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Initial Report of Joint Mental Health Expert Kathryn A. Burns MD MPH, U.S. District Court Southern District of Florida, 2018

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EXHIBIT A

UNITED	STATES	DISTRICT	COURT	
SOUTHERN	DISTRICT	OF	FLORIDA	
	
	
Ollie	Carruthers,	et	al.,	v	Scott	Israel,	et	al.	
Case	No.	76-6068-CIV-MIDDLEBROOKS	
	
	
INITIAL	REPORT	OF	JOINT	MENTAL	HEALTH	EXPERT	
KATHRYN	A	BURNS	MD,	MPH	
	
	
	
I	was	appointed	to	serve	as	the	joint	mental	health	expert	in	accordance	with	a	
Settlement	Agreement	(“Agreement”)	in	the	above	captioned	case.		I	was	charged	with	
assessing	operations	and	conditions	at	the	Broward	County	Jails	and	to	render	an	opinion	
regarding	whether	there	are	current	and	ongoing	violations	of	federal	rights	as	pertaining	
to	inadequate	mental	health	care	and	facilities.		If	I	believe	there	are	current	and	ongoing	
violations	of	federal	rights,	I	was	charged	with	providing	the	specific	basis	for	each	finding	
and	draft	an	Implementation	Plan	designed	to	remedy	the	violation(s).			
	
I	originally	drafted	a	report	and	implementation	plan	and	distributed	them	to	the	
parties.		I	received	their	responses	to	the	report	and	carefully	considered	their	feedback	
and	suggestions.		I	incorporated	their	information	and	edited	the	main	body	of	report	as	I	
deemed	appropriate.		In	the	course	of	this	review	and	editing	process,	the	parties	began	to	
discuss	and	negotiate	the	terms	of	the	implementation	plan	using	the	initial	draft	and	
subsequent	iterations	to	negotiate	an	agreement.		Subsequently,	I	have	removed	the	
portion	of	this	report	that	dealt	with	an	implementation	plan	and	supported	the	efforts	and	
ultimately	the	adoption	of	a	jointly	agreed	upon	implementation	plan.			Consequently,	this	
document	represents	the	Initial	Mental	Health	Report	which	provides	supporting	rationale	

for	the	terms	of	the	Implementation	Plan.		It	represents	the	state	of	the	jail	and	mental	
health	services	at	the	time	of	the	development	of	the	Implementation	Plan	and	the	baseline	
conditions	upon	which	the	agreed	upon	actions	and	improvements	will	be	measured.					
	
	

In	order	to	assess	operations	and	conditions	at	the	jails,	I	organized	my	inquiry	

around	the	six	criteria	for	constitutionally	adequate	psychiatric	care	that	were	originally	
articulated	in	Ruiz	v	Estelle	(1980)1	because	they	form	a	useful	framework	for	the	
discussion.		The	criteria	are:	
•

Systematic	screening	and	evaluation	

•

Treatment	that	is	more	than	mere	seclusion	or	close	supervision	

•

Participation	by	trained	mental	health	professionals	(in	appropriate	numbers)	

•

Safeguards	against	psychotropic	medications	that	are	prescribed	in	dangerous	
amounts,	without	adequate	supervision	or	otherwise	inappropriately	administered	

•

Accurate,	complete	and	confidential	records	

•

Suicide	prevention	program	

It	is	worth	noting	that	while	these	six	items	are	described	separately	for	purposes	of	
review	and	discussion,	the	separation	is	somewhat	artificial	in	that	they	are	not	only	
related	but	actually	entwined	with	one	another.		For	example,	systematic	screening	and	
evaluation	is	not	possible	without	participation	by	an	adequate	number	of	trained	mental	
health	professionals	and	the	records	must	be	accurate	and	complete	in	order	to	provide	
treatment	interventions	and	measure	progress.		Separating	the	components	is	simply	a	

																																																								
1	Ruiz	v	Estelle,	503	F.Supp.1265	(S.D.Tex	1980)	
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way	to	organize	the	review	and	discussion	and	I	will	address	each	of	them	in	the	sections	of	
the	report	that	follow.		
	
	

The	Broward	County	Sheriff’s	Office	(BSO)	operates	four	jail	facilities	housing	

inmates:		Main	Jail	(MJ),	North	Broward	Bureau	(NBB),	Joseph	V.	Conte	Facility	(Conte	or	
JVCF)	and	Paul	Rein	Detention	Facility	(PRF).		The	facilities	differ	somewhat	in	their	
missions	and	the	types	of	inmates	housed	in	them.		For	purposes	of	this	report,	I	will	focus	
on	the	jails	and	missions	most	relevant	to	the	delivery	of	mental	health	care	to	inmates	
with	serious	mental	illness	though	I	recognize	that	each	of	the	facilities	serves	other	
equally	important	and	critical	functions	for	the	BSO	and	Broward	County.		The	MJ	serves	as	
the	booking/intake	facility	for	the	rest	of	the	jails	and	thus	serves	a	key	function	in	
screening	and	assessment,	crisis	intervention,	suicide	prevention,	and	detoxification	from	
alcohol	and	drugs.		MJ	operates	a	large	infirmary	and	also	houses	maximum	security	
inmates,	administrative	segregation	inmates	and	youthful	offenders	among	its	many	
missions.		NBB	is	identified	as	the	facility	to	provide	housing	and	residential	mental	health	
care	to	inmates	in	need	of	such	care	due	to	their	condition	and/or	functional	impairment	
which	prevents	their	placement	in	general	population	housing	units	at	other	facilities.		
Conte	and	PRF	house	general	population	inmates	some	of	whom	receive	programming	
from	BSO	staff	and	“outpatient”	psychotropic	medication	management	from	Armor	
Correctional	Health	Services	(Armor)	staff.		(Armor	also	provides	mental	health	
assessments	and	crisis	intervention	as	necessary	at	the	“outpatient”	jails	but	has	the	ability	
to	request	transfer	of	inmates	to	NBB	for	housing	and	additional	treatment	if	necessary.)			

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The	jails	have	been	accredited	by	the	National	Commission	on	Correctional	Health	
Care	(NCCHC)	since	1998	and	received	reaccreditation	in	2015.		They	are	scheduled	for	reaccreditation	in	2018,	in	accordance	with	the	regular	NCCHC	three-year	reaccreditation	
cycle.		The	NCCHC	accreditation	is	for	all	health	services,	including,	but	not	specific	to	
mental	health	services.		The	jails	have	also	been	accredited	by	the	American	Correctional	
Association	(ACA)	since	1996	and	underwent	a	re-accreditation	audit	in	November	2016,	
receiving	reaccreditation	in	January	2017.		The	jails	have	also	been	accredited	by	the	
Florida	Corrections	Association	Commission	(FCAC)	since	1998,	receiving	reaccreditation	
in	October	2015.			Having	been	a	physician	surveyor	for	the	NCCHC	and	involvement	with	
ACA	accreditation	in	my	own	facilities,	I	understand	these	to	be	important	and	helpful	in	
terms	of	providing	a	judgment	on	the	effectiveness	and	efficiency	of	correctional	
operations	and	healthcare	by	comparing	a	facility	or	facilities	processes	to	a	set	of	
standards	developed	by	the	accrediting	body	and	professional	organizations.		However,	the	
accrediting	organizations	themselves	are	also	clear	that	while	such	accreditation	is	helpful	
and	may	protect	against	adverse	events	and	reduce	liability,	they	also	explicitly	recognize	
that	accreditation	does	not	guarantee	or	represent	constitutional	adequacy	of	a	facility	or	
system.				
	
	

Medical	and	mental	health	care	provided	to	inmates	with	serious	mental	illness	and	

other	mental	health	diagnoses	confined	in	the	Broward	County	Jails	is	provided	through	a	
contract	between	the	BSO	and	Armor.		Armor	mental	health	staff	consist	of	psychiatrists,	
advanced	registered	nurse	practitioners	(ARNP),	physician	assistants	(PAs)	and	counselors	
(master’s	prepared	mental	health	providers.)		The	BSO	also	has	a	number	of	mental	health	
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professionals	at	some	of	the	jails	(BSO	Program	Staff)	that	provide	psychosocial	
interventions,	group	and	counseling	and	substance	abuse	programming	(SAP)	to	the	
inmate	population.		BSO	Program	staff	may	also	provide	some	individual	counseling	but	
their	primary	interventions	are	programs	provided	to	groups	of	inmates.		There	is	some	
overlap	in	that	both	Armor	mental	health	staff	and	BSO	Program	Staff	may	serve	the	same	
inmate	or	group	of	inmates,	but	Armor	is	primarily	responsible	for	screening,	evaluation,	
psychotropic	medication	management,	crisis	intervention/suicide	watch	assessments	and	
discharge	planning.		The	Armor	patient	population	consists	of	inmates	with	serious	mental	
illness	(SMI)	and	other	mental	health	diagnoses,	the	overwhelming	majority	of	whom	are	
prescribed	or	require	psychotropic	medication	for	their	condition(s).		The	persons	served	
by	BSO	Program	Staff	may	or	may	not	be	prescribed	or	require	medication	and	may	or	may	
not	have	a	mental	health	diagnosis.		It	is	important	to	note	that	BSO	Program	Staff	cannot	
serve	inmates	that	are	so	functionally	impaired	by	symptoms	of	serious	mental	illness	that	
they	are	unable	to	participate	in	programs	due	to	the	acuity	of	their	illness.		The	BSO	
Program	Staff	are	consequently	able	to	serve	only	a	portion	of	the	inmates	with	SMI	–	both	
in	outpatient	facilities	as	well	as	in	the	residential	Mental	Health	Unit	(MHU)	at	NBB	as	a	
result	of	inmate	illness	acuity	as	well	as	staffing	levels,	both	of	which	are	discussed	more	
fully	in	the	sections	that	follow.	
	
	

Deputies	supervising	inmates	in	intake,	segregation	units,	the	residential	mental	

health	units	at	NBB	and	other	program	areas	receive	a	40-hour	Crisis	Intervention	Team	
(CIT)	training	and	participate	in	annual	refresher	courses	as	well.		The	CIT	program	for	
correctional	facilities	better	trains	officers	to	identify	mental	health-based	problems	
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promoting	early	referral	to	mental	health	staff.		CIT	training	also	enhances	communication	
skills	for	dealing	with	persons	with	mental	illness	and	used	by	officers	during	psychiatric	
emergencies	to	minimize	or	avoid	the	use	of	force	which	reduces	injuries	to	inmates	and	
staff,	avoids	adverse	incidents	and	improves	inmate	mental	health	outcomes.			
	
	
	
Qualifications	
	
	
I	am	a	Medical	Doctor	licensed	in	the	state	of	Ohio.		I	am	Board	Certified	in	the	
practice	of	General	Psychiatry	and	Forensic	Psychiatry.		I	also	have	a	Master’s	Degree	in	
Public	Health.		I	am	a	Distinguished	Fellow	of	the	American	Psychiatric	Association.		I	am	
Board	Certified	by	the	American	Board	of	Psychiatry	and	Neurology	(ABPN)	in	General	
Psychiatry	and	Forensic	Psychiatry.		I	have	served	both	as	a	Board	Examiner	for	the	ABPN	
general	adult	psychiatry	oral	examination	and	on	the	forensic	psychiatry	committee	
writing	examination	questions	and	preparing	the	forensic	psychiatry	board	examinations.	
	
	

Since	July	2013,	I	have	served	as	the	Chief	Psychiatrist	for	the	Ohio	Department	of	

Rehabilitation	and	Correction,	a	position	I	also	held	from	May	1995	to	August	1999.		I	have	
provided	psychiatric	care	to	inmates	in	jails	and	prisons	in	addition	to	holding	
administrative	posts.		I	have	been	a	physician	surveyor	of	health	services	for	the	National	
Commission	on	Correctional	Health	Care	in	the	past	and	am	a	Certified	Correctional	Health	
Professional.		I	have	written	correctional	mental	health	policies	and	procedures	and	
developed	staffing	plans	for	correctional	mental	health	services.		I	have	written	and	been	
published	in	journals	and	peer	reviewed	textbooks	on	topics	pertaining	to	correctional	
mental	health	care.	
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I	have	served	as	both	a	consulting	and	testifying	expert	witness	in	legal	cases	

involving	correctional	mental	health	care.		I	have	conducted	assessments	of	the	adequacy	of	
mental	health	care	in	individual	correctional	facilities	as	well	as	state	systems	including	
Massachusetts,	Pennsylvania,	Indiana,	Illinois,	Ohio	and	Alabama.	I	have	also	been	a	
monitoring	expert	in	correctional	litigation	cases	including	Coleman	v	Brown	(California),	
Disability	Rights	Network	of	Pennsylvania	v	Wetzel	(Pennsylvania),	Disability	Law	Center	v	
Massachusetts	Department	of	Correction	(Massachusetts),	Graves	v	Arpaio	(Maricopa	
County,	Arizona)	and	Carty	v	Mapp	(US	Virgin	Islands).			
	
	

		
A	copy	of	my	current	curriculum	vitae,	which	includes	a	list	of	all	publications	

authored	and	a	list	of	all	cases	in	which	I	have	testified	at	trial	or	deposition	during	the	past	
four	years	is	attached	to	this	report.	
	
	

In	forming	my	opinions,	I	have	relied	on	my	training	and	experience	in	general	

psychiatry,	forensic	psychiatry	and	correctional	psychiatry:		I	have	provided	psychiatric	
care	to	inmates	in	jails	and	prisons	and	supervised	the	care	provided	by	other	mental	
health	professionals;	I	have	experience	in	administration	and	oversight	of	correctional	
mental	health	care	and	I	have	visited	dozens	of	correctional	facilities	and	interviewed	staff,	
administrators	and	hundreds	of	prisoners	and	detainees.		I	am	familiar	with	the	standards	
for	the	delivery	of	mental	health	care	promulgated	by	the	National	Commission	on	
Correctional	Health	Care	(NCCHC)	as	well	as	position	statements	and	guidelines	
promulgated	by	other	professional	organizations	including	the	American	Psychiatric	
Association.	

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Sources	of	information	
	
	
In	conducting	the	assessment	and	forming	my	opinions,	I	considered	information	
gathered	and	observations	made	during	a	series	of	site	visits	to	the	jail	facilities.		Site	visits	
consisted	of	facility	tours,	meetings	with	BSO	staff	(including	Program	Staff)	and	Armor	
mental	health	staff,	observation	of	mental	health	housing	and	program	areas,	infirmaries	at	
MJ		and	NBB,	reviews	of	medical	records,	interviews	with	individual	inmates,	reviews	of	
various	documents	including	jail	housing	plans,	organizational	charts	and	staffing	rosters,	
BSO	program	schedules,	caseload	rosters	and	logs	maintained	in	the	course	of	business	
including	hospital	transfers	and	returns,	crisis/suicide	watches,	restraint	logs	and	mental	
health	appointment	schedules.	
	
	

I	visited	each	of	the	jail	facilities	on	the	indicated	dates:	
•

Main	Jail	(MJ)	–	August	22,	2016;	February	9,	2017;	and	May	15,	2017	

•

North	Broward	Bureau	(NBB)	–	August	23,	2016;	February	6,7	and	8,	2017		

•

Paul	Rein	Facility	(PRF)	–	May	17,	2017	

•

Joseph	V	Conte	Facility	(JVCF)	–	May	16,	2017	

	
	

Case	summaries	of	inmate	medical	records	reviewed,	dates	of	reviews	and/or	

interviews	(where	applicable)	are	appended	to	this	report.		(The	Appendix	also	includes	
reviews	of	medical	records	requested	of	inmates	that	committed	suicide	in	the	jail	and	jail	
deaths	of	inmates	on	the	mental	health	caseload.)	While	a	few	inmate	case	examples	are	
cited	in	various	sections	of	this	report,	the	Appendix	contains	more	complete	summaries	of	
all	inmate	information	reviewed	in	the	course	of	my	review.		Each	summary	is	followed	by	
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my	assessment/conclusions	in	italics.		The	cases	cited	in	the	various	sections	of	the	report	
are	simply	illustrative	of	a	certain	point	but	not	the	only	instance	in	which	certain	
observations	and/or	deficiencies	existed.	
	

In	addition	to	facility	visits	and	review	of	documents	on	site,	I	also	reviewed	a	

number	of	additional	documents	that	included:	
•

Carruthers	v	Israel	Settlement	Agreement	

•

Armor	Correctional	Health	Services,	Inc.	Policies	&	Procedures		

	
A- Governance	and	Administration	
B- Managing	a	Safe	and	Healthy	Environment	
C- Personnel	and	Training	
D- Health	Care	Services	and	Support	
E- Inmate	Care	and	Treatment	
F- Health	Promotion	and	Disease	Prevention	
G- Special	Needs	and	Services	
H- Health	Records	
I- Medical/Legal	Issues	
						
•

BSO	Standard	Operating	Procedures:	
5.16	Use	of	Restraints	
5.21	Emergency	Rescue	Tool	(revised	6-9-15)	
7.13	Inmate	Programs	
7.30	Administrative	Segregation	
7.31	Disciplinary	Segregation	(revised	11-30-15)	
8.3	General	Policies	–	Health	Care	(revised	11-30-15)	
8.4	Inmate	Health	Care	Consent	(revised	6-28-06)	
8.5	Health	Care	Personnel	(revised)	
8.6	Health	Care	Services	(revised	9-19-07)	
8.7	Inmate	Health	Records	(revised	11-30-15)	

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8.8	Levels	of	Care	
8.9	Management	of	Chemical	Dependency	
8.24	Health	Screenings	and	Examinations	(revised	11-30-15)	
8.27	Inmate	Mental	Illness	&	Developmentally	Disabled	Policy	
8.30	Suicide	Prevention	and	Intervention	–	Health	Care	(revised	3-3-16)	
•

	
Agreement	Broward	Sheriff’s	Office	and	Armor	Correctional	Health	Services	
(February	1,	2014-January	31,	2017);	amendment	for	implementation	of	electronic	
medical	records	system	(January	21,	2015);	second	amendment	extending	terms	of	
agreement	for	another	year	(February	9,	2017)	

	
•

Hospital	Services	Agreement	between	Armor	Correctional	Health	Services	and	
North	Broward	Hospital	District	

	
•

An	expert	report	of	Jeffrey	L	Metzner,	MD	dated	March	5,	2006	related	to	the	
delivery	of	mental	health	care	at	the	jails	much	earlier	in	this	litigation.			

	
•

Commission	on	Accreditation	for	Corrections	Standards	Compliance	Reaccreditation	
Audits	conducted	in	the	fall	of	2013	of	each	of	the	jail	facilities	(MJ,	NBB,	JVCF	and	
PRF)	

	
•

Armor	Correctional	Health	Services	Quality	Assurance/Quality	Improvement	
reports	and/or	audits	for	the	past	two	years	2	

	

•

Special	Needs	Management	Meeting	Minutes	

	
																																																								
2	This	did	not	include	some	expected	information	such	as	several	of	the	items	outlined	in	
the	Armor	Continuous	Quality	Improvement	policy	including	incident	reports,	several	
Morbidity/Mortality	reports	and	psychological	autopsies,	suicide	prevention	committee	
meeting	minutes	and	process	and	outcome	studies.		I	was	told	that	there	were	no	process	
or	outcome	studies	specific	to	mental	health	conducted	during	the	twelve-month	period	for	
review	which	explains	their	absence	from	the	materials	produced.		I	was	provided	
assurance	that	all	other	available	information	requested	was	produced	and	proceeded	on	
this	assurance.	
	
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Main	Jail	(MJ)	
	
Site	visits:		August	22,	2016;	February	9,	2017;	May	15,	2017	
	
	
	
The	Main	Jail	(MJ)	serves	as	the	central	point	of	intake	for	the	jails	and	booking,	
intake,	health	and	mental	health	screening	and	assessment	are	major	missions	of	the	
institution.		In	addition,	there	is	an	infirmary,	drug	and	alcohol	detoxification	observation	
beds	as	well	as	general	population	housing	for	adult	men	of	all	security	classifications,	
protective	custody,	and	disciplinary	and	administrative	segregation.		The	facility	houses	
male	inmates	though	there	are	two	very	small	holding	units	on	the	intake	floor	for	females	
until	they	are	assigned	to	another	facility.		
	
	

There	are	1542	beds	in	the	MJ.		The	population	count	at	the	time	of	the	February	site	

visit	was	1111	with	385	inmates	(34%	of	the	population)	identified	as	being	on	the	mental	
health	caseload.	
	
	

As	previously	noted,	the	jail	serves	as	the	booking	and	intake	facility	for	the	jails.				

The	jail	has	experienced	a	decline	of	approximately	2000-3000	bookings	annually	over	the	
last	five	years.		In	2012,	there	were	50,930	bookings	and	the	number	in	2017	was	34,596;	
this	is	certainly	a	welcome	reduction	but	even	34,596	bookings	last	year	demonstrate	that	
the	MJ	intake	and	booking	process	remains	a	very	busy	service	area.			Emergency	Medical	
Technicians	(EMTs)	are	on	site	at	the	jail	and	provide	medical	clearance	for	admission	to	
the	jail	for	detainees	even	before	they	physically	enter	the	booking	area	to	be	certain	that	
detainees	do	not	need	diversion	to	emergency	medical	care	prior	to	entering	the	jail.		The	
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intake	screening	is	then	completed	inside	the	booking	area	and	consists	of	more	detailed	
questions	about	health	and	mental	health	history	in	addition	to	observations	of	detainee	
condition	and	behaviors.		Inmates	placed	on	watch	or	needing	watch	are	expedited	through	
the	booking	process	and	sent	to	the	infirmary	or	over	to	NBB	for	suicide	watch	or	
psychiatric	observation.		(Additional	information	about	the	intake	and	assessment	process	
is	found	in	the	Intake	Screening	and	Assessment	section	of	this	report.)	
	
	

The	infirmary	at	the	MJ	contains	30	beds:		4	cells	are	ADA	accessible	and	4	cells	

contain	closed	circuit	cameras	to	monitor	inmates	on	watch	status.		Inmates	undergoing	
detoxification	(detox)	from	drugs	and/or	alcohol	are	in	plastic	beds	(like	a	boat	or	sled)	on	
the	floor	outside	of	the	cells.		Armor	mental	health	staff	conduct	rounds	in	the	infirmary	
and	evaluate	inmates	on	mental	health	watch	status	daily.		The	4th	floor	of	the	MJ	also	
contains	detox	observation	beds	for	inmates	that	are	less	acute	in	terms	of	their	
withdrawal	symptoms.		They	are	monitored	and	continued	on	a	detoxification	protocol	that	
includes	symptomatic	monitoring	and	medication(s).		The	decisions	on	whether	to	admit	a	
patient	to	the	infirmary	or	to	the	detox	observation	unit	are	made	on	a	case-by-case	basis	
by	medical	staff.		Inmates	initially	placed	in	the	infirmary	for	detoxification	are	also	
generally	stepped	down	to	the	detox	observation	unit	as	their	condition	improves	for	some	
additional	monitoring	prior	to	being	sent	to	general	population	housing.		Mental	health	
staff	must	also	clear	all	detox	inmates	prior	to	release	to	general	population.		There	is	a	full	
time	Armor	psychologist	assigned	to	doing	these	mental	health	detox	evaluations.		He	also	
does	some	brief,	individual	counseling.	

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Juvenile	offenders	are	housed	on	the	5th	floor	of	the	MJ	which	includes	general	

population	and	lock-down	housing	pods	for	juvenile	inmates.			There	are	3	suicide	watch	
cells	located	there	for	this	population	in	need	of	watch	placement	as	well.		There	are	
administrative	segregation	cells	for	adult	male	inmates	in	some	of	the	7th	floor	housing	
units	and	in	all	of	the	8th	floor	housing	units.		There	are	3	additional	suicide	watch	cells	on	
the	8th	floor.		Prior	to	placement	in	administrative	segregation,	there	is	a	medical	staff	
record	review	of	the	proposed	placement	to	identify	any	contraindications	or	
accommodation	required.	3		Mental	health	staff	conduct	weekly	rounds	in	the	
administrative	segregation	units	as	the	conditions	there	are	considered	“extreme	isolation”	
according	to	the	Armor	policy.		(Lesser	forms	of	isolation	require	less	frequent	mental	
health	rounds	per	policy.)		Contacts	during	rounds	occur	at	the	cell	front.		Rounds	are	not	
considered	treatment	interventions	but	rather	a	form	of	monitoring	to	assess	condition	and	
determine	whether	any	additional	mental	health	intervention	is	necessary.		The	
psychiatrist	sees	inmates	being	prescribed	psychotropic	medication	at	least	monthly.		The	
inmates	are	seen	by	the	psychiatrist	in	the	nursing	office	or	at	the	cell	front.		
	
Armor	mental	health	staffing	at	the	MJ:	
•

Psychiatrist	works	4	weekdays	per	week;	0.8	FTE	

																																																								
3	While	I	saw	some	of	these	review	forms	in	many	of	the	records	reviewed,	I	saw	no	
instance	in	which	the	review	resulted	in	the	inmate’s	exclusion	from	placement	in	
administrative	segregation	–	even	when	the	inmate	was	diagnosed	and	being	treated	for	a	
serious	mental	illness.		Examples	are	provided	later	in	this	report.		This	process	and	
whether	it	resulted	in	diversion	would	be	an	excellent	item	to	monitor	through	a	quality	
improvement	process	in	light	of	the	known	deleterious	effect	of	long	term	segregation	on	
inmates	with	serious	mental	illness.	
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•

ARNP	works	1	day	per	week;	0.2	FTE	

•

ARNP	works	weekends	to	do	rounds	of	patients	on	crisis/watch	status;	fractional	
FTE	

•

Psychologist	–	assigned	to	detox	evaluations	and	some	counseling;	1.0	FTE	

•

Licensed	Mental	Health	Counselor	–	assigned	to	do	initial	psych	evaluations	and	
some	counseling;	0.8	FTE	

BSO	Program	staff	at	MJ:	
•

Part-time	(0.6	FTE)	program	specialist	–	assigned	to	provide	Substance	Abuse	and	
Life	Skills	programming	for	Juvenile	and	protective	custody	inmates,	not	specific	to	
inmates	on	the	mental	health	caseload	or	SMI	inmates		

	
Mental	health	staffing	is	discussed	further	in	a	subsequent	section	of	the	report.		
However,	the	mental	health	staffing	levels	for	the	MJ	are	woefully	inadequate	for	the	
number	of	bookings	annually	and	the	number	and	volume	of	diverse	missions	of	the	facility	
-	medical	infirmary,	detoxification,	suicide	watches	in	at	least	3	areas	of	the	jail	(not	
including	intake),	juvenile	housing,	protective	custody,	disciplinary	and	administrative	
segregation.		Other	than	the	intake	and	assessment	forms	and	psychiatric	(or	nurse	
practitioner)	evaluations,	medication	checks	and	medication	administration	records	
(MARs)	indicating	that	ordered	medications	were	offered/provided	to	the	inmate,	there	
was	no	documentation	in	any	of	the	records	reviewed	of	any	other	form	of	mental	health	
treatment	intervention	at	MJ	which	was	not	surprising	given	the	mental	health	staffing	
levels.		
	
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North	Broward	Bureau	(NBB)		
	
Site	visits	–	8/23/16,	2/6-8/17	
	
	
	
The	North	Broward	Bureau	(NBB)	contains	1206	beds	in	housing	units	11	and	12.		
Housing	unit	12	contains	the	residential	mental	health	housing	units	for	the	entire	jail	as	
well	as	an	infirmary.		The	mental	housing	units	are	located	in	lettered	housing	wings	E,	F,	G	
and	H	and	each	of	these	contain	five	smaller	pods	numbered	1	through	5	that	radiate	off	of	
a	central	correctional	officer	office/command	center	for	that	particular	lettered	housing	
area.		Each	of	the	lettered	housing	units	also	have	both	numbered	housing	pods	on	the	first	
floor	of	the	building	and	corresponding	numbered	pods	located	on	the	second	story	of	the	
building.			
	
	

The	NBB	infirmary	houses	medical	patients	in	need	of	infirmary	care	but	also	has	

some	safe	cells	for	inmate	patients	requiring	suicide	watch	or	observation.		Unlike	the	
other	housing	units,	it	is	located	only	on	the	first	floor.	
	
	

The	mental	health	housing	pods	vary	in	size	from	3-4	beds	to	a	maximum	of	21	beds	

and	the	construction	varies	from	single	cells	to	larger	multi-inmate	“rooms”	that	remain	
open	to	the	central	area	of	the	pod.		Celled	pods	are	known	as	“closed	mental	health”	units	
and	are	used	to	house	inmates	who	have	been	determined	to	be	too	ill	to	house	in	the	
“open	mental	health”	pods,	(i.e.,	pods	that	contain	multi-inmate	rooms)	those	serving	a	
disciplinary	sanction	(disciplinary	segregation)	or	those	inmates	in	administrative	
segregation	status.		Inmates	in	closed	mental	health	(CMH)	are	housed	alone	in	cells.		Some	
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of	the	individual	housing	unit	pods	in	housing	unit	12	have	missions	unrelated	to	mental	
health:		two	pods	in	housing	unit	F	serve	as	step-down	for	inmates	with	medical	issues,	a	
unit	on	E	pod	housed	child	offenders.		The	remaining	housing	units	are	described	below.	
	
	

Housing	wing	E	contains	protective	custody	(1E1),	closed	mental	health	(1E2,	2E1,	

2E2,	2E3),	open	mental	health	(1E4,	1E5,	2E4),	a	7-bed	housing	unit	for	suicide	watch	
(1E3)	and	a	3-bed	housing	unit	for	suicide	watch	overflow	(1E2).		E	houses	male	inmates.		
Note	that	the	number	preceding	the	letter	indicates	whether	first	or	second	floor,	the	
number	following	the	letter	indicates	which	of	the	5	pods	is	indicated.	
	
	

Housing	wing	F	contains	closed	mental	health	pods	(1F1,	1F2,	1F3,	2F3),	

disciplinary	segregation	for	mental	health	inmates	(2F1,	2F2)	and	two	open	mental	health	
units	(2F4,	2F5).		Note	that	2F5	is	considered	the	Intensive	Program	Unit	(IPU)	in	which	
BSO	program	staff	conduct	daily	(weekday)	treatment	programs,	including	addiction	
education	groups	for	inmates	with	mental	health	and	substance	use	disorders	so	long	as	
they	are	clinically	stable	and	able	to	participate.		These	programs	are	very	good	but	can	
only	serve	a	fraction	of	the	population	housed	in	MHU	due	to	program	staffing	levels	but	
also	because	a	large	number	of	inmates	in	the	MHU	are	simply	unable	to	participate	due	to	
their	level	of	clinical	instability	or	problematic	symptomatology.		Male	inmates	are	housed	
on	F.	
	
	

Female	inmates	are	housed	in	the	G	units.		There	is	a	six-bed	unit	for	women	on	

suicide	watch	(1G1);	closed	mental	health	units	(1G2,	1G3,	2G1,	2G2,	2G3),	and	open	
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mental	health	units	(1G4,	1G5,	2G5).		2G5	is	the	female	program	unit	served	by	BSO	
program	staff.		1G4	is	an	open	mental	health	unit	but	it	also	serves	as	female	intake	into	
NBB	mental	health.	
	
	

Housing	wing	H	contains	male	inmates	in	both	closed	mental	health	(1H1,	1H2,	1H3,	

2H1,	2H2,	2H3)	and	open	mental	health	units	(1H4,	1H5,	2H4	and	2H5).		Housing	pod	1H4	
is	open	but	also	serves	as	the	intake	unit	for	men	entering	NBB	mental	health.		BSO	
Program	staff	provide	treatment	programs	in	housing	pod	2H3	–	a	7-bed	transitional	
program	unit	providing	treatment	services	4	days	per	week	to	assist	in	transitioning	stable	
inmates	from	closed	to	open	mental	health	units.		BSO	Program	staff	and	programs	are	very	
good	but	able	to	serve	only	a	small	number	of	inmates	on	the	mental	health	caseload	and	a	
fraction	of	inmates	with	serious	mental	illness	due	to	staffing	levels,	program	space	and	the	
severity	of	symptoms,	functional	impairment	experienced	by	many	inmates	with	SMI	that	
precludes	their	ability	to	participate	in	the	types	of	activities	offered.	
	
	

Inmates	housed	in	the	closed	mental	health	units	receive	recreation	once	per	week.		

Armor	mental	health	counselors	monitor	inmates	on	the	closed	mental	health	units	weekly	
at	the	cell	front	(as	opposed	to	an	individual,	confidential	interaction.)		These	contacts	are	
conducted	at	the	cell	front	“for	safety	reasons.”		Armor	mental	health	staff	also	seeks	input	
from	security	and	nursing	staff	about	the	inmates	in	closed	mental	health	as	part	of	this	
monitoring.		A	“mental	health	contact”	form	is	completed	and	filed	in	the	medical	record.	
(Such	cell	front	“monitoring”	visits	are	known	as	“rounds”	–	another	kind	of	screening	
and/or	triage	function	in	which	the	state	of	the	inmate	is	briefly	assessed	at	the	cell	front.		
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Rounds	are	not	mental	health	treatment.	The	purpose	of	rounding	is	to	determine	whether	
someone	is	doing	alright	or	has	decompensated	and	in	need	of	further	assessment	and	
treatment.)			
	
	

The	open	mental	health	units	receive	recreation	twice	per	week.		Open	mental	

health	units	also	receive	at	least	1	group	treatment	offered	weekly.		BSO	program	staff	
provide	these	groups	and	some	individual	counseling	sessions.			Armor	mental	health	staff	
do	not	provide	any	group	treatment.		Armor	reported	that	their	role	is	primarily	
“identification	and	stabilization.”		Armor	mental	health	counselors	may	do	some	individual	
counseling	sessions	with	some	inmates	which	is	supportive	in	nature	and	done	on	an	“as	
needed”	as	opposed	to	a	regular	basis	or	to	provide	an	actual	course	of	treatment,	which	is	
also	true	of	the	individual	counseling	sessions	provided	by	BSO	program	staff.		Counseling	
and	other	appointments	(for	assessments)	are	conducted	at	a	table	in	the	hallway,	not	in	
confidential	treatment	space.		The	only	other	mental	health	intervention	provided	by	
Armor	at	NBB	is	psychotropic	medication	management.		In	these	instances,	a	given	inmate	
may	see	one	of	several	different	prescribers,	rather	than	having	a	standing	treatment	
relationship	with	any	one	particular	person.		(This	impairs	the	formation	of	a	trusting	
treatment	relationship	and	also	leads	to	frequent	assessment,	reassessment	at	every	
appointment	with	persons	having	different	prescribing	practices.			It	is	not	ideal	can	delay	
access	to	effective	treatment;	psychotropic	medications	take	6-8	weeks	at	a	therapeutic	
dose	to	assess	effectiveness,	frequent	changes	of	medications	do	not	permit	adequate	time	
to	assess	effectiveness	and	the	net	effect	can	be	to	delay	effective	treatment.)		Medication	
management	appointments	occur	at	intervals	of	30	days	generally.			A	few	more	frequent	
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contacts	are	required	after	a	watch	is	discontinued,	but	it	quickly	reverts	to	the	monthly	
frequency	as	opposed	to	being	driven	by	clinical	need.		Medication	management	
appointments	also	occur	in	the	hallway	or	at	cell	front	and	not	in	confidential	treatment	
space.		
	
	

BSO	program	staff	conduct	daily	program	groups	during	the	week	on	2F5	and	2G5.		

Each	of	these	contain	21	beds.	The	programs	are	psychoeducational	in	contrast	to	
psychotherapeutic.		Inmates	must	be	psychiatrically	stable	in	order	to	participate	and	these	
programs	are	not	available	to	anyone	in	closed	mental	health.		The	programs	are	well	done	
but	simply	not	an	option	available	to	the	majority	of	inmates	with	serious	mental	illness	in	
the	mental	health	treatment	facility	at	NBB.		
	
	

There	are	no	regular	treatment	team	meetings	to	discuss	each	patient	on	the	mental	

health	caseload	housed	at	NBB.		There	is	a	treatment	team	meeting	to	discuss	some	
patients	(2-3	patients	discussed	in	a	given	week)	that	are	selected	either	by	BSO	program	
staff	or	Armor	mental	health	staff	because	they	present	a	particular	issue	or	issues	
(readiness	for	admission	to	the	program	unit,	discharge	from	NBB,	release	planning,	etc.)		
The	meeting	is	attended	by	Armor	mental	health	staff	and	BSO	staff	and	is	conducted	in	the	
middle	of	the	hallway	just	outside	the	officers’	station.		It	is	not	private	or	confidential	from	
anyone	else	who	may	be	on	the	unit.		The	inmate	and	the	primary	staff	person	working	
with	the	inmate	sit	at	a	table	while	the	others	present	stand	in	a	semi-circle	around	them.		
The	discussions	I	observed	provided	useful	information	but	were	not	typical	mental	health	
treatment	team	meetings.			A	progress	note	is	written,	signed	by	the	persons	attending	the	
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meeting	and	placed	in	the	inmate’s	file.		The	actual	treatment	plan	itself	is	not	updated	to	
reflect	any	decision	or	planned	increase	in	intensity,	frequency	or	types	of	contacts	for	the	
inmate	discussed.	
	
	

As	previously	noted,	suicide	watches	may	be	conducted	in	some	of	the	cells	located	

in	the	infirmary	or	on	housing	units	1E3	(males)	and	1G3	(females.)			Suicide	prevention	is	
discussed	more	fully	later	in	this	report.	
Armor	mental	health	staffing	at	NBB:	
•

Psychiatrist	–	1	FTE	and	1	part-time	psychiatrist	

•

ARNP	–	2	FTE	(1	full	time	and	2	part-time	practitioners)	

•

Physician	Assistant	–	1	FTE	(primarily	administrative)	

•

MH	counselors	–	2	FTE	(licensed	mental	health	clinicians)	

•

Discharge	planners	–	2	FTE	

	
BSO	Program	staff	at	NBB4:	
•

Licensed	psychologist	–	2	FTE	

•

MH	counselors	–	3	FTE	(master’s	level	clinicians)	

	

																																																								
4	The	BSO	Program	also	supports	mental	health	professional	training.		There	are	2	FTE	
doctoral	interns	and	2	part-time	doctoral	practicum	students	(each	for	12	hours	per	week).		
The	jail	is	an	accredited	by	the	American	Psychological	Association	as	an	Internship	
Training	site.	
	
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Staffing	is	discussed	in	a	subsequent	section	of	this	report.		However,	it	is	clear	that	

NBB	Armor	mental	health	and	BSO	program	staffing	levels	(including	trainees	who	require	
supervision),	do	not	reflect	the	numbers	or	varied	types	of	staff	necessary	to	provide	a	
residential	treatment	level	of	care.		Nothing	other	than	medication	management	is	
provided	for	the	vast	majority	of	inmates,	and	even	that	is	relatively	infrequent,	not	based	
on	clinical	assessment	of	need	and	may	be	provided	by	someone	different	at	every	visit.		
While	inmates	do	not	have	a	“right”	to	see	the	same	provider	at	every	clinical	visit,	failing	to	
do	so	leads	to	fragmentation	in	the	provision	of	care,	being	subjected	to	differing	
prescribing	practices	and	frequent	medication	changes;	compromises	the	development	of	a	
consistent	treatment	relationship	such	that	every	visit	is	a	“new”	assessment	rather	than	
furtherance	of	a	course	of	treatment.		Such	fragmentation	impacts	care	provided	and	
prolongs	the	time	it	takes	for	symptoms	to	respond	to	treatment.		Delays	in	the	provision	of	
care	have	been	shown	to	negatively	impact	both	the	time	it	takes	to	respond	to	treatment	
as	well	as	the	degree	of	the	response;	it	takes	symptoms	longer	to	respond	and	the	
response	is	not	as	robust	as	that	which	occurs	when	treatment	is	provided	timely.			
	
Frankly,	although	this	is	the	facility	containing	the	mental	health	units	to	which	
other	jails	transfer	inmates	in	need	of	a	higher	level	of	mental	health	care,	there	really	is	no	
different	than	the	outpatient	services	provided	at	all	of	the	other	facilities.		It	does	not	
represent	a	higher	or	more	intensive	level	of	care	for	inmates	in	need	of	such	care,	and	
inmates	may	remain	there	for	many	months	or	even	years	while	awaiting	further	legal	
proceedings.		Conditions	on	the	closed	mental	health	units	and	in	the	infirmary	for	weeks	
and	months	on	end	actually	mimic	solitary	confinement/segregation	in	terms	of	very	
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limited	(if	any)	out-of-cell	time,	limited	opportunity	for	social	interaction,	limited	property	
and	cell	front	interactions,	rather	than	the	provision	of	actual	mental	health	treatment.		
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
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Joseph	V	Conte	Facility	(Conte	or	JVCF)	
	
Site	visit	-	05/16/17	
	
	
	
Conte	is	a	male	facility	housing	minimum	and	medium	security	male	inmates.		The	
capacity	of	the	jail	is	1328	but	the	average	daily	population	(ADP)	has	been	1000-1050	for	
the	past	year.	On	the	day	of	the	site	visit,	there	were	1008	male	inmates	at	JVCF;	319	of	
them	were	on	the	MH	caseload	(32%	of	the	population.)	
	
	

JVCF	has	no	infirmary	and	does	not	have	the	capacity	to	conduct	suicide	watches.		

Inmates	identified	as	needing	that	level	of	care	are	transferred	out	to	NBB.		The	physical	
plant	is	structured	such	that	there	are	two	“towers”	of	housing	–	A	&	B	tower.		Each	tower	
contains	8	housing	units.		All	of	the	housing	units	are	two-story,	and	the	majority	of	cells	
are	2-man	cells	though	there	are	4-man	and	6-man	cells	also.			
	
	

Three	of	the	units	house	inmates	participating	in	specific	programs:	a	Spiritual	

Learning	program	run	by	religious	chaplains	is	located	on	housing	unit	B5,	a	Substance	
Abuse	Program	(SAP	on	housing	unit	A6)	and	a	Life	Skills	Program	(A5)	are	offered	by	BSO	
Program	staff.		The	SAP	and	Life	Skills	Program	consist	of	group	interventions	and	both	are	
4	weeks	in	duration.		There	is	no	documentation	of	group	notes	contained	in	the	medical	
records,	but	inmates	get	a	certificate	of	completion	if	they	participate	for	the	4	weeks.		Most	
inmates	participating	in	SAP	are	court-ordered	but	some	request	to	participate.		The	JVCF	
also	provides	Narcotics	Anonymous	and	Alcoholics	Anonymous	meetings	on	a	voluntary	

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and	court-ordered	basis	as	well	as	GED	training.		This	facility	has	ample	program	and	
outpatient	treatment	space.	
	
	

Mental	health	services	consist	primarily	of	medication	management	appointments	

scheduled	at	monthly	intervals.		When	inmates	are	transferred	from	MJ,	medication	orders	
remain	in	effect	for	the	duration	ordered	by	the	psychiatrist	at	the	MJ	so	that	continuity	is	
maintained.		Medical	nurses	provide	two	medication	administration	times	daily:		9-10	AM	
and	4-6	PM.		Other	mental	health	services	may	include	new	assessments	based	upon	
referral	(staff	referral	or	inmate	self-referral)	though	the	vast	majority	of	inmates	on	the	
mental	health	caseload	were	identified	by	virtue	of	the	intake	process	at	the	Main	Jail.	
	
	

The	Medication	Administration	Records	(MARs)	were	reviewed	on	site	during	the	

visit.		There	was	very	little	polypharmacy	(inappropriate	use	of	multiple	medications),	
which	is	a	positive	finding.		Some	medications	were	prescribed	at	very	low	doses	(lower	
than	the	recommended	lowest	effective	dose	such	as	Risperdal	0.25	mg	and	Zoloft	50	mg	
long	term).		It’s	not	clear	that	such	low	doses	would	have	any	therapeutic	benefit,	but	
neither	is	it	harmful	except	to	the	extent	that	it	further	spreads	already	thin	staff	resources	
for	medication	management	appointments.		This	is	not	just	a	difference	in	prescriptive	
opinion;	requirements	to	see	inmates	on	medication,	even	if	it	is	prescribed	in	
inappropriately	low	and	ineffective	doses,	take	time	away	from	seeing	inmates	who	are	
seriously	mentally	ill	and	preclude	time	to	hold	treatment	team	meetings	on	inmates	on	the	
mental	health	caseload,	which	puts	them	at	risk	of	decompensation	and	impedes	access	to	
care.		As	an	aside,	there	were	a	number	of	people	that	had	MARs	who	did	not	appear	on	the	
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caseload	roster.		Any	number	of	reasons	explain	this:		a	recent	transfer/admission	to	the	
facility	not	yet	added	to	the	roster	or	the	intervals	at	which	the	roster	list	is	
updated/refreshed	weekly	and	the	inmate	arrived	just	after	the	last	update	and	before	the	
next	one.		There	are	probably	other	valid	and	understandable	reasons	for	the	discrepancy	
as	well	but	in	the	worst-case	scenario,	inmates	will	be	missed	for	follow-up	appointments	
because	they	are	not	listed	on	the	roster	which	is	used	for	scheduling.		In	any	event,	I	
suggested	on	site	that	developing	a	mechanism	to	ensure	the	roster	list	was	reconciled	
more	regularly	with	the	MARs/inmates	physically	present	at	the	facility	to	promote	better	
tracking/efficiency	and	follow-up	could	be	worthwhile	Continuous	Quality	Improvement	
(CQI)	project.		
	
BSO	Program	Staff	at	JVCF:	
7.5	FTE:		1.0	FTE	Supervisor	(Jones),	4.5	FTE	SAP	staff;	2	FTE	in	Life	Skills	(1	FTE	is	vacant)		
	
Armor	mental	health	staffing	at	JVCF:	
•

Psychiatrist	works	3	days	per	week;	0.6	FTE		

•

ARNP	works	1	day	per	week;	0.2	FTE	(also	works	at	NBB)	

•

Licensed	Mental	Health	Counselor	works	1	day	per	week;	0.2	FTE	(He	also	works	at	
Main	Jail	0.8)		

	
	

BSO	Program	staff	do	not	provide	mental	health	treatment	per	se,	they	provide	

programs.		There	are	significant	differences.		To	name	just	a	few:		BSO	program	staff	do	not	
write	progress	notes	in	the	medical	record	and	the	specific	programs	are	not	reflected	as	
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an	intervention	specific	to	a	particular	mental	health	problem	on	the	mental	health	
treatment	plan.		Inmate	progress	toward	goal	attainment	is	not	measured	or	reviewed	by	
members	of	the	treatment	team	or	discussed	in	treatment	team	meetings.		This	is	not	
intended	as	a	criticism	of	the	BSO	programs,	which	are	quite	good;	they	are	simply	not	
provided	as	mental	health	treatment	interventions	specific	to	inmates	with	mental	illness,	
they	are	programs.		Armor	mental	health	staffing	levels	permit	nothing	in	terms	of	mental	
health	treatment	except	very	brief	medication	management	appointments	at	monthly	
intervals	given	the	size	of	the	jail	and	the	numbers	of	inmates	on	the	mental	health	
caseload	prescribed	psychotropic	medication.	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
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Paul	Rein	Detention	Facility	(PRF)		
	
Site	visit	–	5/17/17	
	
	
	
PRF	houses	minimum	and	medium	security	male	and	female	inmates.		The	capacity	
of	the	jail	is	1068	but	the	census	on	the	day	of	the	site	visit	was	728,	which	has	been	fairly	
typical	for	some	time.		There	were	242	inmates	at	the	facility	on	psychotropic	medication	
(33%	of	the	facility	population	though	proportionately	more	women	than	men	were	on	
medications.		The	Director	of	Nursing	explained	that	while	women	constituted	only	about	
¼	of	the	population,	they	represented	about	½	of	the	number	of	inmates	on	medications.		
This	is	not	atypical	with	female	inmates	throughout	the	country.)			
	
	

The	physical	plant	floor	plan	at	PRF	is	essentially	the	same	as	that	of	Conte	with	the	

exception	that	a	wall	divides	adjacent	units	(rather	than	simply	open	space	between	the	
two	as	at	Conte.)		There	are	two	towers	(C	and	D)	containing	8-9	housing	units.		Women	are	
housed	on	C	tower;	Men	on	D	tower.	Supervision	is	direct	–	a	correctional	officer	is	right	on	
the	unit	in	direct	contact	with	the	inmates.		In	some	of	the	housing	units	(for	the	minimum	
inmates),	the	“cells”	are	multi-person	and	really	just	cubicles	with	partial	walls	that	do	not	
reach	the	ceiling	with	no	doors.		These	are	on	the	third	floor	of	the	facility	and	called	“open”	
units.		The	1st	floor	housing	units	are	“closed”	–	contain	actual	multi-person	cells.	
	
	

There	is	a	medical	exam	room	on	each	housing	unit.		It	is	used	for	mental	health	

appointments	as	well	as	nursing	sick	call.		There	is	sufficient	classroom/group	treatment	
space	in	the	hallway	just	outside	but	connected	to	the	housing	unit.		This	eliminates	the	
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need	for	security	escorts	to	programs	as	the	inmates	simply	enter	the	central	corridor	
where	the	programming	space	is	located	directly	from	the	housing	unit	rather	than	having	
to	be	escorted	to	some	other	location.	
	
	

C	Tower,	housing	female	inmates,	contains	units	for	disciplinary	and	administrative	

segregation.	(Housing	unit	C4	contains	28	beds	for	disciplinary	segregation	and	C5	is	
administrative	segregation	and	has	20	beds.)		At	the	time	of	the	site	visit,	there	were	8	
women	on	disciplinary	segregation,	3	were	prescribed	psychotropic	medication	(37.5%).		
There	were	14	women	on	administrative	segregation,	12	(86%)	of	whom	were	on	
psychotropic	medication.		This	degree	of	difference	between	the	prevalence	of	women	on	
the	mental	health	caseload	in	population	and	disciplinary	segregation	versus	the	very	high	
prevalence	of	women	on	the	mental	health	caseload	in	administrative	segregation	is	
remarkable	and	is	ripe	for	a	quality	improvement	study	to	determine	the	cause(s)	–	
particularly	in	light	of	the	evidence	that	inmates	with	serious	mental	illness	do	not	do	well	
in	long-term	segregation	settings.		Health	care	staff	conduct	a	file	review	prior	to	placement	
in	administrative	segregation	to	determine	whether	there	are	any	contraindications	for	
placement	or	need	for	accommodation.		The	charts	of	inmates	in	administrative	
segregation	contained	the	pre-placement	documentation	but	none	of	them	found	
contraindications	to	placement	or	recommended	any	accommodations.		Inmate	MD’s	
confinement	clearance	form	indicated	she	was	on	psychotropic	medication,	had	a	prior	
history	of	self-harm,	was	diagnosed	with	major	mental	illness	and	had	been	on	behavioral	
health	monitoring	status	within	the	preceding	90	days,	but	she	was	sent	to	segregation	in	
spite	of	multiple	risk	factors	and	there	was	no	documentation	that	facility	mental	health	
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staff	were	notified	of	the	placement.		(MD’s	case	is	summarized	in	the	Appendix	on	page	53.		
Additional	examples	of	inmates	cleared	for	placement	include	inmates	SM,	DC	and	SD	
summarized	on	pages	54-55.)			
	
	

Inmates	in	administrative	segregation	are	reviewed	weekly	for	8	weeks	by	a	

multidisciplinary	staff	that	includes	the	Director	of	Nursing;	thereafter,	the	team	reviews	
them	monthly.		A	referral	for	mental	health	assessment	is	routine	after	8	weeks	of	
confinement.		Inmates	in	segregation	can	be	seen	by	mental	health	staff	privately	in	a	
medical	room	located	off	the	dayroom	or	at	tables	on	the	dayroom	floor	(which	is	not	
confidential.)		Staff	reported	that	inmates	in	segregation	are	permitted	out	of	cell	1	hour	
per	day,	7	days	per	week.		Deputies	supervising	inmates	in	segregation	units	or	other	
program	units	take	40-hour	Crisis	Intervention	Team	(CIT)	training	and	have	an	annual	
refresher	course	as	well.	
	
	

There	was	a	restraint	chair	in	the	hallway	between	segregation	units.		I	asked	about	

its	use	the	Director	of	Nursing	reported	that	it	hadn’t	been	used	in	at	least	the	last	5	years.		
She	further	reported	recalling	only	1	instance	of	the	need	for	a	cell	extraction	during	the	12	
years	that	she	has	been	at	PRF.	
	
	

Also,	similar	to	programming	at	Conte,	BSO	Program	staff	at	PRF	provide	SAP,	Life	

skills	Program	and	a	Lifestyles	program.		There	is	also	a	GED	program	at	PRF.		BSO	
Program	staff	do	not	provide	mental	health	treatment.	

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Armor	mental	health	staff	primarily	provide	psychotropic	medication	management.		

There	is	a	Psychiatric	Physician’s	Assistant	at	PRF	four	days	per	week,	0.8	FTE.		A	licensed	
mental	health	counselor	is	at	PRF	on	Sundays.		Inmates	requiring	crisis	care	or	watch	
placement	are	transferred	to	NBB.		Staff	reported	transfers	are	timely	though	I	did	not	see	
any	logs	to	quantify	the	timeliness	of	the	transfers.		There	is	a	safe	space	in	the	intake	area	
of	the	facility	–	a	large	cell	that	permits	direct	visibility	into	all	areas	from	the	officer’s	
station	immediately	across	from	it	(a	“fish	tank”	cell.)		This	is	used	to	temporarily	house	
suicidal	inmates	until	they	are	moved	to	NBB.			
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
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Systematic	Screening	and	Evaluation	
	
	
The	Main	Jail	serves	as	the	centralized	intake	and	booking	facility	for	the	jail	system.		
An	initial	screening	is	conducted	by	trained	emergency	medical	technicians	at	the	front	
door	of	the	jail	on	every	inmate	entering	the	system.		The	initial	screening	process	is	
intended	to	ensure	that	inmates	are	sufficiently	medically	stable	to	be	admitted	to	the	jail	
and	to	identify	other	critical	needs	such	as	drug	withdrawal,	the	need	for	suicide	watch	and	
other	conditions	that	require	medical	attention	such	as	diabetes	and	hypertension.		There	
are	additional	levels	of	medical	and	mental	health	screening	following	the	booking	
procedure.		Appropriately	trained	and	credentialed	Armor	staff	complete	these	
assessments.		Inmates	who	screen	with	a	positive	mental	health	screen	are	referred	on	for	
a	more	comprehensive	evaluation.			
	
	

Based	on	my	review	of	many	records,	the	measured	prevalence	rate	of	inmates	with	

mental	illness	in	the	system	and	Armor’s	own	quality	assurance	auditing,	the	processes	
appear	adequate	procedurally.		However,	there	are	some	components	of	the	process	
requiring	focused	improvement	to	facilitate	access	to	the	appropriate	and	necessary	level	
of	care	at	the	earliest	possible	time,	improve	timeliness	of	identification	and	sustain	
adequacy.			
	
	

The	initial	screening	should	contain	a	mechanism	to	divert	not	only	inappropriate,	

critical	medical	conditions	from	the	jail,	but	also	divert	cases	of	complicated	drug	
withdrawal	that	require	hospital	management	and	expedite	the	referral	of	persons	in	need	
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of	psychiatric	hospitalization	to	that	level	of	care.		Several	examples	were	found	in	record	
reviews.			
	
	

Inmate	LB	was	“agitated,	bizarre”	at	the	time	of	intake	to	the	jail	7/28/16	to	the	

extent	that	the	mental	health	screening	could	not	be	completed,	but	he	was	accepted	into	
the	jail	where	he	has	steadily	deteriorated.		At	the	time	of	my	site	visit	to	NBB,	he	was	
locked	in	a	closed	mental	health	unit	and	appeared	regressed	to	the	point	where	he	
expressed	no	meaningful	communication.		(A	full	summary	of	his	case	is	found	in	the	
Appendix	on	pages	24-25.)			This	is	an	example	of	a	person	that	should	have	been	
immediately	referred	to	a	psychiatric	hospital	after	being	processed	rather	than	being	
maintained	at	the	jail.		(Florida	state	law	requires	persons	arrested	for	a	felony	be	
processed	through	a	jail	before	going	to	a	psychiatric	hospital,	although	acceptance	into	the	
hospital	is	not	guaranteed.		Nevertheless,	the	jail	has	to	refer	these	cases	immediately	after	
processing	rather	than	maintaining	them	in	the	jail	for	weeks	or	months	before	
contemplating	attempts	to	psychiatrically	hospitalize.)		
	
	

Inmate	CB	had	a	history	of	substance	abuse	and	treatment	for	depression.		This	

information	was	known	at	the	time	of	his	booking	into	the	jail,	but	his	mental	health	
referral	was	“routine”	although	he	was	placed	into	a	detox	unit.		Therefore,	he	was	not	
evaluated	by	mental	health	prior	to	his	death	by	suicide	the	following	day.		Substance	abuse	
and	treatment	for	depression	are	significant	risk	factors	for	suicide	and	should	have	
triggered	an	immediate	mental	health	referral	for	a	suicide	risk	assessment.		The	suicide	
death	was	reviewed	but	processes	to	triage	and	prioritize	mental	health	referrals	for	
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suicide	risk	assessment	of	individuals	with	psychiatric	history	and	drug	withdrawal	have	
not	changed	and	do	not	include	an	immediate	referral	when	these	factors	are	present.			
(The	full	summary	of	CB	is	found	on	pages	64-65	of	the	Appendix.)	

	

	
	

Attempting	to	psychiatrically	hospitalize	inmates	in	need	of	a	higher	level	of	care	

than	can	be	provided	in	a	jail	at	the	earliest	possible	time	is	particularly	important	for	
several	reasons.		One	reason	is	to	be	able	to	ensure	that	care	is	provided	timely	so	that	the	
response	to	treatment	is	timely	and	the	response	to	treatment	is	better	the	sooner	that	
treatment	is	started.		Another	reason	is	that	as	inmates	continue	to	deteriorate	and	become	
increasingly	ill,	civil	hospitals	are	less	likely	to	agree	to	take	them	which	makes	timely	
access	to	inpatient	care	essentially	non-existent.		The	clinical	need	for	psychiatric	
hospitalization	takes	a	back	seat	to	containment	–	civil	hospitals	will	not	accept	“violent”	
jail	detainees	and	even	the	Baker	Act5	pre-screeners	who	come	to	the	jail	to	determine	
whether	or	not	to	approve	inmates	for	admission	to	the	hospital	seem	to	believe	that	
holding	people	in	segregation,	or	a	closed	mental	health	unit	or	a	in	a	crisis	cell,	without	
treatment	is	the	equivalent	of	psychiatric	inpatient	care	and	don’t	approve	the	transfer	to	a	
hospital	level	of	care.		(This	will	be	discussed	more	fully	in	the	treatment	section	of	the	
report	relating	to	hospitalization.)		After	the	inmate	is	denied	access	to	a	hospital	level	of	
care	by	way	of	the	Baker	Act,	the	only	effective	means	of	accessing	care	requires	a	legal	
finding	of	incompetence	to	stand	trial,	but	that	generally	doesn’t	happen	until	after	months	

																																																								
5	The	Baker	Act	is	the	Florida	law	regarding	involuntary	psychiatric	hospitalization	and	
pre-screeners	come	to	the	jail	to	determine	eligibility	for	hospital	admission	when	Armor	
mental	health	staff	file	an	application	for	hospital	admission.	
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of	a	jail	stay,	severely	delaying	access	to	care.			Delayed	access	to	hospital	level	of	care	leads	
to	worsening	of	symptoms	increasing	the	risk	of	harm	to	self	and	others,	a	delayed	
response	to	treatment	and	a	less	robust	treatment	outcome.	
	
	

Multiple	instances	of	persons	being	considered	too	psychiatrically	ill,	uncooperative	

or	unsafe	to	complete	the	medical	intake	process	were	discovered	in	record	reviews.		In	
these	instances,	medical	assessment	forms	were	simply	marked	as	“refused”	or	“unable	to	
complete.”		There	was	no	documentation	that	the	intake	evaluation	was	completed	at	a	
later	point	in	the	inmate’s	jail	stay,	regardless	of	the	length	of	stay.		Persons	with	serious	
mental	illness	can	also	have	serious	medical	problems	that	must	be	assessed	and	treated.		
Failing	to	do	so	can	have	disastrous	consequences.	
	
	

Inmate	RP	was	unable	to	be	screened	at	the	time	of	intake	because	he	“sits	there	and	

talks	to	himself,	won’t	answer	questions.”		The	health	assessment	form	has	a	line	drawn	
across	the	page	diagonally	with	the	word	“Refused”	hand-written	on	the	paper	as	well.		RP	
was	accepted	into	the	jail	and	housed	in	NBB	mental	health	units.		He	displayed	signs	of	
serious	medical	problems	that	included	significant	weight	loss,	blood	in	his	urine	and	
swollen	feet	with	“wounds”	according	to	the	mental	health	PA.		Eventually,	RP	was	sent	out	
to	a	medical	hospital	where	he	was	admitted	to	the	intensive	care	unit.		When	he	returned	
to	the	jail	after	his	hospital	stay,	he	was	initially	admitted	to	the	NBB	infirmary,	but	then	
sent	to	closed	mental	health.		He	remained	there	until	he	was	discovered	unconscious	and	
subsequently,	he	died.		(RP’s	summary	is	on	pages	68-69	of	the	Appendix.)		RP	was	in	the	

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jail	in	2012,	but	current	record	reviews	demonstrate	that	these	types	of	problems	continue	
to	exist.	
	
	

Inmate	SO	was	physically	ill	when	booked	into	the	jail	3/22/16,	having	been	

hospitalized	medically	just	prior	to	his	booking.		He	had	cirrhosis	of	the	liver,	ascites,	
varices	and	hepatosplenomegaly.		Nevertheless,	he	was	admitted	to	a	detox	floor	and	
remained	there	for	the	duration	of	his	time	in	the	jail.		His	physical	condition	continued	to	
deteriorate.		On	3/25/16,	he	was	found	face	down	on	the	floor	with	labored	respirations	
and	unable	to	get	up	without	the	assistance	of	two	other	people.		He	was	kept	at	the	jail	on	
the	detox	unit	another	10	days	until	an	emergency	transfer	out	to	the	hospital.		He	did	not	
return	to	the	jail.			(SO’s	case	is	summarized	on	page	74	of	the	Appendix.)6			
	
	

The	above	cases	are	relevant	to	mental	health	care	because	they	exemplify	the	

problems	with	access	to	appropriate	medical	care	when	housed	in	mental	health	or	detox	
units	which	is	why	the	medical	assessment	at	intake	is	so	important	–	and	cannot	be	left	
undone	or	incomplete.		
	
	

ED,	an	inmate	with	serious	mental	illness	in	jail	since	7/18/16,	never	had	a	medical	

assessment	completed.		Initially,	he	refused	it	and	then	the	medical	health	assessment	form	
contains	“behavior	inappropriate”	written	across	the	second	page	dated	8/1/16.		As	of	the	

																																																								
6	BSO	reported	that	this	case	is	in	litigation	and	the	facts	are	subject	to	dispute.	
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time	of	his	file	review	in	November,	the	assessment	remained	undone.		(Inmate	ED’s	
summary	is	on	pages	12-13	of	the	Appendix.)	
	
	

The	Armor	quality	assurance	audits	of	the	mental	health	intake	process	are	

quantitative	in	nature	and	contain	no	measure	or	assessment	of	quality.		The	audits	consist	
of	questions	that	address	completion	of	forms,	whether	referrals	are	seen,	and	compliance	
with	time	frames	articulated	in	policy	that	require	only	a	“yes”	or	“no”	finding.		Additional	
multi-step	items	such	as	whether	medications	requiring	laboratory	testing	have	those	
multiple	labs	ordered,	drawn,	reported	and	reviewed,	contain	only	one	simple	“yes”	or	“no”	
response	which	doesn’t	permit	an	analysis	of	whether	there	are	problems	at	any	step	in	the	
process	or	with	a	particular	medication	or	lab	study.		Inmates	may	be	on	multiple	
medications	that	require	multiple	types	of	laboratory	studies.		The	presence	or	absence	of	
other	forms,	such	as	the	treatment	plan,	provides	no	indication	of	whether	the	plan	is	
complete,	individualized,	meaningful	or	relevant.			
	
	

Staffing	levels	and	task	assignment	impact	the	quality	of	psychiatric	assessments	

completed	at	the	Main	Jail.		The	assessments	are	cursory	due	to	insufficient	staffing	and	the	
delegation	of	this	task	to	the	psychiatrist	and	ARNP	at	the	Main	Jail,	rather	than	including	
other	licensed	mental	health	staff	that	are	permitted	to	assess	and	diagnose	mental	illness	
by	virtue	of	training	and	state	law.		(The	part-time	licensed	mental	health	counselor	does	
do	some	initial	psychiatric	assessments,	but	diagnosis	and	treatment	plans	are	left	to	the	
prescribing	professionals.		The	full-time	psychologist	does	detox	evaluations	and	some	
counseling.)		In	addition,	there	is	potentially	an	issue	with	regard	to	whether	the	Main	Jail	
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psychiatrist	has	a	tendency	to	minimize	inmate	psychiatric	complaints	and/or	attribute	
their	reports	of	symptoms	to	malingering	for	secondary	gain.			There	were	many	examples	
of	this	tendency.		One	case,	inmate	CS	entered	jail	4/27/17.		He	was	tearful	at	the	time	and	
facing	charges	of	murder.		ARNP	Keane	did	the	initial	mental	health	evaluation	4/28/17.		
The	psychiatrist	saw	the	inmate	5/1/17	and	diagnosed	“adjustment	disorder	with	
depressed	mood”	though	both	antidepressant	(Celexa)	and	antipsychotic	(Risperdal)	
medications	were	ordered	for	him,	which	would	seem	to	indicate	something	more	severe	
than	an	adjustment	disorder.		Eventually,	the	diagnosis	was	updated	to	Major	Depressive	
Disorder	with	psychotic	features,	but	the	case	exemplifies	my	concern	regarding	the	
tendency	to	minimize	symptomatology,	diagnoses	and	draw	conclusions	about	secondary	
gain	–	and	particularly	the	psychiatrist	at	MJ	–	the	front	door	to	services.		(The	CS	case	is	
summarized	on	page	39	in	the	Appendix.)			Other	examples	include	HB	(page	2	in	the	
Appendix),	CW	and	LT	(page	34),	W	(pages	36-37)	and	RA	(page	41).		This	issue	should	be	
monitored	and	addressed	with	a	meaningful	peer	review	process,	and	although	there	are	
other	mechanisms	for	referral	and	assessment	later	in	an	inmate’s	jail	stay,	identification	at	
the	front	door	is	absolutely	critical	to	ensure	timely	access	to	care.		Delays	in	accessing	care	
increases	the	risk	of	worsening	symptoms	and	increased	suffering	and	the	risk	of	harm	to	
self	and	others.		Sufficient	staffing	levels	to	permit	a	more	time	to	conduct	these	
evaluations	would	also	be	helpful	as	would	permitting	rotation	of	psychiatric	staff	to	
perform	this	task	at	intake	to	prevent	burn	out.	
	
	

It	was	often	difficult	to	determine	whether	or	not	outside	treatment	records	were	

requested,	much	less	received	and	reviewed	in	many	of	the	charts	I	reviewed.		Armor	staff	
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reported	that	many	times	even	when	records	are	requested,	outside	treatment	facilities	do	
not	send	them.		This	seems	to	have	had	the	effect	of	discouraging	the	process	of	requesting	
such	records	(in	spite	of	a	policy	requirement	to	request	them)	rather	than	stimulating	a	
discussion	with	outpatient	treatment	providers	to	send	the	records.		Review	and	
incorporation	of	information	contained	in	outside	treatment	records	permits	a	more	wellrounded	assessment	of	diagnosis	and	functional	capacity	than	can	be	completed	with	a	1520-minute	examination	in	a	jail	where	the	only	information	is	self-report	and	it	improves	
continuity	of	care,	particularly	with	regard	to	psychotropic	medication	management.			It	is	
particularly	important	to	verify	outside	medication	prescriptions	and	there	appears	to	be	
no	reliable	process	to	do	this	in	every	case	of	an	inmate	booked	into	the	jail.		Medication	
continuity	is	important	for	patient	care	to	maintain	stability	or	improve	condition	with	a	
medication	known	to	have	worked	in	the	past	rather	than	starting	the	process	from	scratch	
over	and	over	with	different	medications,	risking	a	re-emergence	of	symptoms,	needless	
suffering	and	increased	risk	of	harm	to	self	or	others	as	a	result	of	decompensation.			
	
Additional	examples	of	problems	with	failing	to	get	or	consider	information	from	
outside	treatment	records	include	inmate	II	who	was	transferred	directly	into	the	jail	from	
the	South	Florida	Evaluation	and	Treatment	Center,	where	he	had	been	hospitalized	for	3	
½	months.		Upon	reception	at	the	jail,	II	refused	his	initial	health	assessment	including	a	
test	for	tuberculosis.		For	this	reason,	he	was	housed	in	an	infirmary	isolation	cell	from	
7/29/16	“until	further	notice.”		II	was	still	in	that	infirmary	isolation	cell	at	NBB	at	the	end	
of	August	when	I	visited	the	jail.		When	I	learned	he	had	come	directly	from	the	state	
hospital,	I	asked	to	see	the	records	and	in	fact,	II	had	a	tuberculin	skin	test	at	the	hospital	–	
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which	was	negative.		He	did	not	need	another	one	at	the	jail	and	he	did	not	need	to	be	kept	
in	isolation	in	the	infirmary.		The	records	from	the	hospital	were	actually	at	the	jail	but	had	
not	been	reviewed	which	led	to	housing	II	in	infirmary	isolation	unnecessarily.		After	my	
site	visit,	II	was	relocated	to	general	population	housing.		(II’s	case	is	summarized	on	pages	
13-14	of	the	appendix.)	
	
Inmate	MW	had	a	long-standing	diagnosis	of	schizophrenia	and	received	outpatient	
care,	including	psychotropic	medication,	at	the	Veterans	Administration	(VA).		He	refused	
to	take	psychotropic	medication	in	the	jail	until	the	VA	records	came	to	the	jail	to	verify	the	
medication	regularly	prescribed	to	him.		He	signed	a	release	of	information	to	get	the	
records.		MW	explained	this	to	me	in	August	2016	and	again	in	February	2017	and	it	is	also	
documented	in	the	progress	notes	of	his	chart;	he	was	waiting	for	verification	of	his	
medication	from	the	VA	and	said	he	would	take	that	medication,	but	not	other	substitutes.		
When	I	inquired	whether	the	VA	records	had	arrived,	Armor	PA	Shootes	checked	and	found	
a	stack	of	records	from	the	VA	that	was	about	2”	tall.		It	was	not	clear	when	they	arrived,	
but	it	was	clear	that	they	hadn’t	been	reviewed.		MW	was	prescribed	a	small	daily	dose	of	
Seroquel	from	the	VA.		PA	Shootes	told	me	that	it	was	not	on	formulary	and	she	would	not	
make	a	non-formulary	request.		MW	remained	psychotic	in	the	jail,	outside	treatment	
records	were	not	reviewed	when	they	arrived	and	in	spite	of	verification	of	a	valid	
prescription,	Armor	refused	to	prescribe	the	medication	for	him.		(MW’s	case	is	
summarized	in	the	appendix	on	page	17.		His	case	also	illustrates	issues	around	
psychotropic	medication	which	are	more	fully	described	in	a	later	section	of	this	report.)	

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Inmate	P	was	housed	in	administrative	segregation	when	I	saw	him	2/9/17.		He	had	
been	returned	from	the	state	hospital	after	a	3	½	month	stay	and	underwent	intake	to	the	
jail	1/4/17.		The	only	information	that	accompanied	him	from	the	state	hospital	was	a	
medication	list.		Medications	were	ordered	at	the	jail	as	the	“inmate	is	well	known	to	jail	
from	prior	stays.”		There	was	no	indication	that	any	additional	information	about	his	
hospital	stay	was	requested.		When	I	spoke	with	him,	he	was	clearly	psychotic	and	
provided	irrelevant	and	mostly	incoherent	responses	to	questions.		Continued	confinement	
in	administrative	segregation,	which	makes	symptoms	worse,	was	contraindicated.		Review	
of	hospital	records	describing	the	inmate’s	condition	there,	progress	in	treatment	and	
interactions	with	others	is	useful	information	in	determining	housing	placement	at	the	jail.		
If	Armor	mental	health	staff	gave	any	consideration	to	his	placement	in	segregation	being	
contraindicated	based	upon	his	being	a	state	hospital	return	and	current	psychotic	mental	
state,	it	was	not	documented	in	the	record.		(Inmate	P’s	case	is	summarized	in	the	appendix	
on	pages	37-	38.)	
	
Failure	to	request	and	review	outside	treatment	records	can	result	in	delayed	access	
to	care	or	even	denial	of	effective	treatment;	it	prolongs	jail	stays	and	leads	to	needless	
suffering	and	mental	decompensation	increasing	the	risk	of	harm	to	self	and	others.		
Requests	for	outside	treatment	records	should	be	made	at	the	time	of	intake/reception	into	
the	jail	which	is	why	these	case	examples	are	provided	in	this	section	of	the	report	
although	much	of	the	same	information	is	also	relevant	to	the	later	section	on	Records.			
Actually	reviewing	outside	treatment	records	and	considering	the	information	contained	in	

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them	are	equally	important	with	requesting	the	records	in	developing	a	timely	and	
clinically	appropriate	treatment	plans	for	inmates	in	the	jail.	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
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TREATMENT	
	
	
Treatment	is	more	than	mere	seclusion	or	close	supervision.		Jail	inmates	with	
serious	mental	illness	must	have	access	to	the	continuum	of	mental	health	care,	including	
timely	access	to	an	inpatient	level	of	care.		Inmates	in	the	Broward	County	Jails	are	not	
given	access	to	adequate	mental	health	care.		Access	to	inpatient	care	is	nearly	non-existent	
except	when	court	ordered	for	restoration	of	competence	to	stand	trial.	
	
	

Deficiencies	related	to	the	provision	of	mental	health	treatment	have	been	grouped	

under	separate	headings	and	sub-categories	though	there	are	items	that	may	cut	across	
several	areas.			
	
Outpatient	mental	health	care	
	
	
This	level	of	care	is	analogous	to	outpatient	care	in	the	community.		Patients	are	
clinically	stable,	and	their	behavior	and	functioning	are	not	impaired	or	only	mildly	
impaired.		Patients	function	well	in	a	community	setting	and	have	periodic	appointments	
with	a	mental	health	professional	that	may	include	a	mental	health	counselor	and	a	
psychiatrist	(or	other	person	licensed	to	prescribe	medication.)		The	frequency	of	
appointments	is	based	upon	the	clinical	stability	of	the	patient	as	well	as	the	type	of	
treatment	interventions	being	provided	and	may	range	from	weekly	group	treatment	or	
counseling	appointments	to	monthly	support	sessions	and	quarterly	medication	
management	appointments.		In	the	community,	mental	health	staffing	levels	are	sufficient	
to	be	able	to	respond	quickly	to	crises	and	increase	therapeutic	contacts	until	the	crisis	is	
resolved.		Unfortunately,	this	is	not	the	manner	in	which	outpatient	services	are	provided	
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in	the	jails.		Although	the	majority	of	inmates	with	serious	mental	illness	are	housed	in	
general	population	and	receive	outpatient	care,	there	are	insufficient	numbers	of	Armor	
staff	to	provide	an	adequate	level	of	treatment	service	to	inmates	with	serious	mental	
illness	residing	in	general	population;	there	are	no	mental	health	groups	offered	and	
individual	counseling	is	not	available	to	the	vast	majority	of	inmates	on	the	mental	health	
caseload.		
	
	

Outpatient	care	at	the	Broward	County	Jails	consists	almost	exclusively	of	

psychotropic	medication	if	the	inmate	consents	to	take	it.			There	is	virtually	no	other	
mental	health	treatment	as	a	consequence	of	insufficient	staffing,	both	in	terms	of	the	types	
of	mental	health	staff	providing	services	as	well	as	the	numbers	of	staff	to	provide	care	to	
the	majority	of	inmates.		Inmates	are	seen	at	intervals	of	three	months	for	medication	
management	and	have	a	brief	monthly	contact	with	a	mental	health	counselor,	although	
sometimes	these	two	types	of	visits	are	combined	into	one	contact	to	ensure	that	everyone	
on	the	caseload	gets	seen.		There	is	not	enough	psychiatric7	time	to	provide	adequate	
assessment	and	follow-up	in	response	to	clinical	need.		Mental	health	clinician	positions	are	
also	severely	deficient.		Conte	and	Paul	Rein	Facilities	each	have	a	mental	health	counselor	
available	only	one	day	per	week	for	a	combined	population	of	approximately	1700	inmates,	
more	than	550	of	whom	are	on	the	mental	health	caseload.		Outpatient	treatment	plans	are	
meaningless;	purport	to	offer	services	that	simply	don’t	exist;	contain	no	measurable	

																																																								
7	In	this	section,	the	term	psychiatrist	is	intended	to	include	psychiatric	physicians	as	well	
as	mid-level	providers	(ARNPs	and	PAs).	
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objectives;	and	are	never	updated	to	reflect	any	change	in	the	inmate’s	condition	(suicide	
watch	placements,	transfers	to	NBB,	etc.)	no	matter	how	long	the	jail	stay.			
Inmate	AR	is	housed	at	Conte	and	receives	outpatient	services.		He	is	seen	monthly	
by	the	mental	health	counselor	who	completes	a	Mental	Health	Rounds/Contact	Form	and	
is	prescribed	antipsychotic	medication.		The	medication	was	increased	5/8/17	because	he	
reported	a	worsening	of	symptoms.		However,	there	was	no	plan	for	more	frequent	contact	
by	either	the	counselor	or	psychiatrist	to	determine	whether	the	dose	increase	was	
effective	or	to	provide	any	other	mental	health	intervention	in	response	to	the	inmate’s	
break-through	symptoms.		(AR’s	case	is	on	pages	45-46	of	the	Appendix.)			
	
DI	was	housed	in	disciplinary	segregation	at	the	time	of	the	PRF	site	visit.	Her	initial	
mental	health	evaluation	was	dated	2/17/17	and	she	was	diagnosed	with	an	anxiety	
disorder.		She	was	prescribed	Atarax	for	anxiety.		In	March,	the	medication	was	
discontinued,	and	she	was	prescribed	a	different	medication,	Buspar.		The	dosage	of	Buspar	
was	increased	at	subsequent	psychiatry	appointments	4/12/17	and	5/10/17	because	the	
inmate	reported	continued	symptoms	of	anxiety.		No	other	treatment	interventions	were	
provided;	no	counseling,	no	group	or	individual	therapy.		The	frequency	of	contacts	was	
not	increased	in	response	to	continued	symptoms.		The	treatment	plan,	dated	2/16/17	(the	
day	before	the	mental	health	evaluation	was	dated),	was	not	updated	or	changed	in	any	
way.		(A	more	complete	summary	of	DI	is	found	in	the	Appendix,	pages	52-53.)	
	
	

Inmate	HA	was	sent	from	the	Main	Jail	to	NBB	4/8/17;	from	NBB	to	PRF	4/13/17;	

from	PRF	back	to	NBB	saying	she	didn’t	want	to	live	anymore;	and	returned	from	NBB	to	
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PRF	4/26/17.		She	was	housed	in	administrative	segregation	at	the	time	of	the	site	visit.		
HA	was	not	seen	for	follow-up	from	having	been	on	suicide	watch	until	4/30/17,	four	days	
after	returning	from	NBB.		She	was	not	seen	by	psychiatry	until	5/11/17.			HA	has	been	
bounced	back	and	forth	between	facilities,	but	her	treatment	plan	is	not	changed,	she	has	
no	treatment	except	medication	and	is	currently	housed	in	administrative	segregation.		(HA	
case	is	summarized	on	page	55	of	the	Appendix.)		HA	also	reported	that	she	stopped	taking	
her	medications	because	she	felt	she	no	longer	needs	them.		HA	presents	multiple	risk	
factors	for	suicide	–	history	of	psychiatric	hospitalization,	prior	suicide	watch	placements,	
non-compliance	with	medication,	placement	in	administrative	segregation	to	name	a	few.		
Yet,	there	is	no	change	in	the	frequency	of	intensity	or	types	of	contacts,	support	or	closer	
mental	health	monitoring	of	her	condition.	
	
	

Maintenance	care	and	access	to	care	at	an	early	stage	of	a	problem	or	at	the	earliest	

sign	of	symptom	recurrence	can	prevent	the	progression	to	a	full-blown	crisis,	suicide	
watch,	transfer	and	admission	to	NBB	or	need	for	inpatient	level	of	care.		Infrequent	
contacts	and	Armor	staffing	levels	do	not	permit	the	provision	of	this	level	of	care	–	
patients	not	identified	early	and	even	if	identified,	do	not	receive	additional	outpatient	
interventions,	more	frequent	contacts	or	mental	health	support	and	monitoring.			Clinical	
studies	have	demonstrated	that	the	effects	of	psychotropic	medication	are	enhanced	when	
combined	with	other	forms	of	mental	health	treatment.		Outpatient	services	are	inadequate	
and	this	places	inmates	with	mental	illness	at	risk	of	harm	to	self	or	others	and	to	
experience	needless	suffering.		
	
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Outpatient	mental	health	clinicians	should	play	a	role	with	security	staff	in	

attempting	to	de-escalate	crises	in	instances	when	a	planned	use	of	force	is	contemplated.		
This	can	help	in	avoiding	the	planned	use	of	force,	which	can	result	in	injuries	to	inmates	
and	staff.		(Obviously,	this	is	not	applicable	in	a	spontaneous	or	reactive	use	of	force	
situation.)		This	function	is	not	articulated	in	BSO	or	mental	health	policy	and	I	found	no	
documentation	that	this	function	occurred	in	the	clinical	records	reviewed.	
	
	

Mental	health	clinicians	should	also	play	a	consultative	role	in	the	disciplinary	

process	for	inmates	on	the	mental	health	caseload	or	for	any	other	inmate	for	whom	there	
is	a	concern	about	his	or	her	understanding	of	the	process,	behavior	or	mental	condition.		
Such	consultation	may	lead	to	temporary	or	permanent	diversion	of	the	inmate	into	
residential	mental	health	treatment	or	hospitalization	if	the	behavior	is	believed	to	be	a	
manifestation	of	serious	mental	illness.		In	other	instances,	an	alternative	sanction	to	
confinement	in	segregation	may	be	proposed.		I	did	not	find	this	function	articulated	in	BSO	
procedures	or	Armor	policy.		I	understand	a	similar	type	of	informal	consultation	may	
occur	some	of	the	time	in	some	situations,	but	it	needs	to	be	formal,	routine	and	occur	in	all	
relevant	situations.		This	can	lead	to	early	identification	of	symptom	recurrence,	diversion	
into	treatment	and	risk	reduction	through	treatment	interventions	aimed	at	addressing	the	
problematic	behaviors	rather	than	placement	into	segregation	which	is	harmful	to	inmates	
with	serious	mental	illness	and	simultaneously	makes	access	to	them	more	difficult	due	to	
the	required	security	precautions	in	effect	in	those	areas.	
	
	
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Mental	health	services	in	segregation	units	
	
	

There	is	growing	recognition	within	the	corrections	profession	of	the	harmful	

effects	of	segregation,	particularly	on	inmates	with	serious	mental	illness	though	others	
also	experience	harmful	psychological	effects.		Inmates	entering	segregation	should	be	
screened	for	contraindications	to	segregation	placement.		In	general,	inmates	with	serious	
mental	illness	should	not	be	placed	in	segregation	for	prolonged	periods	of	time.		(The	
2012	Position	Statement	of	the	American	Psychiatric	Association	defines	a	prolonged	
period	of	time	as	3-4	weeks.)		In	response	to	the	growing	recognition	of	the	harmful	effects	
of	segregation	on	inmates	with	serious	mental	illness,	some	correctional	systems	have	
developed	high	security	living	units	with	intensive	mental	health	care	into	which	inmates	
can	be	diverted	for	placement	when	necessary	for	the	safety	of	others	or	as	a	consequence	
of	a	rule	infraction	rather	than	being	sent	to	segregation.		In	systems	or	facilities	without	
this	option,	there	is	recognition	that	if	inmates	with	serious	mental	illness	are	put	into	
segregation	even	for	a	short	period	of	time,	mental	health	treatment	must	continue	in	
accordance	with	the	services	on	the	treatment	plan	or	be	enhanced	based	upon	the	clinical	
state	of	the	inmate	and	the	conditions	of	confinement.		Mental	health	staffing	levels	have	to	
be	sufficient	to	conduct	regular	rounds	in	segregation	and	clinical	interventions	when	
necessary	for	other	inmates	housed	there.			
	
	

Current	staffing	levels	in	the	jails	are	not	sufficient	to	provide	adequate	mental	

health	care	to	inmates	in	segregation.		Firstly,	although	there	is	a	medical	screening	
conducted	in	the	jails	prior	to	segregation	placement,	it	appeared	rote	and	did	not	lead	to	
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diversion	of	inmates	with	serious	mental	health	risk	factors	from	being	placed	in	
segregation.		In	fact,	it	didn’t	appear	to	result	in	notification	of	mental	health	staff	of	the	
placement	of	the	inmate	into	segregation	which	is	critical	in	terms	of	continuing	mental	
health	care	during	placement	in	segregation.		My	sample	was	small	but	the	process	seemed	
to	be	done	to	comply	with	policy	requirements	rather	than	with	an	understanding	of	the	
importance	or	purpose	of	doing	the	task.			
	
	

The	“Use	of	Confinement/Restraint	Clearance”	form	in	the	chart	of	inmate	FJ	

indicated	she	has	a	major	mental	illness	but	it	did	not	preclude	her	placement	into	
segregation	or	ensure	any	additional	mental	health	contact	or	monitoring	when	she	was	
there.		In	fact,	it	did	not	indicate	that	mental	health	staff	had	been	notified	of	her	placement	
in	order	to	assure	the	provision	of	regularly	scheduled	on-going	care.		(FJ	summary	is	on	
page	53	of	the	Appendix.)	
	
	

Inmate	DC	was	placed	into	segregation	5/4/17.		Pre-placement	screening	indicates	

“Yes”	in	responses	related	to	being	on	psychotropic	medication,	having	major	mental	
illness	and	being	on	special	accommodation	(detox	protocol).		However,	she	was	still	
“cleared”	for	confinement	and	mental	health	was	not	notified.	(DC	summary	is	on	page	54	
in	the	Appendix.)	
	
	

Inmate	SD	was	on	suicide	watch	at	NBB	4/6/17	–	4/17/17	for	having	placed	a	

plastic	bag	over	her	head	in	an	attempted	suicide.		The	watch	was	reduced	to	psych	
observation	until	4/20/17.		She	was	transferred	to	PRF	5/11/17	and	was	placed	into	
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segregation.		Pre-placement	clearance	indicates	“Yes”	responses	to	history	of	self-harm	
(plastic	bag	over	head)	and	behavioral	health	monitoring	status	in	the	last	90	days.		She	
was	not	excluded	from	placement	in	segregation,	nor	was	mental	health	staff	notified	of	the	
placement.			(SD’s	case	is	summarized	on	page	55.)	
	
	

If	not	diverted	altogether,	it	is	imperative	that	mental	health	staff	are	at	least	

notified	of	the	placement	of	caseload	inmates	in	segregation	–	an	area	where	
proportionately	more	suicides	are	completed	in	correctional	facilities	of	all	types.			As	it	
stands,	mental	health	staffing	levels	at	the	jails	permit	only	brief,	cell	front	contacts	(rounds	
in	segregation),	but	minimally,	mental	health	staff	should	be	aware	that	their	patients	are	
in	segregation	and	at	risk.		
	
Mental	Health	Unit	(MHU)	Residential	care	–	NBB	
	

The	mental	health	units	at	NBB	purport	to	be	treatment	units,	but	deficient	staffing	

levels,	inadequate	confidential	treatment	space	and	overall	failure	to	appreciate	the	
mission	of	residential	treatment	per	se,	make	these	open	mental	health	units	simply	an	
extension	of	any	other	general	population	outpatient	housing.		The	conditions	of	
confinement	in	the	closed	mental	health	units	actually	appear	to	mimic	the	conditions	in	
segregation	along	many	parameters	(limited	out	of	cell	time,	cell	front	contacts,	limited	
socialization)	rather	than	intensive	treatment	settings.			
	
	

Treatment	modalities	in	correctional	facility	residential	mental	health	housing	units	

generally	include	psychoeducational	groups,	psychotherapeutic	groups,	psychosocial	and	
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activity	groups,	individual	counseling	and	medication	management.		At	NBB,	there	is	
virtually	no	treatment	except	medication	for	the	majority	of	inmates	sent	there	for	mental	
health	treatment.		A	very	few	inmates	received	occasional	supportive	counseling	sessions,	
but	even	these	are	not	conducted	in	a	confidential	setting.		Individual	appointments	are	
conducted	at	a	table	in	the	common	area	of	the	housing	unit,	in	the	hallway	outside	of	the	
housing	unit	or	at	the	cell	front.	8		Confidentiality	is	a	necessary	requirement	for	all	of	
health	care,	but	particularly	mental	health	care.		BSO	program	staff	provide	
psychoeducational	programming	in	two	of	the	open	mental	health	units	though	this	is	
limited	to	inmates	that	are	stable	and	considered	“programming”	rather	than	“treatment”	
according	to	staff.	
	
	

There	are	no	clear	admission	or	discharge	criteria	from	the	NBB	mental	health	units.		

There	are	no	regularly	occurring	treatment	team	meetings.		Individual	inmate	condition,	
progress	toward	goal	attainment	and	adjustment	of	interventions	to	achieve	desired	
outcomes	should	be	reviewed	by	a	multidisciplinary	treatment	team	at	regular	intervals	
and	anytime	there	is	a	change	in	the	inmate’s	condition.		Every	inmate	should	have	an	
updated	treatment	plan	when	admitted	to	the	mental	health	units.		As	with	outpatient	
services,	the	treatment	plans	in	the	mental	health	units	are	meaningless.		They	do	not	
reflect	services	actually	provided	or	available	contain	no	objective	criteria	by	which	to	
measure	progress	and	are	not	updated	to	reflect	a	change	in	the	inmate’s	condition,	
placement	or	diagnosis.		There	are	no	treatment	program	guidelines	with	respect	to	the	
																																																								
8	This	practice	appears	unchanged	since	at	least	2006	when	Dr.	Metzner	recommended	it	
be	addressed.	
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types	and	frequency	of	treatment	interventions	to	be	provided	in	the	open	and	closed	
mental	health	units.	There	has	been	a	long-standing	recommendation	that	inmates	in	
residential	treatment	be	offered	at	least	10	hours	of	unstructured	out-of-cell	time	and	10	
hours	of	out-of-cell	structured	therapeutic	activity	per	week.			The	BSO	staff	programming	
units	exceed	these	guidelines	and	the	other	open	mental	health	units	provide	more	than	
the	requisite	10	hours	of	unstructured	out	of	cell	time.		The	closed	mental	health	units	
provide	neither.9		There	are	no	practice	guidelines	for	transitioning	inmates	out	of	the	
mental	health	units	back	into	population.		(Preparation	of	the	inmate	for	the	discharge,	
frequency	of	contacts	in	the	new	jail,	etc.)		The	lack	of	transitioning	can	have	severe	
consequences.			
	
	

Inmate	JV	entered	jail	2/15/13	as	a	state	hospital	return	with	diagnoses	of	

“malingering,	adjustment	disorder	with	mixed	anxiety	and	depressed	mood.”		While	in	
booking,	he	was	found	trying	to	hang	himself.		He	was	placed	on	suicide	watch	and	
admitted	to	the	infirmary	in	the	Main	Jail.		He	was	transferred	to	NBB	on	suicide	watch.			
	
	

JV	remained	at	NBB	for	a	little	over	a	year	and	was	“transferred	per	classification	

request	to	MJ”	on	March	3,	2014	though	the	transfer	acceptance	form	was	not	completed	at	
the	Main	Jail	until	March	7,	2014.		(He	appears	to	have	been	released	to	population	at	NBB	
for	a	matter	of	hours	prior	to	being	sent	to	population	in	the	Main	Jail.)		JV	committed	

																																																								
9	This	also	appears	unchanged	since	Dr.	Metzner’s	criticism	of	it	and	recommendations	
made	in	2006.	
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suicide	by	hanging	at	the	Main	Jail	on	March	8,	2014.		(JV’s	case	summary	is	on	pages	67-68	
of	the	Appendix.)	
	
	

The	NBB	mental	health	units	fail	to	provide	mental	health	treatment	interventions	

other	than	psychotropic	medication	for	the	majority	of	inmates	sent	there	for	treatment.		
BSO	program	staff	provide	daily	program	groups	on	two	of	the	open	mental	health	units	as	
described	earlier	in	the	NBB	section	of	this	report,	each	of	which	houses	21	inmates.			
However,	programming	in	the	closed	mental	health	units	is	especially	problematic.		
Coincidentally,	inmates	in	the	closed	mental	health	units	are	also	by	and	large,	the	most	
seriously	ill	and	symptomatic.			There	is	little	structured	programming	offered	in	the	closed	
units	and	inmates	can	remain	there	for	months	and	months	and	months,	suffering	and	
without	treatment	of	their	serious	mental	illnesses.		Some	of	these	inmates	refuse	
medication	and	the	jail	cannot	override	their	refusal.		Consequently,	they	are	too	ill	to	
participate	in	what	little	structured	treatment	is	offered	(an	“open”	mental	health	group)	
and	sometimes	too	ill	and/or	dangerous	to	be	let	out	of	their	cells	for	any	opportunity	for	
other	psychosocial	interactions	or	individual	assessment	or	counseling.		Some	of	the	
inmates	in	closed	mental	health	were	in	need	of	psychiatric	hospitalization.			
	
	

Inmate	LB	was	mentioned	in	the	Screening	and	Assessment	section	of	this	report,	

but	his	case	is	also	relevant	here	and	as	an	example	of	an	inmate	in	desperate	need	of	
psychiatric	inpatient	care.		When	seen	in	his	closed	mental	health	unit	cell,	LB	was	making	
guttural	sounds	and	wearing	something	that	looked	like	a	diaper	or	swaddling	shorts.		He	
appeared	very	regressed	and	didn’t	verbalize	anything	that	was	comprehensible	as	speech.		
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The	inmate	had	been	locked	in	what	amounts	to	segregation	for	almost	a	year	with	no	
treatment	interventions.		There	was	no	documentation	that	psychiatric	hospitalization	was	
being	considered.		Mental	health	staff	stood	outside	his	door	periodically	to	round	on	him.		
LB	was	too	regressed	for	meaningful	interaction	or	communication.		(A	more	complete	
summary	on	pages	24-25	of	Appendix.)		There	is	no	way	that	this	man	would	be	able	to	
appear	in	court	in	this	condition,	nor	could	there	be	any	sort	of	release	planning	if	his	
charges	were	dropped.		(Note	that	the	Defendants	reported	that	LB	was	transferred	to	the	
state	forensic	hospital	on	5/26/17.		I	believe	this	was	for	restoration	of	his	competency	to	
stand	trial	rather	than	as	a	result	of	a	Baker	Act	commitment	given	his	condition	and	
pending	felony	charges	which	would	allow	civil	hospitals	to	refuse	him	admission	under	
Florida	law.)					
	
	

In	summary,	there	are	a	number	of	serious	issues	in	the	MHU.		Non-compliant	and	

acutely	severely	mentally	ill	inmates	who	refuse	medication	and	are	denied	access	to	
inpatient	care	must	wait	until	they	are	sent	to	a	state	hospital	for	restoration	of	
competency	to	stand	trial	before	they	receive	treatment	is	the	most	serious	of	the	issues.		It	
is	a	constitutional	violation.		While	the	BSO	and	its	contractor	cannot	control	whether	or	
not	civil	hospitals	agree	to	accept	seriously	mentally	ill	inmates,	there	are	other	options	
that	are	not	routinely	exercised	that	would	address	and	if	not	eliminate	this	issue,	would	
certainly	ameliorate	the	suffering.		A	partial	list	of	these	options	includes,	enacting	an	
internal	involuntary	medication	process	(discussed	more	fully	in	the	Medication	section	
infra),	initiating	guardianship	proceedings	to	seek	guardian	permission	to	medicate	over	
the	ward’s	objection,	increased	out-of-cell	structured	treatment	programming,	
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individualized	treatment	planning	and	treatment	team	meetings	for	every	inmate	to	
increase	intensity,	frequency	and	types	of	interventions	in	order	to	engage	the	inmate	in	
treatment	participation.			Other	options	are	also	possible	as	well.		As	currently	
operationalized,	as	inmates	with	serious	mental	illness	refuse	medications	and	deteriorate,	
treatment	interventions	are	reduced	rather	than	intensified;	the	inmate	is	held	in	closed	
mental	health	housing	units	and	staff	see	him	only	at	the	cell	front.	
	
Access	to	inpatient	care	
	

Access	to	inpatient	level	of	care	for	patients	who	desperately	need	it	is	profoundly	

lacking	and	appears	to	be	a	long-standing	problem	as	it	was	also	a	focus	of	concern	at	the	
time	of	Dr.	Metzner’s	report	in	2006.		The	jail	doesn’t	provide	the	types	of	services	available	
in	a	hospital	and	BSO	and	Armor	staff	acknowledge	that	use	of	Florida’s	civil	commitment	
process	(the	Baker	Act)	is	not	a	reliable	path	to	hospitalization.		Inmates	charged	with	
violent	felonies	are	not	eligible	for	hospitalization	via	the	Baker	Act.		These	inmates	must	
wait	months	to	access	a	hospital	level	of	care	until	being	found	incompetent	to	proceed	
with	their	criminal	court	case.		During	my	visits	to	the	MHU	and	infirmary,	there	were	
many	inmates	in	need	of	hospital	level	of	care.		Generally,	BSO	and	Armor	mental	health	
staff	agreed	that	these	inmates	were	in	need	of	hospitalization.		In	some	instances,	they	had	
initiated	Baker	Act	proceedings,	but	the	receiving	facility	assessors	refused	hospital	
admission.		In	other	instances,	staff	knew	that	even	attempting	to	use	the	Baker	Act	was	
futile	and	were	simply	waiting	for	the	criminal	court	to	find	the	inmate	incompetent	and	
order	hospitalization	for	restoration	of	competency.				

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The	route	to	civil	commitment	via	the	Baker	Act	is	nearly	unavailable	to	inmates	in	

the	jail:		receiving	institutions	can	refuse	admissions	based	upon	their	assessment	that	the	
patient	cannot	be	managed	safely	in	their	facility	and	the	North	Broward	Hospital	District	
will	not	admit	inmates	with	pending	felony	changes.			There	also	appears	to	be	some	
strange	equivalency	between	being	held	in	segregation-like	status	at	the	jail	with	no	
treatment	and	inpatient	psychiatric	care	in	the	minds	of	many	of	the	Baker	Act	receiving	
facility	“assessors”	which	is	absolutely	ridiculous	and	defies	the	obvious	difference	
between	jails	and	hospitals.		While	it	may	be	tempting	to	simply	say	that	some	of	these	
factors,	such	as	the	Baker	Act	itself	and	the	receiving	facilities’	refusal	to	accept	inmates,	
are	wholly	outside	the	BSO’s	control	and	therefore,	the	BSO	should	not	be	held	responsible	
or	accountable	for	failing	to	provide	timely	access	to	inpatient	care,	their	responsibility	is	
not	so	easily	dismissed.		Armor’s	contract	with	the	local	hospital	system	covers	many	
medical	specialties	but	is	silent	with	respect	to	psychiatric	inpatient	care.		Inmates	needing	
a	hospital	level	of	care	are	held	in	the	jail	and	receive	less,	rather	than	more	intensive	
treatment	or	attempts	at	treatment	than	other,	less	ill	inmates	as	has	previously	been	
discussed;	contacts	are	at	the	cell	front,	frequency	and	types	of	contact	are	not	increased,	
the	treatment	plan	is	not	reviewed/updated.		Nominally,	increasing	the	frequency	and	
intensity	of	treatment	modalities	and	contacts	is	required	while	awaiting	inmate	transfer	to	
a	more	appropriate	level	of	care.	
	
	

		Inmate	DW	came	into	the	jail	from	the	state	hospital	4/15/15;	was	on	watch	

multiple	times	and	for	extended	periods	of	time.		When	not	on	watch,	he	was	housed	in	
closed	mental	health	and	seen	only	for	weekly	rounds	at	the	cell	front.		Notes	indicate	he	
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“didn’t	engage”	and	that	is	the	extent	of	treatment	summary.		He	attacked	staff,	or	tried	to	
attack	staff,	but	was	given	no	medications.		He	was	considered	too	violent	to	take	out	of	his	
cell	for	any	sort	of	mental	health	assessment	or	treatment.		He	was	considered	too	
unpredictable	and	violent	to	go	to	the	clinic	but	was	let	out	to	the	visiting	room	to	see	the	
outside	psychologist	sent	to	do	a	competency	evaluation	–	and	he	tried	to	attack	that	
person.		This	is	an	example	of	a	case	that	makes	little	logical	sense.		The	jail	received	this	
man	from	a	state	hospital.		He	refused	treatment	at	the	jail	and	clearly	decompensated.		He	
was	housed	in	isolation,	both	in	closed	mental	health	and	in	the	infirmary	and	staff	(BSO	
and	Armor)	were	essentially	powerless	in	terms	of	getting	him	treatment.		They	could	not	
or	did	not	involuntarily	medicate;	DW	was	considered	too	violent	and	unpredictable	to	
civilly	commit	via	Baker	Act	and	so	he	continued	psychotic,	suffering	and	highly	
symptomatic	to	the	point	where	medical	and	mental	health	staff	could	only	attempt	to	
interview	him	from	outside	the	cell	due	to	the	deputies’	concerns	for	staff	safety.		He	
presented	such	a	high	risk	of	harm	to	others	that	he	was	not	permitted	out	of	cell	to	attend	
medical	or	mental	health	appointments.		Finally,	and	only	by	virtue	of	his	severe	
decompensation,	DW	was	transferred	to	an	outside	treatment	facility	9/22/16,	but	it	took	
more	than	a	year	of	needless	suffering,	untreated	mental	illness	and	dangerousness	
towards	others	to	get	to	treatment.		Jail	inmates	must	have	access	to	a	hospital	level	of	care.		
(A	more	complete	summary	of	DW	is	on	page	60	of	the	Appendix.)				
	
	

In	the	case	of	TD,	Armor	staff	did	attempt	to	have	him	evaluated	for	a	hospital	

admission	pursuant	to	the	Baker	Act.		Inmate	TD	underwent	intake	into	the	Main	Jail	
9/8/16	and	was	housed	in	the	infirmary	and	then	the	detox	unit	for	several	days.		TD	was	
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on	suicide	watch	9/16/16-9/25/16;	10/3/16-10/24/16;	11/21/16-11/23/16;	11/25/1612/3/16;	12/8/16-12/19/16	and	again	12/27/16.		He	was	moved	into	the	NBB	infirmary	
on	suicide	watch	2/1/17	because	he	was	not	speaking	or	eating.		The	inmate’s	body	weight	
and	other	vital	signs	were	not	routinely	collected	either	by	virtue	of	the	inmate’s	refusal	or	
the	deputies’	not	permitting	nursing	staff	to	enter	the	inmate’s	cell	to	examine	him.		Armor	
staff	did	attempt	to	send	him	to	a	civil	hospital	in	February,	but	the	Baker	Act	pre-screener	
wrote:	“The	client	is	currently	in	a	highly	monitored	and	secured	institution	that	would	
afford	a	greater	degree	of	safety	than	any	community	inpatient	facility.		As	such,	the	
assessing	clinician	determined	the	client	does	not	currently	meet	the	full	and	necessary	
criteria	for	an	involuntary	psychiatric	assessment	at	a	community	inpatient	psychiatric	
facility	while	remaining	in	a	highly	secured	and	monitored	setting	as	that	of	the	BSO	
Detention	Facilities.		This	assessment	should	not	in	and	of	itself	be	interpreted	to	justify	the	
client’s	release	or	continued	placement	on	any	suicide	watch	process.”		(Of	note,	the	prescreener	did	not	interview	the	inmate	because	he	refused	to	come	out	of	the	infirmary	cell	
for	an	interview.)		The	pre-screener’s	conclusion	that	an	inmate	who	has	been	on	multiple	
suicide	watches	for	extended	periods	of	time,	who	is	refusing	treatment,	food	and	to	
communicate	doesn’t	meet	the	“full	and	necessary	criteria	for	involuntary	psychiatric	
assessment”	is	preposterous.		BSO	and	Armor	staff	reported	that	hospitalization	had	been	
denied	by	the	pre-screener	for	similar	types	of	conclusions	on	many	other	occasions	as	
well.		Ultimately,	denying	hospitalization	for	these	types	of	reasons	has	a	chilling	effect	on	
the	willingness	of	BSO	and	contract	staff	to	even	attempt	to	use	the	Baker	Act;	there	is	no	
point	in	doing	so	if	the	hospitalization	is	going	to	be	denied.		Waiting	for	the	criminal	court	
to	act	on	trial	competency	is	a	much	surer	path	to	hospitalization	even	though	it	can	take	
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months	to	accomplish.		TD	is	suffering	needlessly	and	at	risk	of	serious	illness	or	death.		
(TD’s	case	summary	is	on	page	29	of	the	appendix.)			
	
Lack	of	access	to	hospital	level	of	care	is	a	long-standing	problem.		I	reviewed	
records	of	inmate	WH	who	died	in	2012	after	a	hunger	strike	that	lasted	more	than	40	
days.		He	was	originally	admitted	to	the	jail	10/26/12	though	he	was	there	previously	and	
treated	with	antipsychotic	and	antidepressant	medication.		He	was	identified	as	having	a	
psychotic	disorder	not	otherwise	specified	and	bipolar	disorder	“by	history.”		He	said	he	
was	fasting	as	part	of	some	“spiritual	belief”	and	placed	on	suicide	watch.		He	continued	to	
fast	and	was	medically	hospitalized	for	5	days	in	November	due	to	electrolyte	
abnormalities	and	compromised	kidney	function	(consequences	of	prolonged	fasting.)		WH	
was	returned	to	the	jail	11/13/12	and	housed	in	the	infirmary.		No	lab	studies	were	drawn	
at	the	jail	and	no	medications	were	ordered	for	him.		The	medical	center’s	psychiatrist	
planned	to	petition	for	a	civil	commitment	via	the	Baker	Act	but	WH	was	returned	to	the	
jail	where	the	discharge	planner	asked	the	criminal	court	to	move	up	the	date	of	a	court	
appearance	in	hopes	that	the	judge	would	send	WH	to	a	hospital	for	competency	
restoration.		The	hearing	date	was	moved	up	to	11/16/12	but	WH	collapsed	in	police	
custody	that	day.		He	was	transferred	as	an	emergency	to	the	hospital	where	he	was	
admitted	medically.		WH	never	regained	consciousness	and	died	12/23/12	due	to	
complications	of	electrolyte	imbalance	due	to	prolonged	fasting.		(WH’s	case	is	summarized	
on	page	73	in	the	appendix.)			
	

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Inmates	with	serious	mental	illness	are	suffering	needlessly.		The	risks	of	untreated	
serious	 mental	 illness	 are	 increased	 and	 include	 self-injury,	 suicide,	 assault	 and	 injury	 to	
other	 inmates	 and	 staff.	 	 Furthermore,	 when	 treatment	 is	 delayed,	 it	 takes	 longer	 for	
symptoms	to	improve	and	the	improvement	is	not	as	robust	as	it	would	otherwise	have	been	
if	treatment	had	been	provided	more	timely.		It’s	absolutely	inhumane.		Short	of	a	change	of	
the	state	civil	commitment	procedures,	I	don’t	see	a	solution	other	than	the	jail	contracting	
directly	 with	 an	inpatient	provider	to	 permit	 admissions	of	 jail	 transfers	 or	opening	their	
own	inpatient	unit,	which	is	not	feasible.	
	
Integrated	Care		
	

Chart	reviews	demonstrated	that	there	are	problems	with	integrating/coordinating	

medical	care	for	inmates	with	serious	mental	illness.		At	the	time	of	intake,	if	the	inmate	
was	highly	symptomatic	or	uncooperative	with	medical	staff,	the	medical	assessment	was	
not	completed.		It	did	not	appear	to	have	re-attempted	at	a	later	date	and	the	inmate	never	
received	the	medical	assessment	in	some	instances.		Case	examples	were	provided	in	the	
screening	and	evaluation	section	of	the	report.			
	
	

There	were	issues	with	access	to	medical	care	for	inmates	with	serious	mental	

illness	confined	in	the	closed	mental	health	units	at	NBB.		This	was	noted	in	one	particular	
case	summarized,	but	also	recognized	to	be	an	access	problem	by	the	medical	doctor.		SB	
had	serious	mental	illness	at	the	time	of	his	booking	into	the	jail	in	mid-February	2016.		He	
was	initially	admitted	to	the	detox	unit	but	transferred	to	NBB	and	placed	into	a	closed	
mental	health.		He	experienced	some	mental	changes	(delusions	and	delirium)	that	were	
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attributed	to	his	mental	illness,	but	he	also	complained	of	abdominal	pain	and	had	
tenderness,	low	blood	pressure,	elevated	heart	rate,	vomiting,	diarrhea	and	became	
incontinent	of	urine	and	stool.		He	was	eventually	admitted	to	the	infirmary	but	should	
have	been	sent	out	for	emergency	medical	care.		He	died	of	peritonitis	due	to	a	bowel	
perforation.		In	this	case,	neither	his	psychiatric	condition	nor	his	physical	condition	was	
appropriately	assessed	or	treated	promptly.		In	reviewing	the	case,	the	medical	services	
physician	at	the	jail	concluded	“diuretics	should	be	avoided	in	close	mental	health	where	
labs	are	not	regularly	and	often	monitored	specially	if	on	multiple	BP	meds.”		Oddly,	rather	
than	address	the	very	serious	issue	of	access	to	permit	regular	monitoring	and	laboratory	
studies,	the	proposed	solution	was	to	limit	blood	pressure	treatment	options	though	this	is	
fairly	indicative	of	the	way	other	cases	of	patients	with	both	psychiatric	and	medical	issues	
have	been	managed.		(SB’s	summary	is	on	pages	65-67	of	the	Appendix.)		The	case	of	RP	
was	also	mentioned	in	the	Screening	and	Assessment	section	of	the	report.		He	was	the	
inmate	with	severe	weight	loss	and	blood	in	his	urine	that	was	sent	to	the	intensive	care	
unit	but	put	back	into	closed	mental	health	back	at	the	jail	where	his	access	to	medical	care	
was	impeded.		(RP’s	case	summary	is	on	pages	68-69	of	the	Appendix.)	
	
	

Finally,	there	were	cases	in	which	acute	changes	in	mental	state	were	incorrectly	

attributed	to	psychiatric	illness.		In	some	instances,	this	occurred	during	substance	use	
withdrawal	but	in	others,	there	were	serious	metabolic	problems.			
	
	

AF	was	booked	into	the	jail	and	placed	on	a	withdrawal	protocol.		She	had	a	history	

of	having	had	a	withdrawal	seizure	in	the	past.		Notes	from	the	nurse	indicate	she	was	
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“very	jaundiced”	5/18/16	at	1800;	she	was	incontinent	of	urine	and	feces	5/18/16	at	0300,	
and	disoriented	and	“inappropriate”	so	no	labs	were	drawn.				AF	was	unresponsive	around	
midnight	with	no	vital	signs	5/18/16	and	transported	out	by	EMS	after	midnight	on	
5/19/16.			AF’s	case	review	raises	concerns	about	the	way	in	which	acute	changes	in	
mental	status	are	managed	at	the	jail.		(AF’s	summary	is	on	pages	73-74	of	the	Appendix.)			
	
	

TB	was	booked	into	the	jail	5/27/16.		He	had	a	history	of	schizoaffective	disorder	

and	had	previously	been	a	patient	at	the	South	Florida	Evaluation	and	Treatment	Center	
(SFETC).		He	was	placed	on	psych	observation	5/28/16	and	sent	from	the	Main	Jail	to	NBB.		
On	6/8/16,	there	was	a	determination	that	the	inmate	had	bilateral	pneumonia.		He	was	
transferred	out	to	the	hospital’s	emergency	department	but	refused	care.		He	was	returned	
to	the	jail	the	same	day	and	placed	in	the	NBB	infirmary.		On	the	same	day,	a	Baker	Act	
certificate	was	completed	indicating	the	inmate	was	“medically	cleared”	for	psychiatric	
admission,	though	this	does	not	appear	to	be	the	case	since	he	had	pneumonia	and	refused	
treatment.		At	1605,	the	Baker	Act	team	and	EMS	took	the	inmate	to	BGH.		It	does	not	
appear	from	the	record	that	he	ever	returned	to	the	jail.		(TB	case	summary	is	on	pages	6364	of	the	Appendix.)	
	
	

Finally,	in	the	case	of	MV,	summarized	on	pages	61-62	of	the	Appendix,	the	medical	

physician	was	advocating	for	an	immediate	transfer	to	a	psychiatric	hospital.		However,	the	
inmate	in	question	had	very	serious	medical	problems	and	had	recently	been	medically	
hospitalized.		He	should	have	been	sent	out	for	medical	stabilization.		As	it	was,	he	died	
after	a	second	emergency	medical	hospitalization	when	found	“unresponsive	and	gasping”	
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at	the	jail	-	-	-	not	a	consequence	of	mental	illness	but	rather,	a	serious	medical	condition.		
He	was	housed	in	closed	mental	health	and	was	not	eating,	but	his	metabolic	issues	were	
not	addressed.		The	proposed	solution	was	transfer	to	a	psychiatric	hospital.	
	
	

Regular	multidisciplinary	treatment	team	meetings	that	include	participation	of	

medical	and	mental	health	providers	for	every	inmate	with	co-existing	serious	medical	and	
mental	health	needs	are	necessary	to	reduce	the	risk	of	worsening	physical	condition	and	
death.			
	
Continuous	Quality	Improvement	
	

A	Continuous	Quality	Improvement	(CQI)	program	is	the	process	utilized	in	health	

care	organizations	to	assess	a	number	of	parameters	including	timeliness	of	treatment,	
appropriateness	of	treatment	interventions,	cost	efficiency	and	patient	response	to	
treatment,	among	other	parameters	to	identify	trends	and	patterns	to	determine	whether	a	
corrective	action	is	required	to	improve	care.		It	includes	comprehensive	reviews	of	critical	
incidents	and	deaths,	process	and	outcome	studies,	professional	peer	review	and	patient	
satisfaction.			
	
	

At	the	time	of	Dr.	Metzner’s	2006	report,	the	program	was	relatively	new	at	the	jail	

and	he	had	a	number	of	suggestions	of	quality	improvement	studies	that	included:	
•

Timeliness	of	new	admissions	receiving	prescribed	psychotropic	medication	

•

Participation	rate	of	inmates	participating	in	structured	therapeutic	activities	in	the	
closed	mental	health	units	with	focus	on	how	rate	could	be	increased	

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•

Increasing	structured	therapeutic	out-of-cell	time	and	unstructured	out-of-cell	time	
offered	on	a	daily	basis	to	inmates	on	the	closed	mental	health	units	

•

Treatment	interventions	related	to	inmates	refusing	psychotropic	medications	

•

Clinical	course	of	inmates	returning	to	jail	from	psychiatric	hospitalization	

	
Clearly,	given	the	current	state	of	mental	health	care	provided	at	the	jail,	some	of	the	
suggestions	made	in	2006	cannot	be	completed:		measuring	participation	rates	for	
structured	and	unstructured	out-of-cell	time	is	not	relevant	when	there	is	so	little	
structured	intervention	on	the	closed	mental	health	units,	staffing	levels	do	not	permit	any	
sort	of	intervention	for	inmates	refusing	medication	or	increasing	structured	therapeutic	
out-of-cell	time	on	the	closed	mental	health	units.		The	clinical	course	of	inmates	returning	
to	jail	is	not	studied	in	quality	improvement	studies.		Unfortunately,	what	may	have	started	
as	an	ambitious	CQI	program	appears	to	have	stagnated	into	a	much	earlier	type	of	“quality	
assurance”	program	of	chart	audits,	at	least	as	far	as	mental	health	is	concerned.10		
	
	

The	information	provided	to	me	related	to	the	QI	program	pertaining	to	mental	

health	consisted	primarily	of	chart	audits	to	measure	the	presence	or	absence	of	various	
elements	relative	to	specific	policies	and	procedures.		(Examples	were	provided	regarding	
intake	in	which	audit	questions	simply	check	whether	or	not	various	forms	were	completed	
requiring	a	“yes”	or	“no”	response	and	compliance	with	timelines	stated	in	policy.)		The	

																																																								
10	Defendants	provided	studies	of	participation	rates	in	the	closed	mental	health	units	
conducted	in	response	to	Dr.	Metzner’s	suggestions	conducted	in	2006,	2007	and	2009,	
none	more	recent.				
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chart	audits	are	repeated	at	regular	intervals	and	have	not	changed	substantially	in	several	
years.		There	were	no	process	or	outcome	studies	for	mental	health	services	during	the	
past	twelve	months.				
	
	

A	robust	quality	improvement	program	consists	of	much	more	than	chart	audits	and	

allows	systems	to	identify	problems,	take	corrective	action(s)	and	re-assess	the	issue	to	
determine	whether	or	not	the	corrective	action	was	successful	in	reducing	or	eliminating	
the	problem.	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
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Staffing	
	

	
Armor	staffing	levels	are	inadequate	to	provide	any	treatment	services	other	than	

brief	psychotropic	medication	management	appointments	and	rare	supportive	individual	
counseling	sessions	to	very	few	inmates.		This	is	true	in	the	jail	facilities	that	provide	
“outpatient”	mental	health	care	as	well	as	NBB	that	contains	the	mental	health	units.		
Rounds	and	cell	front	contacts	do	not	constitute	treatment.		There	must	be	sufficient	
numbers	and	types	of	staff	to	provide	actual	treatment,	including	individual	and	group	
counseling	as	well	as	psychosocial	programming,	most	especially	in	the	mental	health	
housing	units.			
	
	

Armor	mental	health	staff	appear	to	be	appropriately	trained	and	credentialed	to	

provide	mental	health	care	–	there	simply	aren’t	enough	of	them.		Mental	health	staffing	
levels	must	be	sufficient	to	provide	screening	and	evaluation,	crisis	care,	routine	outpatient	
care	including	rounds	and	treatment	interventions	to	inmates	with	serious	mental	illness	
housed	in	segregation	status	and	a	residential	treatment	level	of	care.	11	Current	staffing	
levels	simply	does	not	permit	Armor	to	provide	the	full	continuum	of	treatment	and	as	a	
result,	inmates	with	mental	illness	are	not	receiving	adequate	care.				
	

																																																								
11	In	discussions	with	Armor	staff,	it	was	not	clear	that	they	shared	the	same	philosophy	
with	respect	to	their	involvement	in	providing	a	continuum	of	services.		I	was	told	that	they	
viewed	their	role	as	“identification	and	stabilization.”	
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The	American	Psychiatric	Association’s	brief	monograph	“Psychiatric	Services	in	

Correctional	Facilities,	Third	Edition”	recommends	that	for	a	jail	general	population	there	
be	“one	FTE	psychiatrist	for	every	75-100	patients	receiving	psychotropic	medication”	and	
one	FTE	psychiatrist	for	every	50	patients	in	residential	treatment	units.12	These	
recommendations	do	not	take	into	account	the	role	of	psychiatrists	in	the	diagnostic	
assessment	process	and	daily	assessments	of	all	inmates	on	suicide	watch	status	which	
results	in	a	greater	need	than	a	simple	ratio	of	one	FTE	to	75-100	general	outpatients.		In	
other	words,	Main	Jail	requires	additional	staffing	based	on	a	very	busy	reception	process,	
frequent	and	extended	suicide	watches	conducted	in	the	infirmary	as	well	as	on	the	8th	
floor,	detoxification	units	and	general	outpatients.		Applying	the	ratio	to	the	385	inmates	
reported	on	the	mental	health	caseload	at	the	Main	Jail	at	the	time	of	the	site	visit,	the	
recommended	staffing	level	would	range	from	3.8	to	5.2	FTE.			The	Main	Jail	has	only	1	FTE	
psychiatrist	(0.8	FTE	psychiatrist	and	0.2	FTE	ARNP).		Having	this	degree	of	deficit	
translates	into	brief,	cursory	evaluations	including	risk	assessments	of	suicidal	inmates,	
non-confidential	cell	front	contacts	at	minimally	required	intervals	rather	than	permitting	
the	flexibility	to	schedule	appointments	according	to	clinical	need.		JVCF	and	Paul	Rein	
Facility	had	a	combined	mental	health	caseload	of	561	at	the	time	of	the	site	visits.		This	
would	require	at	least	5	FTE	psychiatrists	using	the	APA	ratios	but	they	have	a	combined	
total	of	only	1.8	FTE.		In	order	to	actually	provide	a	residential	treatment	level	of	care,	NBB	
requires	a	ratio	of	one	FTE	psychiatrist	for	50	beds	and	there	are	psychiatrists	(1	full	time,	
																																																								
12	The	APA	guidelines	do	not	provide	staffing	levels	for	any	other	type	of	mental	health	
professional	and	do	not	explicitly	address	the	role	of	midlevel	providers	such	as	ARNPs	and	
PAs	used	in	the	Broward	County	jails.		For	purposes	of	this	discussion,	the	ratios	expressed	
shall	be	relevant	to	use	of	either	a	psychiatric	physician	or	midlevel	practitioner.	
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1	part-time),	ARNPs	(3	full	time	and	1	part-time)	and	at	least	one	FTE	PA.		(The	other	PA	is	
primarily	administrative.)		This	facility	is	much	closer	to	the	recommended	numbers	in	
terms	of	the	medication	management	need	but	the	primary	issue	at	NBB	is	the	lack	of	
additional	mental	health	treatment	other	than	psychotropic	medication	management,	for	
patients	that	consent	to	taking	medication.		There	are	only	two	FTE	licensed	mental	health	
clinicians,	which	is	insufficient	to	do	anything	other	than	rounds	and	cell	front	contacts.		
There	must	be	many	more	mental	health	clinicians	in	order	to	engage	patients	in	
meaningful	therapeutic	out-of-cell	activity	on	all	of	the	housing	units	---	not	just	the	
programming	run	by	BSO	program	staff	on	two	open	mental	health	units.		Other	mental	
health	professionals	such	as	psychology	staff	positions,	activity	technicians	and	attendants	
are	also	required	to	provide	residential	treatment.			
	
	

The	need	for	mental	health	counselors	at	the	other	jails	is	equally	dire.		At	Main	Jail,	

the	lone	Armor	psychologist	is	assigned	to	detox	evaluations	and	does	some	counseling.		
The	mental	health	counselor	is	full	time	but	20%	of	his	time	is	spent	as	the	sole	counselor	
at	Conte	one	day	per	week	for	a	caseload	of	319	inmates.		At	the	Main	Jail,	he	is	assigned	to	
do	initial	mental	health	evaluations	and	some	counseling	if	there	is	any	time	left	in	his	32	
hours.		Paul	Rein	Facility	also	has	mental	health	coverage	only	one	day	per	week	for	242	
inmates	on	the	mental	health	caseload.		The	jails	offering	outpatient	mental	health	care	are	
very,	very	short	staffed	in	terms	of	mental	health	counselors.		The	APA	Guidelines	do	not	
address	mental	health	counselor	staffing	levels.		However,	I	recommend	there	be	one	
mental	health	counselor	for	a	range	of	50-100	inmates	on	the	outpatient	caseload,	the	exact	
placement	in	that	range	being	determined	by	the	number	of	other	tasks	required	at	that	
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facility	such	as	initial	assessments,	segregation	rounds,	typical	number	of	mental	health	
crises	at	a	particular	jail	(treatment	of	inmates	on	suicide	watch)	as	well	as	the	security	
level	of	the	facility.		(It	is	easier	to	access	lower	security	level	inmates	because	they	are	
permitted	much	broader	and	unescorted	movement	to	appointments.		Many	more	of	them	
can	be	seen	than	when	providing	care	to	higher	security	inmates	who	have	to	be	searched,	
cuffed	and	escorted	to	and	from	appointments	with	one	or	two	custody	staff	who	also	have	
competing	responsibilities.)	
	
	

The	jail	mental	health	staffing	levels	are	insufficient	to	provide	adequate	mental	

health	treatment	at	any	level	of	care:	intake,	outpatient	and	residential	treatment.			
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
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Medications	
	
	
	
This	provision	was	originally	articulated	to	promote	appropriate	use	and	
monitoring	of	psychotropic	medication.		The	use	of	psychotropic	medication	in	institutional	
settings	has	a	checkered	history	that	involved	use	of	some	of	these	medications	
administered	as	a	means	of	chemical	restraint	rather	than	being	prescribed	for	a	
psychiatric	symptom	indication.			Armor	maintains	a	policy	specific	to	the	use	of	
psychotropic	medication	(J-D-02.5),	which	requires	referral	to	an	appropriately	licensed	
and	credentialed	provider	with	prescriptive	authority	for	all	psychotropic	medication	
orders.		These	include	psychiatrists,	advanced	registered	nurse	practitioners	(ARNPs)	and	
physician	assistants	(PAs.)		Psychotropic	medications	are	not	administered	without	an	
order	from	a	prescriber.			
	
	

Inmates	are	provided	informed	consent	for	medications	and	have	a	right	to	refuse	

them,	except	in	very	limited	emergency	situations.		In	fact,	inmate	refusals	absent	a	time	
limited	emergency	can	be	over-ridden	only	if	they	are	transferred	to	a	hospital	where	
additional	proceedings	may	permit	administration	over	refusal.		However	helpful	and	
clinically	appropriate	these	types	of	orders	may	be,	they	are	relevant	only	during	the	
inmate’s	hospital	stay	and	not	upon	return	to	the	jail	–	where	it	is	most	likely	inmates	will	
again	stop	taking	prescribed	medications.			
	
There	is	another,	infrequently	used	option	for	treatment	over	objection	though	it	
also	often	impractical	and	is	not	timely.		This	option	requires	a	judicial	finding	of	
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incompetence	and	the	appointment	of	a	guardian	to	make	the	ward’s	treatment	decisions.			
As	mentioned,	this	option	is	not	always	practical	in	that	it	involves	an	extensive	clinical	
examination,	a	finding	that	the	inmate	lacks	decision-making	capacity	and	the	availability	
of	a	suitable	guardian	to	consent	to	medical	treatment	and	manage	all	of	the	ward’s	other	
affairs.		There	is	also	no	assurance	that	the	guardian	would	provide	consent	to	the	
medication	recommended	or	consent	to	forcible	administration	if	the	ward	refused	oral	
medication.		This	option	is	possible	but	not	always	practical.	
	
For	all	intents	and	purposes,	the	current	limitations	to	treatment	over	objection	
present	serious	barriers	to	treatment	at	the	jail.		Inmates	with	serious	mental	illness	
refusing	medication	must	get	to	a	hospital	for	treatment	over	objection	but	they	are	denied	
admission.		They	cannot	be	treated	over	objection	at	the	jail	and	so	remain	untreated	and	
eventually,	isolated	and	housed	under	conditions	that	resemble	the	conditions	of	
segregation	–	conditions	which	further	exacerbate	their	serious	mental	illness,	which	
makes	them	less	likely	to	be	approved	for	hospitalization,	and	the	cycle	spirals	ever	
downward.			
	
Other	correctional	systems	and	facilities	have	adopted	a	procedure	similar	to	one	
initially	developed	in	the	Washington	state.		In	1990,	the	US	Supreme	Court	upheld	the	
Washington	policy	that	permitted	correctional	facilities	to	override	medication	refusals	
under	limited	circumstances.	13	The	Washington	policy	made	provisions	for	an	internal	

																																																								
13	Washington	v	Harper	494	US	210	(1990)	
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hearing	process	involving	mental	health/medical	professionals	with	no	current	treatment	
relationship	with	the	inmate	who	were	charged	with	making	the	decision	about	whether	
the	inmate	could	be	involuntarily	treated.			The	inmate	also	had	a	number	rights	at	the	
hearing	including	the	right	to	be	evaluated,	the	right	to	notice	of	the	procedural	hearing,	
the	right	to	be	present	at	the	hearing,	present	evidence	and	cross	examine	witnesses	and	
the	right	to	appeal	the	decision	of	the	hearing	panel.		Additionally,	if	the	hearing	panel	
approved	treatment	over	objection,	the	administration	of	medication	under	these	
circumstances	was	time	limited	and	required	periodic	re-hearings	with	all	of	the	attendant	
rights	for	continuation	of	medication.		Consideration	of	a	similar	sort	of	internal	process	for	
treatment	over	objection	proceedings	could	be	very	useful	in	the	jails	under	limited	
circumstances	such	as	when	inmates	pose	a	serious	risk	of	danger	to	self	or	others	–	the	
type	of	circumstances	that	preclude	Baker	Act	acceptance	for	treatment	in	civil	hospitals.	
	
Turning	attention	to	the	voluntary	use	of	medication,	the	Armor	psychotropic	
medication	policy	contains	some	serious	deficiencies	with	regard	to	implementation	and	
appropriate	use	of	psychotropic	medication	in	the	jail.				
	
	

The	medication	formulary	(list	of	medications	approved	for	use)	is	limited	which	in	

and	of	itself	is	not	uncommon,	particularly	since	there	is	a	mechanism	to	request	approval	
for	psychotropic	medications	not	on	the	list.		The	problem	lies	in	the	failure	to	actually	
make	use	of	this	“Drug	Exception	Request”	to	preserve	continuity	of	care	in	essentially	
every	situation	with	the	exception	of	state	hospital	returns.		Such	practice	leads	to	
unnecessary	delays	in	the	provision	of	treatment	and	causes	needless	suffering.		Delays	in	
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treatment,	even	if	the	medication	selected	by	Armor	is	effective,	will	lead	to	a	slower	
response	to	treatment	and	a	less	robust	response	and,	there	is	no	guarantee	that	the	
chosen	medication	is	going	to	provide	the	intended	improvement	in	response	at	all.		It	is	
inexplicable	why	one	would	opt	not	to	use	a	medication	of	demonstrated	efficacy.		Even	if	
the	medication	is	more	expensive,	the	indirect	costs	of	delaying	treatment	can	far	outweigh	
the	expense	of	the	medication.		Inmates	with	untreated	or	under	treated	serious	mental	
illness	use	more	costly	services:		transfer	to	NBB;	placement	on	watch	status;	housing	in	a	
single	cell	rather	than	a	multiple	person	cell;	longer	jail	stays	due	to	a	finding	of	
incompetence	to	proceed	or	inability	to	find	a	community	placement;	potential	staff	and/or	
inmate	injury	due	to	psychotic	symptoms,	etc.		
	
			

Issues	regarding	medication	continuity	are	not	limited	to	the	jail	admission	process.		

There	are	multiple	prescribing	clinicians	at	NBB	and	an	inmate	may	be	seen	by	any	one	of	
several	people,	all	with	differing	prescribing	practices	and	treatment	philosophies.		
Medication	changes	are	not	infrequent	–	again,	in	and	of	itself	not	unusual,	but	it	could	be	
remedied	with	the	adoption	of	prescribing	guidelines	and	assignment	of	cases	to	specific	
prescribers	rather	than	the	“prescriber	du	jour”	process	currently	in	place.		This	is	
problematic	from	any	number	of	perspectives,	not	the	least	of	which	is	frequent	changes	in	
medication	but	also	from	the	perspective	of	the	failure	to	establish	a	therapeutic	
relationship	between	the	medication	prescriber	and	the	patient.		Every	visit	is	essentially	a	
new,	introductory,	assessment	visit	when	a	patient	is	seeing	a	new	prescriber.		
Documentation	of	the	previous	medication	management	appointment	is	not	always	helpful:		
areas	of	forms	that	are	to	describe	the	inmate’s	condition	at	the	time	of	the	appointment	
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are	fairly	cursory,	if	they	are	filled	out	at	all;	there	is	no	indication	of	the	response	to	
current	treatment	or	a	documented	mental	status	examination.		Every	medication	
management	visit	is	thus	a	“first”	appointment.		Remedies	for	this	problem	also	include	
staffing	levels	that	permit	and	promote	continuity	of	prescriber	and	additional	mental	
health	staff	that	are	able	to	provide	medication	education	and	counseling	with	a	graduated	
response	of	interventions	to	address	instances	of	medication	non-compliance	before	
mental	decompensation	followed	by	the	downward	spiral	described	earlier.		
	
	

Inmates	are	seen	regularly	at	monthly	or	three-month	intervals	for	medication	

management	appointments.		There	is	little	to	no	room	in	the	schedule	to	permit	more	
frequent	contact	in	response	to	changes	in	clinical	condition,	assess	response	to	new	
medications	or	dose	adjustments	and	it	is	not	clear	that	medication	compliance	is	regularly	
reviewed	with	the	inmate	in	that	it	is	not	routinely	documented	in	the	prescriber’s	note	
(though	it	is	available	upon	review	of	the	medication	administration	record.)			
	
	

Review	of	multiple	records	also	revealed	some	positive	findings.		For	example,	there	

was	very	little	polypharmacy	-	the	practice	of	prescribing	multiple	medications	with	no	
clinical	rationale	to	support	the	practice.		Medications	were	prescribed	for	legitimate	
psychiatric	indications	and	in	doses	consistent	with	generally	accepted	standards	of	care	
when	prescribed	for	a	clear	psychiatric	indication.		
	
	
	
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RECORDS	
	
	

The	fifth	criterion	is	accurate,	complete	and	confidential	records.			The	concerns	

with	regard	to	the	medical/mental	health	records	are	related	primarily	to	the	use	of	paper,	
rather	than	an	electronic	health	records	at	the	current	time.		Some	psychiatric	notes	are	
barely	legible	which	is	highly	problematic	given	that	multiple	prescribers	may	see	the	same	
inmate	patient.		(The	“new”	prescriber	may	or	may	not	be	able	to	decipher	the	note	of	the	
previous	one	to	understand	the	condition	of	the	inmate,	the	medications	and	doses	
prescribed,	etc.)		In	other	instances,	forms	are	incompletely	filled	out	and	clinicians	provide	
very	little	narrative	making	it	difficult	to	ascertain	patient	condition,	type	and	severity	of	
symptoms	experienced	and	plan	for	follow-up.		In	general,	the	filing	was	up	to	date	and	
papers	were	filed	in	the	appropriate	place	of	the	record.	
	
	

Problems	can	and	should	be	addressed	through	chart	auditing	and	ultimately	with	

the	adoption	and	implementation	of	an	electronic	health	record.		Illegible	handwritten	
notes	are	eliminated;	forms	can	be	developed	such	that	the	note	cannot	be	“closed”	unless	
all	required	fields	are	completed.	
	
	

More	substantive	concerns	relate	to	the	failure	to	request/review	and	use	the	

information	from	outside	sources	and	contained	in	the	record.		For	example,	inmates	
returning	from	the	state	hospital	are	sent	with	very	little	information	about	the	course	of	
their	treatment	while	hospitalized.		If	an	admission	and	discharge	summary	is	not	
provided,	it	is	not	clear	that	Armor	staff	consistently	request	it.		If	and	when	the	records	are	
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provided,	it	is	not	clear	that	Armor	staff	review	them	and	that	the	information	is	utilized	in	
the	current	treatment	of	the	inmate.			This	is	true	of	prior	hospital	information	as	well	as	
community	outpatient	records.			
	
	

Two	examples	that	illustrate	the	effects	on	care	due	to	the	failure	to	use	records	

were	described	earlier	on	pages	35-36	in	the	section	on	Screening	and	Evaluation.		(Inmate	
II	who	had	refused	a	tuberculin	skin	test	and	housed	in	isolation	in	the	infirmary.		His	
outside	records	were	at	the	jail	but	not	reviewed;	he’d	had	a	recent	negative	test	and	
wouldn’t	have	required	infirmary	isolation.		Inmate	MW	refused	medication	because	he	
wanted	to	take	the	medication	prescribed	for	him	at	the	VA	Medical	Center.		His	records	
had	also	been	received,	but	not	reviewed.		Then,	when	the	records	were	reviewed,	the	PA	
refused	to	order	the	VA	medication	because	it	wasn’t	on	the	formulary.		As	a	consequence	
of	receiving	no	psychotropic	medication,	MW’s	thought	processing	was	disjointed	and	
circumstantial.		His	serious	mental	illness	was	untreated;	mental	health	treatment	was	
severely	delayed,	his	jail	stay	extended	and	legal	proceedings	delayed	by	questions	
regarding	his	competency	to	stand	trial.)			
	
	

Accurate,	complete	and	confidential	records	are	vitally	important	and	using	them	

appropriately	has	a	profound	impact	on	the	delivery	of	care.		
	
	

	

	
	
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Suicide	prevention	
	
	
	
The	National	Commission	on	Correction	Healthcare,	which	accredits	the	jail’s	
medical/mental	health	services,	identifies	eleven	essential	components	of	a	correctional	
suicide	prevention	program:		training,	identification,	referral,	evaluation,	treatment,	
housing	and	monitoring,	communication,	intervention,	notification,	review	and	debriefing.		
Armor	policy	J-G-05	lists	these	key	components	and	in	subsequent	paragraphs	describes	
the	related	procedures	for	the	component	in	some	detail	–	except	the	treatment	
component.		The	policy	is	silent	on	this	component.		This	silence	also	reflected	in	
implementation.		Inmates	on	watch	receive	assessments	and	daily	reassessments,	but	few	
receive	treatment	other	than	medication	if	it	is	ordered	and	the	inmate	agrees	to	take	it.		
This	is	a	critical	deficiency.		Treatment	must	be	provided	to	address	the	suicidal	thoughts	
and	behaviors.		Treatment	is	more	than	a	brief	daily	assessment	which	is	conducted	in	
private	sometimes	but	more	often	at	the	cell	front	(MJ	8th	floor,	NBB	infirmary)	or	in	a	
hallway	(NBB).		
	
	

The	assessments	that	are	completed	do	not	contain	a	uniform,	standardized	risk	

assessment	instrument	of	which	there	are	several	to	choose	from	which	would	permit	the	
development	of	a	safety	plan	and	treatment	interventions	that	are	individualized	and	
aimed	at	reducing	risk.		The	assessments	reviewed	in	the	records	were	highly	idiosyncratic	
to	the	prescriber	conducting	the	assessment.		I	saw	no	cases	in	which	a	treatment	plan	had	
been	modified	to	address	an	inmate	patient	having	been	placed	on	watch,	maintained	on	
watch	(sometimes	for	months	and	months)	or	those	having	multiple	watch	placements.		
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Upon	release	from	watch	status,	a	follow-up	appointment	is	scheduled	to	occur	within	7	
days	of	release,	but	subsequent	follow-ups	revert	back	to	the	usual	minimum	contact	
schedule	dictated	by	policy	(brief	monthly	medication	management	appointment	which	
may	or	may	not	be	with	a	provider	previously	seen),	rather	than	dictated	by	the	inmate’s	
clinical	need.		Examples	of	lengthy	watch	placement	include	inmates	ES	(Appendix	page	8)	
and	TD	(Appendix,	page	29).		TD	was	also	identified	as	a	person	with	multiple	watch	
placements.			
	
	

Use	of	a	standardized	assessment	instrument	would	also	eliminate	the	need	for	

automatic	placement	on	suicide	watch	status	if	entering	the	jail	following	a	transfer	from	a	
hospital	or	recent	hospitalization.			At	the	time	of	intake,	2/6/17,	inmate	PT	was	put	on	
watch	based	upon	recent	history	rather	than	current	risk	assessment.		She	was	sent	from	
the	Main	Jail	to	NBB	and	although	the	watch	was	relatively	brief,	it	was	completely	
unnecessary.		(PT’s	case	in	on	page	31	in	the	Appendix.)	
	
	

Additionally,	the	conditions	experienced	by	the	inmate	placed	on	watch	are	at	times,	

unnecessarily	punitive:		there	is	no	privacy	in	some	jail	areas	used	for	watches	which	is	
especially	problematic	when	stripped	of	undergarments	and	jail	issue	clothing	and	given	an	
ill-fitting	suicide	smock.		Inmates	are	not	given	shoes	or	shower	slippers,	not	permitted	to	
shower	regularly,	and	provided	paper	eating	utensils.			While	some	fairly	drastic	
restrictions	are	necessary	to	prevent	or	ameliorate	an	imminent	and	immediate	risk	of	
suicide,	the	conditions	themselves	are	not	therapeutic	and	care	has	to	be	exercised	that	the	
restrictions	be	done	for	the	minimum	amount	of	time	necessary	and	that	the	placement	
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and	restrictions	are	not	used	as	a	type	of	punishment.		Conditions	should	not	be	so	punitive	
so	as	to	discourage	persons	from	reporting	depressed	feelings	and	suicidal	thoughts	in	fear	
of	being	placed	and	held	under	these	conditions.			
	
	

The	Armor	suicide	prevention	policy	describes	three	levels	of	suicide	watch:		

continuous	observation,	close	observation	and	closely	monitored	while	the	corresponding	
BSO	standard	operating	procedure	uses	somewhat	different	terminology:		close	
supervision,	direct	observation	and	closely	monitored.		These	various	levels	of	
observation/supervision	also	contain	some	variations	in	expectations/conditions	as	well.		
It	is	very	important	that	these	concepts	are	reconciled	so	there	is	a	clear	understanding	
between	Armor	and	BSO	staff	about	the	levels	of	watch	and	degree	of	monitoring	required,	
particularly	for	such	a	critical,	potentially	life-saving	process.	
	
	

I	was	provided	only	a	very	small	sample	of	post-suicide	reviews.		It	was	not	clear	

whether	this	was	due	to	no	review	having	been	conducted,	no	documentation	of	the	review	
that	was	conducted	or	whether	the	reviews	were	simply	not	provided.		(Although	there	
was	some	initial	delay	in	receipt	of	some	requested	materials	based	upon	Armor’s	quality	
assurance	confidentiality	concerns,	we	were	able	to	work	through	this	and	I	do	not	believe	
existing	records	were	intentionally	withheld.)		The	individual	records	that	I	received	and	
reviewed	are	located	in	the	Appendix.			I	am	able	to	say	here	that	as	a	general	observation,	
the	review	process	would	be	significantly	improved	with	better	correlation	between	
custody,	medical	and	mental	health	factors	found	during	the	investigations	conducted	
separately	by	all	three	of	these	professions.		Custody	reviews	contain	an	assessment	of	
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whether	monitoring	was	completed	as	required	by	custody	policy	and	custody’s	response	
upon	discovery	of	the	inmate.		Medical	reviews	look	almost	exclusively	at	the	medical	
response	to	the	event.		Mental	health	does	a	psychological	review.		The	findings	from	these	
various	and	different	reviews	can	have	profound	impact	on	conclusions	and	potential	
action	steps	to	improve	the	process.		For	example,	if	custody	has	to	leave	the	site	of	a	
hanging	inmate	to	get	a	cut-down	tool,	medical	should	be	aware	of	this	factor	in	their	
review	of	the	incident	because	a	delay	of	mere	minutes	is	important	in	rescue	and	can	
make	the	difference	between	life	and	death.		The	point	of	these	reviews	is	to	identify	these	
sorts	of	potential	problems/issues,	even	if	determined	that	they	had	no	particular	
relevance	to	the	case	at	hand,	they	could	impact	future	rescue	responses.		In	this	case,	
ensuring	that	cut-down	tools	are	more	immediately	available	certainly	has	potential	
ramifications	in	future	instances.		(Some	facilities	have	officers	assigned	to	certain	locations	
carry	a	form	of	cut-down	tool	on	their	belts.)14		Mental	health	reviews	considered	alone	
won’t	necessarily	uncover	an	instance	in	which	an	inmate	came	back	from	a	court	
appearance	where	he	or	she	received	“bad	news”	though	custody	staff	are	aware	of	it.		
Integrating	this	information	could	have	changed	a	specific	outcome	or	policy	regarding	
notice	to	mental	health	so	that	inmates	returning	from	court	hearings	are	referred	to	
mental	health	staff	for	a	brief	assessment	and	treatment	intervention	if	necessary.		(Inmate	
NW	reportedly	was	overheard	telling	her	mother	that	she	was	going	to	kill	herself	if	she	
received	bad	news	in	her	upcoming	court	hearing.		Information	was	not	relayed	to	mental	

																																																								
14	Inmate	CB	summarized	in	Appendix	pages	64-65;	autopsy	report	indicates	deputy	left	
the	inmate	to	retrieve	cut	down	tool;	also	a	question	of	whether	proper	periodic	checks	
were	done	on	the	unit.	
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health	staff.		She	went	to	court	9/2/14	and	died	by	suicide	9/6/14.		This	is	also	another	
case	where	the	deputy	had	to	leave	the	scene	to	retrieve	a	cut	down	tool.		The	NW	suicide	
was	two	years	after	the	CB	case;	the	issue	regarding	the	cut-down	tool	persisted.			NW	case	
is	summarized	on	page	70.)		As	a	second	general	observation,	the	reviews	would	be	better	
if	the	assessments	were	more	self-critical	so	that	improvements	could	be	made.		There	
were	some	records	in	which	access	to	medical	care	was	limited	or	severely	limited	for	
inmates	with	serious	mental	illness	housed	at	NBB.		In	one	case,	the	medical	review	
recommendation	was	not	to	use	certain	types	of	medication	in	closed	mental	health	
because	of	the	degree	of	monitoring	required	as	opposed	to	actually	improving	ease	of	
access	to	inmates	in	closed	mental	health	units.		I	understand	that	reviewers	are	often	
reluctant	to	document	critical	findings	out	of	fear	of	discovery	in	the	event	that	the	incident	
leads	to	litigation.		However,	if	that	happens,	a	plaintiff’s	expert	is	likely	to	draw	the	same	
negative	conclusions	anyway	and	as	a	system,	it	is	far	better	to	self-identify	and	thereafter	
take	steps	to	address	or	correct	the	problem	than	to	wait	for	legal	proceedings	to	make	you	
do	it.		Frankly,	it	demonstrates	a	far	higher	degree	of	commitment	to	continuous	quality	
improvement	than	incomplete	and	cursory	self-assessment.	
	
	

Record	reviews	of	these	cases	are	found	among	those	cases	summarized	in	the	

Appendix	on	pages	60-74.	
	
	
	
	
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CONCLUSIONS	
	
	

As	stated	at	the	outset	of	this	report,	I	was	charged	with	assessing	operations	and	

conditions	at	the	Broward	County	Jails	and	to	render	an	opinion	regarding	whether	there	
are	current	and	ongoing	violations	of	federal	rights.		I	organized	my	inquiry	around	six	
criteria	and	have	concluded	that	there	are	current	and	ongoing	violations	of	federal	rights	
as	they	pertain	to	inadequate	mental	health	care	and	facilities,	most	particularly	as	related	
to	the	lack	of	treatment	except	psychotropic	medication,	lack	of	timely	and	adequate	access	
to	inpatient	psychiatric	care	resulting	in	prolonged	stays	in	the	closed	mental	health	units	
and	infirmary	at	NBB	under	conditions	that	are	as	isolating	as	those	found	in	segregation	
and	make	symptoms	worse	and	access	to	treatment	more	difficult.		However,	inasmuch	as	
all	six	of	the	criteria	reviewed	are	interconnected,	each	of	them	contributes	to	the	current	
and	ongoing	violations,	some	to	a	greater	and	some	to	a	lesser	degree.		I	have	organized	my	
conclusions	to	articulate	the	areas	needing	improvement	to	correct	the	deficiencies.		This	
organization	also	served	as	the	basis	for	development	of	the	Implementation	Plan.			
	
Systematic	Screening	and	Evaluation	
Generally	appropriate	to	identify	persons	with	mental	health	needs	for	further	assessment	
and	placement	on	the	mental	health	caseload.				
Areas	for	improvement:	
•

Diversion	of	serious	drug	withdrawal	to	hospitals	for	complicated	medical	
detoxification	and	referral	of	inmates	with	obvious	and	severe	psychiatric	illness	to	
a	hospital	setting	as	soon	as	possible	consistent	with	Florida	statute	rather	than	

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housing	them	in	the	jail	for	weeks	or	months,	with	no	ability	to	treat	them	to	await	
criminal	court	action.	
•

Document	that	outside	treatment	records	have	been	requested,	reviewed	and	
considered	in	the	treatment	of	the	inmate	at	the	jail.	

•

Preserve	continuity	of	care	with	respect	to	psychotropic	medications	when	
prescriptions	are	verified	and	response	has	been	favorable.	

•

When	medical	assessments	cannot	be	completed	at	intake	due	to	the	condition	or	
refusal	of	the	inmate	with	serious	mental	illness,	further	attempts	must	be	made	so	
that	the	medical	assessment	is	eventually	completed,	documented	and	filed	in	the	
chart	in	the	area	reserved	for	physical	examinations/medical	assessments.		A	
medical	progress	note	should	also	document	the	reason	the	initial	intake	
assessment	was	postponed,	and	subsequent	medical	progress	notes	should	
document	attempts	to	complete	the	assessment.	

•

Postpone	development	of	a	mental	health	treatment	plan	so	that	it	is	an	accurate	
reflection	of	the	inmate’s	condition	and	describes	the	interventions	that	will	be	
provided,	by	whom	and	in	what	time	frame	as	opposed	to	having	a	non-specific	plan	
drawn	up	on	the	basis	of	a	single	psychiatric	assessment.					

	
Treatment	that	is	more	than	mere	seclusion	or	close	supervision	
There	is	very	little	mental	health	treatment	provided	other	than	psychotropic	medication	
for	inmates	that	consent	to	take	it.			
Areas	for	improvement:	

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•

The	overwhelming	majority	of	inmates	with	serious	mental	illness	may	be	
appropriately	treated	as	outpatients	in	general	population	settings.		However,	
outpatient	mental	health	treatment	must	include	opportunities	for	counseling,	
individual	and/or	group	treatment	interventions	as	clinically	indicated	and	crisis	
intervention	in	addition	to	periodic	medication	management	appointments.			

•

Residential	care	must	include	more	structured	out-of-cell	therapeutic	activities	as	
well	as	unstructured	out-of-cell	time,	particularly	in	the	closed	mental	health	units.		
This	is	true	for	all	inmates	transferred	and	maintained	at	NBB	for	treatment	of	
mental	illness,	not	just	those	housed	on	some	of	the	housing	units.	

•

Mental	health	treatment	must	be	conducted	in	space	that	affords	sound	privacy;	not	
at	the	cell	front,	in	the	hallway	or	in	non-private	areas	of	the	housing	unit.	

•

Admission,	discharge	and	mental	health	treatment	programs	must	be	developed	for	
the	mental	health	units	at	NBB.	

•

Inmates	requiring	a	higher	level	of	care	than	can	be	provided	at	NBB	must	be	timely	
transferred	to	inpatient	care.		Inpatient	care	must	be	readily	available	and	
accessible.		Access	to	care	cannot	wait	until	a	court	determines	a	transfer	is	
necessary	for	purposes	of	competency	to	stand	trial	restoration,	or	until	the	inmate	
is	released	from	jail.	

•

Confinement	in	a	closed	mental	health	unit	or	infirmary	for	seriously	mentally	ill	
inmates	is	the	equivalent	of	segregation	in	terms	of	social	isolation,	amount	of	time	
confined	in	cell	and	cell	front	contacts	with	staff	–	not	mental	health	residential	care.		
This	must	change	immediately.		

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•

Mental	health	and	medical	care	must	be	better	integrated	to	provide	appropriate	
services	to	inmates	with	both	conditions.		Access	to	medical	services	should	not	be	
impeded	due	to	the	presence	of	a	serious	mental	illness	or	being	housed	in	a	mental	
health	unit.	

•

Ensure	treatment	continues	whenever	an	inmate	is	confined	in	segregation.	

•

Incorporate	mental	health	clinicians	into	crisis	de-escalation	when	possible	to	avoid	
a	situation	in	which	the	use	of	force	is	planned.			

•

Formalize	the	role	of	mental	health	in	the	inmate	disciplinary	process.		

•

Resume	development	of	a	comprehensive	CQI	program.	

	
Staffing		
Vendor	staff	are	trained	mental	health	professionals	and	appropriately	licensed	and	
credentialed	for	the	tasks	they	are	assigned	within	the	facilities.		In	fact,	masters	prepared	
and	licensed	mental	health	counselors	could	expand	their	role	in	the	provision	of	
diagnostic	assessments	and	group	treatment	interventions.		The	primary	issue	with	regard	
to	staffing	is	simply	related	to	deficient	staff	numbers,	which	profoundly	limits	the	amount	
and	type	of	care	that	can	be	provided.	
Areas	for	improvement:	
•

Increase	staffing	levels	of	mental	health	clinicians	and	prescribers	to	permit	the	
delivery	of	appropriate	levels	of	outpatient,	crisis	and	residential	care.	

•

Ensure	that	there	are	sufficient	custody	staff	to	provide	escort	and	supervision	
when	mental	health	treatment	is	provided.	

	
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Safeguards	regarding	prescription	of	psychotropic	medication	
Generally,	psychotropic	medications	are	prescribed	in	appropriate	doses	for	recognized	
indications.			
Areas	for	improvement:	
•

Better	documentation	of	patient’s	condition	and	response	to	prescribed	medication;	
better	documentation	of	the	rationale	for	medications	prescribed	or	changed.	

•

Improve	continuity	of	care	with	outside	providers	as	well	as	among	various	Armor	
prescribers.	

•

Inmates	should	be	seen	more	frequently	if	clinically	indicated	than	the	minimum	
intervals	dictated	by	policy.		Staffing	levels	must	be	sufficient	to	permit	this.	

•

Monitoring	and	intervention	for	cases	medication	non-compliance	to	include	
medication	education	and	counseling	by	nursing	staff	in	addition	to	notification	and	
referral	back	to	the	prescribing	clinician.	

	
Accurate,	complete	and	confidential	records	
For	a	paper	record	system,	the	records	were	available	and	filing	was	up	to	date.		Problems	
included	illegible	handwritten	notes	and	incomplete	documentation	by	individual	
clinicians	–	but	these	can	have	a	profound	impact	on	care.	
Areas	for	improvement:	
•

Move	to	adoption	of	an	electronic	health	care	record.	

	
	
	
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Suicide	prevention	program	
Suicide	watches	can	be	initiated	at	any	time	and	in	any	jail	in	the	Broward	County	Jail	
system.			However,	more	emphasis	must	be	placed	on	the	provision	of	treatment	during	
watches,	transfer	to	a	higher	level	of	care	if	the	inmate’s	condition	does	not	improve	rather	
than	continued	watch	placement	because	the	conditions	are	unduly	restrictive	and	may	
contribute	to	the	failure	of	the	inmate	to	improve.		
•

BSO	and	Armor	suicide	prevention	policies/procedure	should	track	one	another	in	
terms	of	monitoring	intervals	and	staff	duties	such	that	there	are	not	contradictions	
or	confusion	between	the	two.	

•

Treatment	interventions	must	be	provided	during	periods	of	suicide	watch	to	
include	out	of	cell	contacts	by	mental	health	clinicians	–	not	just	daily	assessments	
by	the	prescriber.	

•

Adopt	a	standardized	risk	assessment	instrument	to	assess	risk	and	serve	as	the	
basis	for	developing	safety	plans	when	appropriate.		(Use	of	a	standardized	risk	
measurement	would	also	prevent	the	need	to	“automatically”	place	inmates	
returning	from	the	hospital	on	a	restrictive	watch.)	

•

Update	individual	treatment	plans	and	interventions	whenever	an	inmate	is	placed	
on	suicide	watch.	

•

Review	the	use	of	suicide	watch	as	a	response	or	type	of	punishment	for	
“manipulative”	behavior	and	consider	development	of	behavior	plans	to	address	
these	types	of	issues.	

•

Individuals	who	remain	suicidal	in	jail	should	be	assessed	for	the	possibility	of	
inpatient	hospitalization	at	appropriate	intervals.	

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•

Suicide	watch	must	respect	individual	dignity	and	privacy	while	ensuring	risk	
reduction	to	prevent	self-harm.		Conditions	while	on	watch	should	not	be	punitive.	

•

Mental	health	follow-up	after	watches	are	discontinued	should	be	based	on	
individual	clinical	assessment	and	need	and	be	particularly	mindful	of	the	inmate	
during	the	transition	off	watch	and	back	into	population.		

	
As	indicated	in	the	opening	paragraphs	of	this	report,	the	original	draft	of	this	
report	shared	with	the	parties	included	a	draft	implementation	plan.		The	parties	used	the	
draft	plan	and	subsequent	iterations	of	it	as	the	basis	for	on-going	discussion	and	
negotiation	of	the	terms	for	an	Implementation	Plan.		I	have	therefore	not	included	such	a	
plan	in	this	report	but	provided	the	data	and	basis	for	my	conclusions	about	current	and	
on-going	constitutional	violations	and	my	recommendations	for	inclusion	in	the	
Implementation	Plan	negotiated	by	the	parties.	
				
Submitted	by:	
	
/s/	
Kathryn	A	Burns	MD,	MPH	
8	August	2018	
	
	
	
	
	
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