2006. Risperdal A June 2008 note that Dr. renewed RisperdaL Inmate 11 was placed in the intervention related to suicidal thinking during July 9, 2008. Subsequent notes were dated July 11, 1 1 I 17, 2008. His intervention cell status was discontinued during July 17,2008. July 2000 eight initial treatment team report indicated the diagnosis of malingering, psychotic disorder NOS and polysubstance dependence. he would would be in Inmates at Lee CI 12. Inmate 12 Inmate 12 was a 23-year-old African-American man who has been incarcerated in SCDe smce and in the SMU since 2004. He reported that he has currently been in the superma.x section four about months. This inmate has been pepper sprayed on numerous occasions as well as having been placed in a restraint chair on multiple occasions. Reference should be made to the report by Steven Martin, Esq. tor a summary of such incidents. Inmate 12 reported chronic eye symptoms that included burning and visual problems. He reported that he has not been assessed by medical related to the symptoms despite requests to receive medical treatment. Inmate 12 reported that his shower, similar to other showers in the supermax section, was nonfunctional. He indicated very limited access to showers, which generally occurred prior to visits with healthcare providers or other official visits. He indicated that he had no access to the outdoor recreational cages. The healthcare record of this inmate was reviewed. An August 12, 2008 note by his M.D. indicated that Inmate 12 stopped taking medication when he returned to Lee CI. His behavioral problems were noted to be related to his Axis II diagnosis. He was also assessed have been a delusional disorder by history as well as an antisocial personality disorder. 2008 following his discharge from inhaler. note a Inmates at Interviews with 16 18 CI note indicated that Inmate 12 was his eyes that continued The plan was to see him as np'>r!p,,~ nr"cu""""" 4, 2008 Inmate 12 drank some cleaning fluid.. He stated that he was feeling unsafe in the prison and wanted to transferred to a hospital.. 2008 following his OPH M.D. evaluated Inmate 12 during January admission. A trial of Tegretol was started and Risperdal was to be tapered.. The diagnoses of intermittent explosive disorder and ADHD were made. Review of his extensive medical record indicated repeated admissions to the intervention unit and assessments by an LPN following use of pepper spray. He was evaluated by CfISIS NP III during December 23 come 2007 due to a sty. A December 21, 2007 treatment team initial note indicated diagnosis of delusional disorder, purse to retype.. Medications included Risperdal and BenadryL A one year prescription for clonidine was written by December 5,2007. , NP III during Inmate 12 was admitted to GPH during September 26, 2007. He was subsequently discharged during November 26,2007. Delusional symptoms were described. Risperdal \vas prescribed. The April 29, 2008 discharge summary from Gilliam Psychiatric Hospital was reviewed. This summary included the following information: 1 with 18 at Lee CI a Due to including was injections of Prolixin and 2008. His behavior Benadryl education on April 10. I and April became calmer and more cooperative and the severity of his paranoid and persecutory ideation decreased after he received each injection. After receiving these injections Inmate 12 became more consistently compliant with oral medications. On April 18, 2008 writer pointed out to Inmate 12 that appears to have better control over his behavior and does not get in trouble as much when he takes his psychiatric medication as prescribed versus when he does not take his medication. Inmate 12 agreed and said his getting fewer disciplinary write-ups \vas the benetit of the taking medication. However, he complained that the medication makes him very sleepy ... He voiced some paranoid ideation about staff being against him but the severity and frequency of his paranoid ideation had decreased ... He described his mood as good but admitted he is quite anxious to be discharged from GPH so that he may return to Lee CI to resume working on his legal paperwork. Discharge medications included Risperdal 3 mg po bid, clonidine 0.1 mg po bid, Cogentin, Prolixin 5 mg and Benadryl 50 mg 1M q 8 hours p.r.n. agitation, Albuterol inhaler, Motrin and Ketlex. Discharge diagnoses include a delusional disorder, persecutory, alcohol dependence by history, cannabis dependence by history, antisocial personality disorder, and history of asthma and history of hypertension. PLT.Jl72a II South Appendix II Lee Correctional Institution Inmates Interviewed and/or Records Reviewed 13. This inmate was a 45-year-old male who reported that he had been in treatment for 8-10 and possibly more because of an ArLxiety Disorder. He reports that he had been housed in the Kershaw dorm for the past two years after his transfer from Perry State Prison. He reported that when he was initially transferred from Perry to Lee he was transferred to the lock-up unit and he had been receiving treatment for his mental health problem and asthma \vhile at Perry. He reported that he did not see anyone from the mental health department tor the first two months after his transfer from Perry to Lee and that he went from the lock-up unit (SMU) to Darlington dormitory. He also reported that prior to his incarceration at Lee he had been in the res program at Kirkland for approximately one year. He reported that he has a history of Anxiety Disorder and "sticking myself' with various objects including paper clips. He reported that he last inserted a paper clip into his stomach on 7/23/07. He reported that he wrote a letter to the Warden on 7/30/07 and got a response from the Warden on 8/10/07 which he displayed during the interview. In his handwritten letter to the Warden he requested that the paper clip be removed from his stomach because he was feeling pain and the response from the Warden indicated that this would be referred to the medical department. He reported that he was told by the medical department on 8/10/07 they would leave the paper clip in place to "teach you a lesson". He stated the physician in the medical department told him they would not remove the paper clip because he would only insert another paper clip. is his With regard to his current treatment at Lee, this inmate reported that Ms. counselor and that he sees her approximately every two to three months. He reports that he attends a stress management group but it was cancelled four of the eight times that it was scheduled. He also reported that Ms. has stated to him that the counselors are inmates off the caseload because there are "too many people". He reported that he to to outpatient status as he currently is on area mental health status because to do his Klonopin in discontinued and his Anxiety Disorder will become out of control behaviors (sticking himselt) and a return of the bruises and sores that he displayed on pictures in his property. Also, there is no documented evidence in the record that the inmate provided written informed consent to any of the medications that he is prescribed. Assessment: This imnate has been prescribed Klonopin for a clearly documented Anxiety Disorder which should be continued as well as Wellbutrin for his depression. He is extraordinarily frightened that should there be any further pursuit of removing the paper clip that remains in his stomach for over one year, there will be repercussions against him which would include taking his much needed medication away from him. There was not evidence in his record that there was participation by a psychiatrist or by medical staff in the treatment planning efforts to manage his overall mental and medical health. 14. This inmate reported that he had been housed at Lee for the past 15 months and recalled having met with me during a previous site visit when he was housed at Kirkland. The inmate reported he is currently receiving Navane 10 mgs and has been receiving mental health care since 1984. He also stated he has medical problems including hypertension for which he takes thrce pills and diabetes which he stated is "ok" although he reported weighing 320 pounds. He reported he has in addition to his other medical problems, sleep apnea, but stated "they don't treat it here". When asked what he meant he stated that he had been prescribed Ambien by a physician but the Ambien has not been given to him \vhile at and there are no provisions for any type of C-PAP or other breathing apparatus to his apnea. out for three to elaborate, he to pill line, he is told by he will and until it is his medical record demonstrates he is prescribed Trit1uoperazine 20 mgs HS and received his medications appropriately for the month of August 2008. However in July and June 2008, there are multiple blanks on the MARs indicating he did not receive his medications as prescribed. Also, in the review of the record, there is no documented evidence the inmate provided written informed consent for any of the medications he is prescribed. Assessment: This inmate's care and treatment are inadequate and there is not an interface between mental health and medical stafTto appropriately treat his schizophrenia, hypertension, obesity, diabetes and sleep apnea. Further, he weighs 320 pounds and a review of his record does not demonstrate any planned efforts to reduce his weight to potentially help with his medical conditions. 15. This inmate is a 36-year-old male who reported he was transferred from Lieber c.r. to Lee C.L in April 2006. He reported he has been receiving mental health care since he was age 11 and has been receiving mental health care in the SCDC since 2001. The inmate reported he is currently prescribed Celexa which was ordered 2 ~ to four weeks prior to this interview but stated that he has yet to receive the Celexa that was ordered by the psychiatrist. He also reported he does receive Geodon 200 mgs each day for the past few years but that he has signed refusals and the medication has been changed. He reported that since his signing a refusal he has been charged for the medications but he is not supposed to be. He stated he is also a member of the IRC Board. and he spoken with him about that he would check with the nurses, the at are no at IS a when are distribution because the nurses don't come to dormitory so that medications are missed for the one or two Also, in the review the record, there is no documented evidence the inmate provided written informed consent to any the medications that he is prescribed. This inmate offered spontaneously "yesterday a man died". When asked what had occurred, the inmate gave the name of the inmate who he believes died because of complications of diabetes. He stated the inmate who died was diabetic and had blood sugars over 300 and the "pusher" (an inmate who pushes another inmate's wheelchair), found this inmate in his room taced down and clammy. He reported that prior to this, the inmate who died had been given a shot by medical and sent back to his unit and after lunch the inmate was found by the pusher and when custody statf responded the inmate had no pulse. This inmate reported that no nurse responded for approximately 20 minutes and a lieutenant was giving the inmate CPR while the nurse "was not in a hurry to get here". The inmate stated he had corresponded with the Nelson Mullins law tirm in the past and they should expect a letter from him describing the problems that he believed \vere responsible for the other inmate's death. When asked what he thought would improve the mental health problem, this inmate stated "training tor COs and mental health" and a "core program" and "staff'. When asked to elaborate on these items, the inmate stated the correctional ofticers are disrespectful to the mentally ill inmates and don't have a basic understanding of mental illness, there is no designated program for the treatment of inmates at Lee and he made references to programs he had encountered while incarcerated in the State of Georgia, and there are inadequate numbers of staff in the mental health program. 176 are in a wheelchair, but "claustrophobia". The inmate reported he requested psychiatrist transfer him to another unit or his door be left unlocked as it had been prior to a lawsuit tiled by another who had had some of his property stolen. This inmate reported, "security keeps locking my door" and he has tiled a grievance. He reported the Warden stated all the doors have to be locked because of the lawsuit tiled by another inmate. He reported further the "West Side is better, no robberies in Kershaw" and expressed his opinion that all of the donns should not be penalized because of the occurrence of a robbery in one of the donns that took place on the East Side of the facility. I asked this inmate what he had done in addition to tiling a grievance and he stated he had talked to his counselor Mr. and he believes the counselor is trying to help him but to date there has been no change in his door being locked which causes him great anxiety as he is claustrophobic. This inmate also offered, "guy died here yesterday". When asked what he meant, he stated the other inmate had been sent to medical and "they sent him right back", and the other inmate subsequently died in his cell. I asked him specifically about his contacts with mental health statf and he reported he sees his counselor every month and a psychiatrist every two months. The inmate then offered that his major problems are with custody statf because he stated custody stafr'sometimes won't open the door to let us out". He continued that custody "let us out when they feel like they enough officers". He stated that when the custody is are locked in their and the doors are not r\ru~n"'n for them to circulate in the by the treatment is not him health, medical in his case custody claustrophobia 24 hour medical status. He reported his anti-anxiety medication has been progressively increased since he has been at Lee his complaints of claustrophobia and there are certainly other interventions could be operationalized for his specific management including management of the locked doors and/or transfer to another facility that could better address his mental health and medical needs. 17. This inmate reported he has been incarcerated at Lee since 2005 when he was admitted to the SCDC from a county facility. He reported he is classitied at the M3 level of care and he is currently receiving Vistaril, Clonidine, loloft and two other medications that he could not recall. He reported he was initially on the East yard but was moved to the West yard and has resided in Kershaw since movement to the West yard. He reported with regard to his medications that he is being weaned from his loloft: and he was very concerned because his previous prescription for Fluoxetine was not working. He stated Dr. is making these medication changes and during the course of his description became progressively more anxious and began crying. This inmate currently works in an oftice and attends a horticulture program and believes these are helpful in maintaining his mental stability. With regard to the mental health program he reported he has attended groups including Stress Management and Anger Management and in those groups there were 10-15 inmates. He reported there are new groups "every once in a while" and stated his opinion groups are "not helpful". When asked to elaborate, he stated the groups are number inmates, some of whom dominate the groups by that don't to much at aiL He stated has not seen I record indicates he was transferred from the Kirkland R&E on Vistaril ,md medications at that time ",.:ere Clonidine. of 9/05 indicated the inmate was on also had a history of suicidal behaviors and currently, as well as a The treatment plans of 1 I 1111 9/06, were all a and indicated the inmate was outpatient mental health His were noted as Dysthymic Disorder, Generalized Anxiety Disorder, and Attention Deficit Hyperactivity Disorder. The staff's assessment of the "problem" was symptoms of paranoia. crying spells, OeD behavior and sporadic compliance with treatment with the "objectives" to be 100% compliance with medication and the use of depression management tools as well as for the inmate to vent/admit feelings of anger. The "approach" was for the counselor to see the inmate and provide case management services pm and to approach the psychiatrist pm, for each of these treatment plans. The most recent treatment plan was a six-month treatment plan update that identified essentially the same problems and objectives with the approaches for the psychiatrist clinic pm, one to one counseling and case management by CCC, group, and the nurse to administer medications. The MARs for August had blanks for Clonidine for four days, Zoloft for five days, Prozac refusals for two days and blanks tor three others. In July the inmate was noted to have no showed for Zoloft on two days with a blank tor administration of Zoloft on one morning. In July there were also two Zoloft orders, one for 100 mgs TID and a second for 200 mgs HS with the indication that the inmate would be getting 400 mgs a day however it appears that he may have gotten 500 mgs per day because the a.m. dosage had not been stopped. There were frequent no shows noted, for the noon dosages of Zoloft so that the inmate was getting 100 mgs at noon when he appeared and 300 mgs in the p.m. in July. [n June 2008 both the inmate's Klonopin and Zoloft expired on 6/8/08 but he appears from the MARs to have continued receiving the Klonopin through 6111 and the Zoloft through 6/17. However, after 6/9/08 the inmate did not appear (did not show), for Zoloft 1 times and Clonidine 15+ times. In May 2008 the inmate did not show or there were blanks for all of his medications in the a.m. and multiple blanks in the MAR tor his noon dosages of medication. Also, in the review of record, there is no documented evidence that the inmate provided written intonned consent to the medications that he is prescribed. ' - " " A U J '..d V On interview, inmates reported they had all been in the facility for a two to months with the exception one who had been in facility \Vhen asked about their treatment from the mental health program, all of for two the inmates reported that their medications have expired for two to three days up to three to four weeks at the times when their medications are to be renewed. They reported when they approached the nurses on the pill lines, they are told the medications have not been reordered and that they cannot be dispensed until they are reordered. Several inmates, however, reported that they have observed nurses "borrowing" medications from another inmate's box when their specifIc medications have not been reordered. The inmates reported there are times when the custody staff "don't call pill line -lock down". They also reported that if an inmate is sleeping he may miss the piIlline and that the times for the pill line varies widely such that the a.m. pill line can be any time trom 4:00 a.m. to 7:00 a.m., the noon pill line begins at approximately 10:30 a.m. to 12 noon, and the p.m. pill line begins at 4:00 p.m. for diabetics and 5:00 p.m. to 6:30 p.m. for other inmates with an 8:00 p.m. to 9:00 p.m. pill line for some inmates although these inmates reported that none of them receive their medications that late. They reported that the problem with lockdowns is signitlcant in that nurses don't come to the dormitories for the tlrst or second day and that they will bring pills but not liquid medications that have been prescribed for the inmates when they do come to the dormitories. One of the inmates reported that he had been in lock up in the SMU and he did not get his medications until the next day or two atler he had been placed in lock up. I then asked the inmates about other components in the mental health program including group therapies as all of these inmates had been selected because they are listed as being in a group together. The inmates reported that there are "eight classes" that comprise a tor one hour each. with two times per the full the 1 they communicate this infonnation to their treatment and treatment reported there are treatment teams". They elaborated that maybe the mental meets "amongst themselves" and one inmate stated he did have two mental health statY members talk to him at the same time when he was in lock up in 2006 at another facility. \Vhen asked about the accessibility of the mental health stan: the inmates all stated they "got to go through your counselor to get to your psychiatrist", [ asked them about going to the counselor to the psychiatrist and they reported there are considerable delays in that they send a request to the counselor that takes "weeks to respond, then wait to see the psychiatrist", One of the inmates elaborated that ifhe submitted a request on the first day of the month he wouldn't see the counselor for a month and then another appointment with a psychiatrist after that which could take weeks to months, When asked about the statJ request or sick call process the inmates stated there is a "mailbox by the cafeteria put it in on Monday, they pick it up on Wednesday, may see you the next Monday, sometimes three to four weeks from now", Two of the inmates stated that if a specialist was required, it would be two to three and up to six months before they would be seen by a specialist. On observation and interview, this group of seven inmates had a wide range of mental health functioning from low mental health functioning to moderately high mental health functioning, with some inmates having considerable difficulty in expressing themselves and others becoming annoyed with those inmates and overriding what they wanted to say, and the need for there to be redirection to hold their comments until the tirst inmate had tinished making his statements. ( asked the inmates why they thought it took so long to see a counselor or psychiatrist and the from two inmates were "these people don't which was by LU""C",,:>, and another "~I don't know", inmate number the MARs HS for tiS and Perphenazine 12 one and June 1. a Wellbutrin 1 Q AM. the month of MAR recorded he was a no show day except for two. July 2008 he was a no show day tor two and was one blank on the MAR lllU"'-~H"Jl'" the medication had not been For June 2008 he was a no seven I reviewed his MARs and he was prescribed Vistaril 100 mgs TID. For August, July and June 2008 the inmate was a no show for all of his A.M. Vistaril but appeared for his noon and p.m. Vistaril prescriptions. 23. This inmate was prescribed Seroquel200 mgs BID. For August 2008 the MAR recorded 12 no shows and five blanks through August with eight additional no shows or blanks for August 1. For July 2008 the MAR recorded 20 no shows and for June 2008 the MAR recorded 15 no shows. The majority of the no shows for these three months were in the mornings. 24. I reviewed the MARs for his Perphenazine 8 mgs HS which was prescribed in August 2008 and indicated four blanks between August 7-31. For July 2008 he was prescribed Seroquel which the MAR recorded as his having received each time for the month of July however for June 2008 the MAR recorded one blank and 13 no shows tor his Seroquel. Assessment: This group of inmates was selected because they had already been placed in a group therapy. Remarkably, the group that they had been placed in was a Medication Management Group and based on my interviews with the inmates as well as my review of several of their MARs in the medical records it appears that medication management is a significant failed component of the treatment process at Lee. All of the inmates reported difficulties in receiving their medications particularly when they are to the indicated that a substantial number 182 important health system. to an in the m one an cell to come out went to the cell to attempt to interview the inmate who IV"''''''''''' his head that he did not want to speak with me. The officer also reported that he would not up for them and although he did stand up and look at me, he shook his head and walked to the back of the celL The inmate was dressed in a jumpsuit and had a suicide proof blanket and reportedly remained on crisis intervention status at the time of the attempted interview. tvu,;:,,-,,, Assessment: I could not assess this inmate based on his refusal to be interviewed. 26. I did interview this inmate who was housed in the SMU in a crisis intervention ceil. I had to wait for a correctional officer to get a jumpsuit for the inmate as he did not have one provided to him as he was on crisis intervention status. When interviewed, the inmate was calm and cooperative and reported to me he had been incarcerated in the SCDC since 2006 and had been transferred to Lee in November 2007. I asked him about his being placed in the crisis cell and he reported this was the second time and that the tirst time had been a few weeks prior when he had cut both of his arms and he demonstrated multiple old cuts on both of his arms. He reported the second time was six days prior to this interview when he had been moved from a SMU cell to the crisis cell because he had threatened to harm himself. When I asked the inmate how long he had been engaged in self-injurious behavior or cutting himselt: he said since age 15 or 16 and he is currently 19 years old. When asked why he does this, he reported he does it because "it relieves the stress". He elaborated he is stressed from not having heard from his family for a couple of months and has been unable to contact them. I asked the inmate ifhe had had mental health treatment in the past and reported he had been placed on Ritalin and when he was eight or old but he wasn't sure how long he stayed on it. He reported that at some point his mother stopped giving it to him. call to at that to have been ADHD. He also a history of behavior by cutting his arms which been well documented and resulted in being placed in the crisis cells twice since his transfer to His counselor making rounds at the cell front but refusing to see him description of outside of the cell or talk with him and his lack of knowledge about how to attempt to access the psychiatrist are in my opinion ret1ections of the poor quality of the intake and assessment process specifically at Lee but quite possibly at Reception as well. This inmate has been placed in the crisis cells twice, has seen the counselor at cell front and yet has not been given a full evaluation to determine his mental health needs or the reasons for his self-injurious behavior. These are inexcusable failures to properly evaluate and quite possibly treat an individual who has a high likelihood of having a serious and persistent mental illness. 27. This inmate was interviewed as he was housed in the SMU in a crisis cell. The inmate reported he is on the mental health caseload and had multiple charges of sexual misconduct. The inmate reported he has been in the SMU for 14 months and has requested protective custody because another inmate had threatened to take his canteen. Since he has been at Lee, he reports he has been charged with sexual misconduct six or seven times and he has been given detention time of six months on each charge. He reported he has been in detention (SMU) for 14 months but has up to 36-42 months total detention time based on these charges. He stated the charges are based on his exposing his penis and masturbating in front of female correctional officers. He got his first two charges of sexual misconduct while he was on the yard and got his tirst six months lockup based on the second charge and has accumulated additional detention time since then. history of having been incarcerated PLT.1184 but he "p,r.ni'''' are for misconduct of the inmate about his continuing to masturbating and reported he does this because he is "trying to relieve my sexual tension - nocturnal emissions". When I asked him since he is single celled why the exposures and he stated "sometimes act without thinking haven't had a charge in a year; still six months detention". tIe reported he plaus to put something up on his window because he has nocturnal emissions but he is not actively exposing himself. I asked the inmate how he would go about obtaining mental health treatment if he felt he needed it, and he stated that he would have to write a stafT request to one of the counselors. He stated he will if he has to and he wants a medication "that will help me without changing up switching". Assessment: This inmate reported he has accumulated years of SMU time based on charges of exposing his penis and masturbation in front of female correctional officers. He reported a history of using bad judgment but also acting without thinking that in my opinion strongly suggest he needs to be evaluated as possibly having a sexual paraphilia i.e., exhibitionism. When seen he was in a pink jumpsuit because inmates who have been found guilty of sexual misconduct are housed in pink jumpsuits for extended periods of time. The stigmatization of this practice and identification of inmates as having sexual misconduct is a system-wide practice. There is however no apparent etTort at evaluating individuals who have repeated sexual misconduct charges such as this inmate for the possibility of a mental disorder that may indeed respond to treatment. Further this inmate a history what appear to be psychotic symptoms aud treatment with anti-psychotic mood medications, none of which he is receiving currently. His aversion to mental health care by his based on his belief that was told lieutenant would move his roommate but thn~atenea to kill or even was admitted to the cell. The been for seven and never a and has never had any history of treatment. He reported he has medication but is concerned that he has no property in the celL He reported does have a thick quilted blanket but no mattress and when on crisis intervention status no clothing, and no paper gown. He reported he sees a mental health counselor walk past the crisis cells once a week or more if there are other people in the cells. He reported he has seen the counselor walk past the crisis cells four times since he has been in the crisis cells tor the past five or six days. This inmate reported he \-\-Tote to the psychiatrist but received no response. He also reported he was told by two counselors that he should sign up for sick call and he has, and when he was seen he was told that he was a drug addict and does not need any mental health services. He reported he has not tiled a grievance even though he has not been placed on the mental health case load and believes that he should be. He reported all of his contacts with the counselor staff have been cell front interviews and speaking with me in an interview room is the tirst time he has talked with a mental health practitioner outside of the cell. Assessment: This inmate is not currently on the mental health caseload although he has requested he be seen by the psychiatrist. He reported the counseling staff have told him that he does not need to be seen by the psychiatrist because he is drug seeking and does not need mental health services. In my opinion, this is an inappropriate judgment for the counseling statf to make and they have not properly evaluated this inmate for his mental health history and mental health needs since his incarceration. He has threatened to cut himself with a razor blade resulting in his being placed in the crisis cell where he has remained despite being taken otf crisis status. The use of the crisis intervention cells is improper and the the mental health staff is inadequate. This inmate is in need of a mental health evaluation by a properly credentialed and trained mental it there are told he was a He reported he has not been except for one incident where he stabbed two reported "I had a major problem with cutting". He added people while at Lieber. He that his counselor "isn't concerned about my mental health or stability she just don't give a damn". [ asked him how often does he see his counselor and he stated he sees his counselor every 60 to 90 days but "the only thing she was interested in was me not bringing her any work she said "well don't cut yourself because I would have to do a bunch of paperwork". He continued "when they do call me up to talk to me, the way I see it they are going through the motions, to put the paperwork in" or to document that they have seen him. He added "the few people here are supposed to be helping don't care if I could put a little bit of trust in the statT I think I would be doing better, feeling better." I asked him if he participates in any of the groups or has had contact with the treatment team and he reported he attended Anger Management class and attended four of eight because four were cancelled because of lockdowns or they didn't have staff. With regard to the treatment team, he reported that at Gilliam Hospital he had met with treatment teams but "not here". He reported there are no treatment teams at Lee where mental health staff discuss with the inmate any treatment issues. I had the opportunity to review this inmate's MARs and his medical record. He appears to have received his Seroquel XR 300 mgs once per day in August 2008 with one exception, in July 2008 with hvo exceptions and June 2008 with three exceptions. Five of the times that he did not receive his medications, there were blanks on the MAR indicating they had not been given and the sixth time he was reported as not showing for which occurred in June 2008. IS to is an on status. He reported his would have not seen him since and 90 2008. He reported he did see the psychiatrist in May and occurred sometime in tor a time the week prior to this interview. He reported he is currently prescribed meds right during lockdowns". Haldol, Cogentin and Celexa but stated he is "not \\lhen asked what happens he stated the nurses bring the noon and p.m. meds at the same time and give them to an officer and then the nurses go to the other side of the building. He reported the officers then give the inmates their medications cell to cell and that he is doubled celled. He reported this practice has been going on since May but it stopped five to six days prior to this interview. He reported the practice applied to any type of medication including psychotropics or "regular until 5-6 days ago". He reported the practice of not getting medications during lockdowns or getting two dosages given to the ofticers who then give them to the inmates resulting in at least one problem with another inmate who is a neighbor of his who had a fight with his cell mate because he hadn't been getting his medication and he was complaining. This inmate reported that his neighbor had two or three seizures and they wouldn't come and get him" and eventually the other inmate had to go to the hospital. This inmate was wearing a pink jumpsuit and I asked him what this meant and he stated it "symbolizes sexual misconduct or masturbation ['m wearing one because classification woman said I groped myself in front of her". He reported he was given a three year sentence by the Disciplinary Hearing Officer (DHO) to wear the pinkjurnpsuit but the Warden knocked it down to two years and put him in the Chesterfield dorm. He reported for 18 months before this charge but he got the three years because in he had no 2004 he had a misconduct charge when he said something "lewd" to the officer. \\lben I asked him what he he stated said to the officer a fat times, 2008 not receiving Desimpramine seven times and Cogentin and Celexa four times, and in June the MARs indicated that his Haldol had been refused five times, blank once and all of his medications were blanks (missed) on June 14 and 15. Assessment: This inmate's care and treatment are inadequate. There have been deficiencies in his having his medications administered consistently, his treatment plans are essentially unchanged, and he has been placed in a pink jumpsuit for sexual misconduct for two years without any assessment or evaluation of whether or not this misconduct is in anyway related to mental illness or mental disorder. 3 1. This inmate was interviewed in Chesterfield dorm and reported he had been incarcerated for the past 18 years. He reported he had been admitted to Gilliam Psychiatric Hospital 12 or 13 times over the past 18 years most recently three months prior to his transfer to Lee and that admission had been for three months. The inmate reported he is currently prescribed Haldol, Cogentin and Prozac. The inmate also reported he had been in the rcs program at Lee in 1994 and 1999, and his diagnosis is Paranoid Schizophrenia. This inmate reported there is no treatment team at Lee like the one at GPH and he believes he needs to have groups and better treatment. He reported he is supposed to see his counselor once per month but he doesn't see him his often and at the whole unit is on lockdown. He reported he when they "run out" or during lockdowns. 1 a.m. medications, and there was no on the 21 st. In July all of his medications were on July The record did not have MARs for the months of April, Mayor June 2008. me~al<:ar!on 4th. Assessment: This inmate's treatment plans and medication management are inadequate and should be reviewed for the appropriateness of his level of care. 32. This inmate was interviewed in Chestertield dorm and reported he had been housed at Lee for just over one year since his admission to the SCDC. He reported he has a past mental health history and treatment for bipolar disorder, anxiety disorder for the past four years and that he has been prescribed Remeron and Vistaril currently. He had been prescribed Depakote but developed side effects so he asked to be taken otf the medication approximately two to three months after he got to Lee. He reports that he has never been in a psychiatric hospital. With regard to his medications, the inmate reported he doesn't get his Remeron and Vistaril "some times don't let us go to the pill line, mainly lockdowns". When asked about the nurses coming to the dorm, the inmate stated they didn't use to come over to his previous dormitory and that dorm sent the inmates to the pill line even during a lockdown, however, he stated the nurses bring the medications to Chesterfield, give the medications to an officer and the officer then slides the medications under the door. This inmate reported his medications were "short three times for three days consistently". I asked the inmate about his counselor and he reported he sees his counselor sometimes two times per month and sometimes not for a \vhole month at aIL He reported he is in a medium dorm and they moved him and his roommate for "no reason" and he .. concluded states was treatment plan of care as area problems were identified as family problems, adjustment, correctional history. objectives were to be evaluated the psychiatrist and to adjust, and the approach was tor the psychiatrist pm, to his medications, one to one and case management pm. He had two treatment plan updates on 1124/08 and 7/24/08 and his diagnosis on 1124108 was entered as ADHD with the same problems, objectives and approach and on 7/24/08 the diagnosis was changed to Major Depressive Disorder with essentially the same objectives and approach. MARs tor August, July and June 2008 indicated he had six blanks for his medications and one no show. Assessment: This inmate's care and treatment appear to be inadequate and his diagnosis does not appear to have been consistent nor do the medications prescribed at the dosages they were prescribed appear to be adequate, particularly based on the inmate's complaints of his being depressed and in need of medication to treat his Bipolar Disorder and anxiety. There does not appear to be participation by the psychiatrist in the treatment planning process and certainly not in discussion directly with the inmate. His anxiety level is also increased by what he has reported as a "dangerous" environment and this does not appear to be addressed in his treatment plan which has nearly identical objectives and approaches regardless of his changes in environment and mental status. 33. This inmate was interviewed in Chestedield dorm. He reported he was admitted to Lee in 2006 from home and he has a 20 year sentence. The inmate reported he had no past mental health treatment but was admitted to GPH from February through March 2007 because "couldn't handle my mental status here". He reported he is not getting his and doesn't the names of the medications anymore. He told me to take what they are . The inmate I asked him this what thought could the mental health better at and he stated "people - staff take time to listen, staff need to be observed and supervised." He added there are "no programs prior to release". The inmate also stated he had no history of treatment for sexual disorder. This inmate's record was reviewed and indicated he had been admitted to SCDC on 817/06 and transferred to GPH from 317 to 3/15/07. A medical screening on 3/20/07 appears to have been done while he was at GPH. The discharge summary indicates the inmate was involuntarily admitted and had diagnoses of Malingering, Polysubstance Dependence by History, Antisocial Personality Disorder and Narcissistic, Histrionic and Borderline Personality Disorder. A treatment plan of 8/25/06 at Lee was signed by a counselor and supervisor and indicated a diagnosis of Malingering and Sexual Impulse Control Disorder. His level of care was area mental health and his problems were identitied as sexual inappropriateness, SIB, suicidal threats/gestures, and Polysubstance abuse. He was noted to be taking Zoloft and Valproic Acid. The objectives were for him to take his medications, refrain from SIB and manipulative behaviors, and to be held accountable for his behaviors. The approach was substance abuse group, the counselors schedule a psychiatric clinic, one to one, and group pm. The treatment plan of 11117/06 was essentially the same. The update on 2112/07 changed the diagnoses to Intermittent Explosive Disorder and Impulse Control Disorder with the same objectives and approach. On 5/11/07 he was noted to have returned trom GPH with suicide attempts/gestures and the same objectives and approach. On 8/24/07 his diagnosis was changed to Psychotic Disorder NOS and his medications included Valproic Acid, Paxil and Risperdal with the same objectives and approach. The update of 12/14/07 was essentially identical to that of although the update of 6/13/08 returned the diagnosis ofIntermittent Explosive Disorder and medications were Depakote, Risperdal and PaxiL Review of revealed he had Valproic Acid levels on 3120/08. and 10, 1 34. in Chesterfield dorm and reported he has at Lee reported he was incarcerated in 2005 and has had mental health treatment since 1997. He reported mental health treatment continued until July 2008. He also reported the mental health treatment included 4-5 admissions to GPH and the prescriptions of Geodon and Benadryl. When asked about his mental symptoms, the inmate reported he has "audio-visual hallucinations" and that "they never told me" a diagnosis but he had killed a man when he was 13 and he sees this man and hears him sometimes. He reported that caused him to attempt to overdose in January 2008 on pills that he got from other inmates at RCI. He reported this resulted in his going to GPH for 30 days and eventually to Lee. He stated he is very unhappy with being at Lee because he had been stabbed at Lee before and believes his life is injeopardy. He stated he is supposed to be a level two but is area mental health and he believes he can only go to Perry or Lieber. He said he was also told he can't be transferred unless he is off the mental health caseload and then he would be able to go to a level two yard. He stated he has asked his counselor about going to Perry or Lieber and he doesn't know why he can't go but he had stopped taking his medications so he can be off the case load. When I asked him how he has been feeling since he stopped taking medications, he said he has been hearing the guy that he killed and he is "paranoid about getting stabbed". He stated he was told by his counselor that a transfer would be up to classitication and believes he is still on the counselor's caseload as an outpatient. He stated he was told that any transfer would be up to classification after he had "been up for two days straight" and he knmvs he needs to be back on his medication, but he wants to be transferred. misconduct was also wearing a pink jumpsuit and stated it was because of a sexual at Ridgeland when "lady officer said she looked through my 1 medication. " sent back to 60 I record that indicates he was transferred from RCI on was done on at RCI. The treatment plan at Lee was done on and signed two counselors and the inmate's level of care was noted as area mental health. His diagnosis was Psychosis NOS and his problems were noted as auditory hallucinations, suicide attempts/gestures, Poly substance abuse and he was prescribed Geodon. The objectives were for him to take his medications, develop coping skills, refrain from SIB and drugs, attend group and the approach was for the counselor to refer him to the psychiatric clinic, monitor compliance with medication, and one to one and group pm. The update of 7/25108 was essentially the same and indicated the next review would be 1/09. A review of the MARs revealed that the last MAR in his record was for May 2008 and he was prescribed Geodon 80 mgs BID. There were 25 no shows or blanks for the morning dose of Geodon in the month of May and five blanks and one no show for the p.m. dose for the month of May. J~L __ '"U''''' Assessment: This inmate's care and treatment are inadequate. He has a substantial history of Psychotic Disorder and possible Mood Disorder. He also has a substantial history of at least 20 sexual misconduct charges for openly masturbating in front of female officers. This inmate has requested help with controlling his sexual urges from mental health staff and according to him has been told that "it is not a part of mental health." He has also requested a transfer to another institution because of his fears of being harmed at this institution and according to him been told that he can't go to another institution because his mental health status so that he has stopped taking medications which he clearly HilHW'''' continues to report psychotic symptoms that also could be related to a PO!Sl-Irallm,;lHC stress disorder. His behavior deserves evaluation for possible them. reported he medical indicates he was on A treatment plan at on 411 provides _'~,"'U'~v_ l;>".,r;>"cn,rp Disorder and Post Traumatic Stress Disorder. He was noted as an outpatient and GBM!. He also had a history of sexual assault, substance abuse, and was prescribed Vistaril and Prozac. The objectives were for him to take medications, develop coping skills and the approach was pm counseling and psychiatric clinic. He had an update on 7/29/05. He was noted to have poor compliance with his medications and group but the objectives and approach remained essentially the same. On 10/28/05 he was noted to have increased anxiety and depression and on 1127106 he was diagnosed with Dysthymic Disorder. My 7/28/06 his diagnosis had been changed to ADHD and he was prescribed SeroqueI. On 115/07 his diagnosis remained ADHD however Generalized Anxiety Disorder was added. The last treatment plan was on 7/20107 and he was diagnosed with ADHD, GAD and Avoidant Personality Disorder and the objectives and approach remained the same. The initial diagnosis of Major Depressive Disorder and PTSD on the treatment plan of 4115/05 is consistent with the discharge summary from GPH of 2/23/05 which gave the diagnoses of Major Depressive Disorder Recurrent, Severe with Psychotic Features, PTSD, and Personality Disorder NOS. A review of his MARs noted that his last psychotropic medications were discontinued on 8/14/07 which consisted of Buspar 30 mgs TID. O,'f'r\"",,, Assessment: This inmate has been determined legally to be gUilty but mentally ill. He has been diagnosed with a Major Depressive Disorder with Psychotic Features and Post Traumatic Stress Disorder as well as Personality Disorder. Those diagnoses have been changed by different clinicians at Lee and the treatment plans have remained essentially the same with exception of some changes in medication until August 2007. The inmate's tor him having what are usually considered severe and persistent to to m pnson. to return to the 37. the treatment with the possible C>V"AY\,T1 was specifically MARs medication inmate was prescribed Risperdal 2 BID and Prolixin Decanoate two weeks. the of June, July and the th """',,""'PH Prolixin injections on June 10 and June 24th. He however did not it until July , four weeks after his last injection, and did not receive it again until 8118/08, three and one-half weeks atter the injection even though it was ordered for two weeks. With regard to his Risperdal, the inmate was noted as a no show on six of nine days in August tor both of his dosages of RisperdaI. In June and July 2008 he was noted as a no show tor all of his dosages of Risperdal except for seven days in June and three days in July when the MARs were blank indicating that the medications were not offered. Assessment: This is a horrific example of poor medication management for an inmate who is on two antipsychotic medications, one of which is an injectable medication to be given every two weeks. The MARs indicate that not only was he not coming to take his oral medications and on some days was not offered his oral medications but he was inconsistently receiving his injectable medication and this occurred over a three month period. This is an example of very poor medication management and ref1ects not only poorly on the nursing service but also on the psychiatrists and counselors in the mental health program as a whole tor not having detected these problems and tormulating alternative interventions and/or more appropriate medication management.