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South Carolina Lee Corr Inst Site Visit Report Mental Health 2008

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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
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
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




2 of 14




mental health
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).

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.


a room near the
did not
an unobstructed


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



side with
on the upper
celled but had
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.
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.
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.


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.
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.
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.



Correctional Institution
Health '''''rutf',''''
6 of 14



at 4 a.m.,


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 ....


C[ status can only
are apparently not
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
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.

or more.
was placed in
chair fur
is minimal
mental health staff
been comacted or have
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
Treatment Planning


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


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
without adequate documentation, both of which
aot)earea to be
to multiple causes
included the following:

Correctional Institution

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.


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


can answer


Lee Correctional Institution
Re: Mental Health Services
Page 12 ofI4

Jeffrey L. Metzner, M.D.

Patterson, M.D.



Correctional Institution
Re: Mental Health Services





Special Management Unit
L Inmate I
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
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
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
history included special education
and completion of the eighth grade.


at Lee CI

2. Inmate 2

Medications include
and Tegretol, which he reported taking due to hyperactivity
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
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



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.
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
Approach: daily medication administration by nursing staff
Objective: inmate to refrain from assaultive behaviors
Approach: 1: 1 counseling and case management by CCC pm



health counselor were at
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
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.


Appendix I
with SMU Inmates at Lee CI


out of the ICS.




4 was
evaluated by
upon his transfer to
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.



A July 11, 2008 note indicated that


Appendix I



note a
with an intennittent
disorder. His medications were continued
and doxepin added. However. BuSpar was ordered in contrast to doxepin.
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
medical problems \\hich are


Appendix I
with SMU Inmates at




to him.
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
personality disorder and narcissistic personality disorder. His self... mutilation


Appendix I


the Youthful

was prescribed Tegretol for
problems, which he thought was
somewhat helpful. Inmate 7 reported seeing a psychiatrist in a private office setting
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
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


note was consistent with this
report of discontinuing
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
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."





a past

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



Appendix I

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.
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
during July 7, 2008. Little change was noted. He was continued on
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
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
included schizophrenia, difIerentiated type,




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


Appendix I

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
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
Laboratory studies were ordered but were refused by the Inmate 10. Inmate 10 stated he
did not refuse to have his blood drawn.

again saw this inmate during September 16, 2008. Labs were reordered and

11. Inmate 11



nrc)lzram was

was ,""V"hW"'''~
was tapered at that time.

in the


magm)SlS during May 17,2006. Risperdal

A June
that Dr.
renewed RisperdaL Inmate 11
was placed in the
intervention related to suicidal thinking during July 9, 2008.
notes were dated July 11, 1 1 I
17, 2008. His
intervention cell status was discontinued during July 17,2008.
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
and in the SMU since 2004. He reported that he has currently been in the
superma.x section four about
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
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



Inmates at

Interviews with


note indicated that Inmate 12 was
his eyes that
The plan was to see him as np'>r!p,,~

4, 2008 Inmate 12 drank some cleaning fluid.. He stated that he
was feeling unsafe in the prison and wanted to
transferred to a
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


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:



at Lee CI


Due to

injections of Prolixin and
2008. His behavior
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.



Appendix II

Lee Correctional Institution
Inmates Interviewed and/or Records Reviewed


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 outpatient status as he currently is on area mental health status because

to do

his Klonopin
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.
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.


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

out for three
to elaborate, he
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
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.

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,


are no

IS a
distribution because the nurses don't come to
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.


in a wheelchair, but
"claustrophobia". The inmate reported he
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
are locked in their
and the doors are not
r\ru~n"'n for them to circulate in the



treatment is not
health, medical
in his case custody
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.

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
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
much at aiL He stated
has not seen

record indicates he was transferred from the Kirkland R&E on
Vistaril ,md
medications at that time ",.:ere Clonidine.
9/05 indicated the inmate was on
also had a history of suicidal behaviors and currently, as well as a
The treatment plans of
were all
and indicated the inmate was
outpatient mental health
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
\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.
two times per
the full


they communicate this infonnation to their treatment
and treatment
reported there are
treatment teams". They elaborated that maybe the
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
from two inmates were "these people don't
which was
LU""C",,:>, and
"~I don't know",

inmate number
the MARs
tiS and Perphenazine 12
and June

Wellbutrin 1
the month of
MAR recorded he was a no show
day except for two.
2008 he was a no show
tor two and
was one blank on the MAR
lllU"'-~H"Jl'" the medication had not been
For June 2008 he was a no

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.

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.


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.
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
difficulties in receiving their medications particularly when they are
indicated that a substantial number


health system.



in the
m one
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.

I could not assess this inmate based on his refusal to be interviewed.

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

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
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.

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
history of having been incarcerated


but he



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".
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
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
was admitted to the cell.


for seven
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
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.
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


there are

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 an
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

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.
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
often and at
the whole unit is on lockdown. He reported he
when they "run out" or during lockdowns.


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.


This inmate's treatment plans and medication management are inadequate and should be
reviewed for the appropriateness of his level of care.

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
dorm and they moved him and his roommate for "no reason" and he



treatment plan of
care as
problems were identified as family
correctional history.
objectives were to be
the psychiatrist and to adjust, and the approach was tor the psychiatrist pm,
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
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.

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
the names of the medications anymore. He
told me to take what they are
. The inmate

I asked him

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



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.


was also wearing a pink jumpsuit and stated it was because of a sexual
at Ridgeland when "lady officer said she looked through my


medication. "
sent back to



record that indicates he was transferred from RCI on
was done on
at RCI. The treatment plan at Lee was done
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'''''

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


reported he

indicates he was
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.

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
exception of some changes in medication until August 2007. The inmate's
tor him having what are usually considered severe and persistent


m pnson.
to return to the


the treatment
with the possible


inmate was prescribed Risperdal 2
BID and Prolixin Decanoate
two weeks.
of June, July and
"""',,""'PH Prolixin injections on June 10 and June 24th. He however did not
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.
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.