Correctional Psychiatric Treatment Unit Report

Issued in December, 2002

• Introduction
• Background Information
  • History
  • Description
  • Administration
  • Program
  • Schedule
  • Use of Force Criteria
• Methodology
  • Interviews
  • Review of Documents
  • Observation of Training Session
• Findings
  • Allegations of Physical and Verbal Abuse and Neglect
  • Suicide Prevention
  • "Lockdown" and C-Wing
  • Medication
  • Access to Psychiatrists
  • Cell Entries
  • Extraordinary Occurrence Reports
  • Lack of Cohesion and Role Differences between Mental Health Staff and Correction Officers
• Conclusions
• Recommendations
• Conclusive Summary

Introduction

The Correctional Psychiatric Treatment Unit (CPTU) of Kentucky State Reformatory is located in LaGrange, Kentucky. CPTU houses persons who have been adjudicated and convicted of a crime or crimes and have been diagnosed with a mental illness.

In January of 2002, Protection & Advocacy (P&A) determined that probable cause existed to believe that persons incarcerated at CPTU were being subjected to alleged abuse and neglect. P&A initiated an investigation of CPTU. This report comprises a description of that investigation, its findings, conclusions, and recommendations.

P&A is a federally mandated program, which protects the rights of citizens of the Commonwealth of Kentucky with disabilities. Pursuant to federal authority, 42 U.S.C. 10801, et seq., Protection and Advocacy for Individuals with Mental Illness (PAIMI), P&A is charged with the responsibility to investigate incidents of abuse and neglect of individuals with mental illness in facilities if probable cause exists to believe that the incidents occurred. Prisons are included in the federal statute's definition of "facilities."[1]

Background Information

History

In 1979, persons incarcerated in Kentucky State Penitentiary (KSP) located in Eddyville, Kentucky, brought an action in the United States District Court for the Western District of Kentucky at Paducah alleging that the conditions of their confinement were cruel and unusual punishment in violation of the Eighth Amendment to the U.S. Constitution. Pursuant to the case, Kendrick v. Bland, 541 F.Supp. 21 (1981), the United States District Court for the Western District of Kentucky approved a consent decree that resolved many of the issues being litigated. The issue of guard harassment, which was excluded from the Consent Decree, was addressed in the underlying case.

The prisoners alleged guard harassment and a coercive informant system. In the underlying case, the Court found that the Eighth Amendment prohibits punishment, which, although not physically barbarous, involves unnecessary infliction of pain. The Court further held that "the use of the informant system . . .was destructive of the penological goals . . . and the goals of deterrence, security and rehabilitation."[2]  The Court in Kendrick found that the assignment of guards to the "Special Needs Unit" at KSP "who were totally untrained in dealing with mentally ill inmates resulted in the 'unnecessary and wanton' infliction of pain."[3] The Court further stated, "the placing of even well-intentioned guards in the position of dealing with inmates who are mentally ill without any training or adequate guidance, resulted in the infliction of much unnecessary cruelty and brutality. The attitude of those few guards who were less than well intentioned, and predisposed to use physical force made matters even worse."[4]

As part of the Consent Decree, the Special Needs Unit at KSP was closed. On September 1, 1998, the Correctional Psychiatric Treatment Unit (CPTU) opened in Kentucky State Reformatory (KSR) located in LaGrange, Kentucky.

Description

CPTU is a one hundred and fifty-bed unit, which is divided into three wings, A, B and C. Inmates who are medically and mentally more fragile than the rest of the population of CPTU are placed on A-Wing. C-Wing is the segregation wing used to house inmates just entering the program, inmates who are serving segregation time and inmates who have been placed on C-Wing from A or B-Wing because they are exhibiting behavior problems, fail to take medication or "their behavior has become unpredictable." Unpredictable behavior "may range from symptoms of psychosis or acute depression to self-abusive behavior related to personality disorders."[5]

CPTU was "constructed in response to the ever-increasing number of mentally ill inmates within the Kentucky Department of Correction."[6] The goal of CPTU is to assist inmates with achieving a level of stability, which will permit them to live in a less restrictive environment in the prison. Staff positions were established for three psychiatrists, seven psychologists, two recreation leaders, one recreation supervisor, two caseworkers, one caseworker supervisor, twenty-four hour nursing staff, security staff and support staff. CPTU is one of the few psychiatric inmate treatment programs in a prison in the United States.

The Policies and Procedures for KSR provide that the CPTU Treatment Program shall offer residential treatment to designated inmates at KSR. According to the Department of Correction (DOC) policies and procedures 18.1, CPTU is a "mental health treatment program" provided by the Division of Mental Health (DMH) of DOC for "an inmate, who, because of brain damage, mental retardation, long term illness or mental disorder, has a limited capacity with a prognosis for limited improvement and needs medical and mental health care."

Administration

DOC policies also state that the program shall be administered by the Division of Mental Health (DMH) within DOC in cooperation with KSR. Treatment services shall be provided by the DMH and security and support services shall be provided by KSR. Pursuant to KSR policies and procedures, the DMH and KSR shall cooperate to ensure:

1. The Treatment Program provides a safe and secure environment to assigned inmates and staff.
2. The Treatment Program provides a therapeutic benefit to the participating inmate.[7]

The policies further state that the Treatment Program shall provide treatment in the least restrictive correctional environment.

Program

The approximate length of time that an inmate stays in the Treatment Program in CPTU is one year. The inmate handbook states that an inmate can move through the program in twenty-five weeks.

Persons incarcerated at CPTU are admitted voluntarily or involuntarily. Criteria for a voluntary admission to CPTU are:

1. The person is in need of treatment,
2. The person must be determined to be mentally competent, and
3. A DMH Request for Voluntary Admission form signed by the inmate, witnessed by two (2) staff members and also signed by a psychologist or psychiatrist to confirm that the person is mentally competent to sign an expressed informed consent form.

For an involuntary admission to CPTU, a Vitek[8] hearing for the inmate is scheduled through the DMH Program Administrator. The Vitek hearing is a requirement of due process. At the hearing, the inmate is represented by counsel and can present evidence, witnesses and has the right to confront and cross-examine witnesses for DOC. A representative is appointed by the Warden to represent the interests of the institution. The hearing is conducted by an independent decision-maker and two correction officers unfamiliar with the inmate's case serve as committee members designated by DOC. The decision is made by majority rule. The inmate may be involuntarily committed for a maximum of 365 days. At the expiration, another commitment can be sought. All involuntary commitments are required to be reviewed 180 days into the commitment to determine if there is a need for continued treatment.

Schedule

The typical weekday schedule of an inmate at CPTU is as follows:

• 6:30—7:30 a.m.    »  Breakfast
• 8:00—8:30 a.m.    »  Pill Call
• 8:30—9:30 a.m.    »  Recreation
• 9:30—11:00 a.m.  »  Group Therapy
• 11:00 — noon       »  Lunch
• 12:30—1:30 p.m.   »  Gym
• 2:00—2:30 p.m.    »  Pill Call

   

• 2:45—3:30 p.m.    »  Count Time

   

• 4:00—5:00 p.m.    »  Dinner

   

• 5:30—7:30 p.m.    »  Educational Classes

   

• 8:00—8:30 p.m.    »  Evening Pill Call

   

• 10:00 p.m.           »  Lights Out

On the weekend, the inmates are expected to use their free time to study their program literature and work on homework assigned by their counselors. "Each Saturday, treatment staff offers 'bonus' activities for all inmates who have met treatment goals for the week, including taking all prescribed medication."[9]

Use of Force Criteria

The DOC policies and procedures, policy 9.1, provide that staff members shall not use physical force against any inmate except:

1. In self-defense;
2. To prevent injury to other persons;
3. To prevent or quell a disturbance;
4. To prevent an escape;
5. For approved medical reasons;
6. To facilitate transportation or movement from one location to another within an institution;
7. To prevent substantial property loss; or
8. To strip an inmate of all of his clothing if he exhibits suicidal gestures or expressions, or upon the recommendation of clinical personnel. An inmate shall be provided a pair of boxer shorts or a paper garment unless he is destroying his clothing, has a history of setting fires, or is jamming locks and doors.

Methodology

Interviews

All of the interviews of inmates and staff were voluntary.

Interviews with Persons Incarcerated at CPTU

P&A interviewed thirty-six inmates housed in CPTU. P&A interviewed inmates housed in each of the three units. Most of the inmates were interviewed in an office provided by CPTU located in the unit in the absence of CPTU staff. The door of the office contains a large window, which looks out to the main desk of the unit staffed by a correction officer. The inmates were told by P&A investigators the reasons for the investigation and the interviews. The inmates were asked structured questions with the ability to discuss other issues of concern to the inmates.

Interviews of Mental Health Staff

P&A interviewed fourteen current and former mental health staff persons. The mental health staff interviewed included the State Psychiatric Director, psychologists, caseworkers, the Program Administrator and the former Program Administrator of CPTU. The interviews of mental health staff were generally unstructured. The P&A investigator informed the staff person about the reasons for the investigation and interview. Most of the mental health staff was interviewed in the same office, which was provided for the interview of inmates. Some mental health staff were interviewed in other locations, including their personal offices.

Interview of the Unit Administrator of CPTU .

The Unit Administrator of CPTU is essentially a liaison between Correction Staff and Mental Health Staff. The Unit Administrator of CPTU was interviewed in her office. The interview was generally unstructured. Although previously informed about the investigation, the Unit Administrator was again told by P&A staff of the reasons for the investigation and the interview.

Interviews of Correction Staff

P&A interviewed nine CPTU correction officers who included former CPTU correction officers, a Correction Lieutenant in CPTU and the Captain of the Correction Officers working in CPTU. The interviews were conducted in offices and meeting rooms located in the Unit and in other sections of KSR. The interviews with correction officers were generally unstructured. The correction officers were informed by P&A interviewers of the reasons for the investigation and interview.

Interview of Supervisor of Recreation

P&A interviewed the Supervisor of Recreation for CPTU. The interview was generally unstructured. The Supervisor of Recreation was informed by P&A interviewers of the reasons for the investigation and interview.

Interviews of Nursing Staff and Nursing Administrator of CPTU

P&A interviewed three current and former nurses working in CPTU including the Nursing Administrator. The interviews of the nurses were generally unstructured. The nurses and Nursing Administrator were told by P&A interviewers the reasons for the interview and investigation.

Review of Documents

The following types of documentation were reviewed:

• Extraordinary Occurrence Report (EOR)[10] data compiled by DOC for each of the correctional facilities within the Commonwealth of Kentucky for the years 1996 through 2001. In meetings with KSR officials, it was learned that the data did not reflect the total number of EORs for each facility. Rather the data reported every individual incident that occurred during an extraordinary occurrence. Each EOR could contain multiple incidents and was tallied as such. The data reflected the number of incidents, not the number of EORs, for each facility. Since the data were not an accurate reflection of the number of EORs by facility, P&A chose not to use the data for comparison purposes.
• KSR EOR "Accumulative Summary Reports" were reviewed for the years 1998 through 2002 to determine trends.
• 102 Individual EORs generated in CPTU in the year 2001 were reviewed to identify trends.
• Behavior Control Reports (BCRs)[11] for the months of January, February and March 2000 and October, November and December 2001 were reviewed to identify trends.
• Review of Individual Records-With authorization—P&A reviewed the records of six inmates. P&A reviewed two videotapes, one of a cell entry.

Observation of Training Session

With the permission of the Director of CPTU, a P&A investigator observed a portion of an all day training session held by CPTU which included correction staff, mental health staff and medical staff. The P&A investigator sat in the back of the room for a portion of the training to observe the training.

Findings

Allegations of Physical and Verbal Abuse and Neglect

Thirteen inmates interviewed alleged that they had either witnessed or experienced physical abuse of inmates by correction staff. Twenty inmates interviewed stated that they had either witnessed or experienced verbal abuse of inmates by correction staff. None of the mental health staff interviewed stated that they had witnessed physical abuse of inmates by correction officers. However, two of the mental health staff interviewed stated that inmates had alleged incidents of physical abuse by correction officers to them. Ten mental health staff stated that they had witnessed verbal abuse of inmates by correction officers. Four correction officers stated that they had witnessed verbal abuse of inmates by other correction officers. During the interviews of inmates, mental health staff and correction officers, the names of four correction officers were mentioned repeatedly as committing the alleged abuse.

Summary of allegations

The following is a summary of allegations of abuse (physical and verbal) and neglect garnered from the interviews of inmates, mental health staff and correction officers. Most of the allegations relate to the same few correction officers:

• An inmate in CPTU alleged that a few weeks prior to the interview during a "take down" of him in the cafeteria at lunch for an outburst in which he threw a cafeteria tray[12] a correction officer stepped on the side of his face with his shoe and rubbed his chin into the floor of the cafeteria. P&A investigators observed scabs on the inmate's chin. Nursing staff interviewed also corroborated the scrapes on the chin of the inmate. The medical records of the inmate were devoid of any mention of the injury. When correction officers were interviewed about this alleged incident, it was explained to the P&A investigators that a helmet was used in restraining the inmate and the helmet has a strap that often scrapes the inmates.
• An inmate alleged that he suffered bruises from a stun gun used by correction officers.
• An inmate alleged that certain correction officers jerked his and other inmates' arms back after they have been placed in handcuffs.
• Two inmates alleged that once the inmate is in the cell, the correction officers ask the inmate to put his hands through the slot in the door to have the handcuffs removed. Once the inmate puts his cuffed hands through the slot in the door, the correction officer pulls on them and then releases them quickly causing the inmate to fall.
• An inmate showed the P&A interviewer a picture of him with a black eye he alleged was obtained after an altercation with a correction officer that threw him against a wall and hit him with his right fist. The inmate alleged that the altercation occurred after he was in hobbles.[13] The inmate stated that he did not file a grievance regarding this alleged incident, because he was on a five-minute watch[14] and was not allowed to have a pencil or paper.
• An inmate alleged that the inmates on C-Wing feel that they have to make threats to hurt themselves in order to see mental health staff.
• An inmate alleged that he was placed in segregation on C-Wing for weeks without any clothing or any blanket.[15]
• Seven inmates alleged that the temperature is very cold on C-Wing and alleged that the air-conditioning is turned on during the winter.
• An inmate alleged that he was put in a cell for segregation on C-Wing that was dirty and the mattress had excrement on it.
• While interviewing an inmate on C-Wing, P&A interviewers observed that the correction officers on duty did not get up from their post and observe the inmates that were on five and fifteen minute watches. Only after the correction officers noticed that they were being observed by P&A interviewers did they get up and check on the inmates in the five and fifteen minute watch cells.
• Ten inmates complained that they are not able to see psychiatrists as often as they would like especially to discuss their medications. One inmate stated that he was not able to access the psychologist on his unit as often as he would like.
• An inmate alleged that he was not allowed to eat a meal when he missed the time to leave for the meal due to seeing a visitor. The inmate alleged that the correction officer told him that he was "shit out of luck" and that he did not get to eat.
• An inmate of CPTU alleged that during a routine "pat-down" type search of approximately fifty inmates, a correction officer called him a "baby raper." The inmate felt compelled to show to several of the other inmates who heard the statement of the correction officer the judgment against him that is for a different crime, not child sexual abuse. The inmate feared that being labeled a child abuser would cause him to become a target among other inmates.
• Nine inmates complained that two correction officers of CPTU were "making out" in the control booth, which has a window, such that the occupants of the booth can be seen by the inmates. The inmates alleged that when the correction officers would meet to engage in inappropriate work behavior the inmates were harassed as to whether they were watching the officers. The inmates also alleged that they were further harassed by the male correction officer as to whether the inmates were "looking at" the female correction officer who had engaged in the activities.
• An inmate alleged that a correction officer dropped his handcuffs on the floor and said to the inmate, "Oops, I dropped the cuff. Hit me. I hope you fucking hit me."
• A mental health staff person overheard a correction officer tell an inmate that he should have received the death penalty for his offense.
• A correction officer stated that some of the other correction officers talk to the inmates "like dogs."
• Several inmates, mental health staff and correction officers alleged or confirmed a practice started by a correction officer of dyeing an inmate's underwear pink upon the inmate's discharge from CPTU in order to prevent the inmate from taking his underwear with him to the general population. The consensus of the inmates and mental health staff was that the practice was intended to degrade and humiliate the inmates.[16]
• An inmate alleged that a correction officer stated to him after a strip search, "I can see why people want to have sex with you."
• An inmate alleged that he was standing next to another inmate and a correction officer asked, "What are you two, sex buddies?"
• Ten of the inmates interviewed did not report allegations of abuse, physical or mental. To the contrary, these inmates did not have any problems with their treatment in CPTU by any staff in CPTU.
• Five of the inmates interviewed were highly complimentary of their relationships with and the mental health treatment that they are receiving from the psychologists and case managers in CPTU.

Suicide Prevention

On April 18, 2002, an inmate housed at CPTU committed suicide. According to the Director of CPTU, this was the first suicide in CPTU since its opening in 1998. Although inmates had attempted suicide in the past, this was the first person to commit suicide. The inmate had been in CPTU since February 26, 2002.[17] The inmate was found at 11:00 a.m. in his cell. He had apparently hung himself with his belt. After a review of the records when they are provided, P&A expects to release a separate report relating to the suicide at CPTU.

"Lockdown" and C-Wing

Lockdown consists of locking an inmate in a cell for some period of time. A sign with the words "Lockdown" is placed on the door of the cell. Whenever an inmate is placed on Lockdown, a Behavior Control Report is to be generated. While on Lockdown, the inmate is not allowed to participate in activities or leave his cell. Inmates are given their food on a tray through a slot in the door of the cell. The inmate receives one hour of recreation in the evenings.

While an inmate is on "hold ticket status," the inmate stays in lockdown for twenty-four hours a day without receiving mental health treatment. Inmates who are entering CPTU as a new admission are placed on a "hold ticket status." The inmates are placed on a "hold ticket" until the paper work in Frankfort is completed. Eight mental health staff and correction officers interviewed stated that this process could take up to up to two to three weeks, and in some cases longer. Eight mental health staff and correction officers stated that this process takes too long.

Many of the inmates are locked down for rule infractions prior to going to the Adjustment Committee.[18] There are certain rules that require immediate lockdown (fighting, sexual contact) which apply to inmates in the general population as well. However, inmates on CPTU are locked down for incidents that would not result in lockdown if they were in the general population. In addition, many inmates are locked down for lengthy periods of time while an investigation is pending into the alleged incident. Inmates can be locked down for sixty days in confinement while an investigation is pending. If the investigation is not completed at the end of sixty days, another lockdown order can be issued.

In one instance, an inmate was in lockdown, not for a rule infraction, but because mental health staff determined that he was not in a good mental state. When this inmate appeared before the Adjustment Committee, the Committee agreed with mental health staff.

Mental health staff alleged that some inmates stay in lockdown for much longer periods of time than other inmates do for the same rule infraction.

Some mental health staff expressed concern that correction officers on C-Wing make the decision of when an inmate comes out of lockdown. However, other mental health staff reported that since the correction officers have the opportunity to observe the inmates for more hours during the day, the correction officers are able to give valuable information about the inmates' behavior to the mental health staff. Mental health staff and correction officers reported that security staff and a treatment staff agree regarding the status of an inmate in over half of the instances.

In its review of records, P&A noted that one report dated October 2, 2001 read the inmate would stay in lockdown "until the discretion of security." Another dated October 2, 2001, read the inmate would stay in lockdown "for awhile." One record read that the inmate was placed in lockdown on October 15, 2001 "due to odd behavior."

Behavior Control Reports (BCR) are completed when an inmate:

• Commits a rule infraction,
• Requires observation due to suicidal behaviors
• Is placed in Lockdown for failure to take prescribed medication, or
• Enters CPTU as a new admission and is placed on C-Wing.

Correction officers and mental health staff fill out a BCR form. The form contains spaces for the staff person to:

• describe the incident,
• notice if there is an investigation that needs to be conducted as a result of the incident,
• notice whether the inmate is required to go to lockdown and report if the inmate is referred to the Adjustment Committee or Court Call.

During the course of the investigation, mental health staff, a few correction officers and inmates expressed concern over the way BCRs are filled out and handled.

P&A reviewed BCRs that were generated during three-month periods in 2000 and in 2001. In its review, P&A found that the majority of the incidents resulted in the inmate being placed in lockdown.

For the period of January-March 2000, there were 284 BCRs (excluding those for new admissions). Of the 284 BCRs, 240 (84.5%) ended in lockdown.

For the period of October-November 2001, there were 232 BCRs (excluding those for new admissions). Of the 232 BCRs, 190 (81.8%) ended in lockdown.

In addition, in its review, P&A found that not all BCRs are filled out immediately and sometimes an inmate is placed in lockdown without a BCR. An example of this occurred during the course of this investigation. An inmate approached a P&A interviewer alleging that the previous night he was placed in lockdown on Unit A without a BCR. The next morning, another correction officer took the inmate off lockdown. Staff confirmed that this inmate had been on lockdown the previous night. When Protection and Advocacy requested to see the BCR, one had not been filled out.

When asked, KSR officials confirmed that if an inmate, without a mental health diagnosis, in the general population begins to exhibit behavior, which suggests that he may engage in dangerous behavior, the inmate will also be placed in lockdown for safety reasons until the behavior subsides. The policy is that a BCR would be generated if the inmate is placed on lockdown. However, the instance in the above paragraph is an example that a BCR is not always generated.

C-Wing of CPTU is the segregation wing of the unit. It houses inmates who are entering CPTU as a new admission, including inmates who have been transferred there and placed on a "hold ticket" status for classification purposes. A classification officer completes the appropriate paper work. The paper work is sent to the DOC office in Frankfort and the transfer is issued.

If the inmate is voluntarily admitted to the program, the inmate may sign himself out of the program at any time. The inmate then, if not already on C-Wing, would be transferred to segregation on C-Wing out in the general population of KSR or to another correctional facility in the state. However, inmates and mental health staff interviewed alleged that if an inmate wants to sign himself out of the program then staff threatens to bring a Vitek action.

A mental health staff person alleged that an inmate being held on a hold ticket on C-Wing wanted to voluntarily sign out of the program at CPTU. The mental health staff person alleged that the inmate was told that he could not leave C-Wing unless he agreed to continue the process of his voluntary admission to CPTU.

Some mental health staff and inmates alleged that there is a perception that inmates are placed on lockdown on C-Wing if they file a grievance. An inmate alleged that he was told by staff to dismiss his grievance and state that he lied about the incident. The inmate was told that if he didn't state that he had lied, then he would be written up and would have to serve time in C-Wing. The grievance filed by the inmate was allegedly about this particular staff. The inmate allegedly did not dismiss the grievance and was placed in lockdown on C-Wing.

CPTU and KSR administration is aware of this perception and strongly states that inmates are not in any way penalized for filing grievances.

When an inmate enters C-Wing as a new admission, he is placed on a five-minute watch for two to three days. He is then changed to a fifteen-minute watch for two to three days.

An inmate on a five-minute or fifteen-minute watch is locked in a cell in C-Wing and, at the direction of a psychologist or psychiatrist, is checked through the window of the cell every five minutes or fifteen minutes by a correction officer.

C-Wing is also used as a segregation unit for mentally ill inmates who have segregation time to serve. They must serve one-half of the time given to them before they can enter the treatment program.

Inmates who show or engage in suicidal behaviors are transferred from A and B-Wings to C-Wing. Inmates who engage in rule infractions are often transferred from A or B-Wings to C-Wing.

While on C-Wing for any reason, psychiatrists and psychologists determine when the inmate moves from five to fifteen minute watches. After that, he is placed on lockdown status until the psychologist and psychiatrist determine that the inmate is ready to transition to A or B Wing.

Any staff person can place an inmate on a five or fifteen-minute watch, but only the psychologists or psychiatrists can move inmates off of watches. The psychologist and the correction officers review the lockdown reports every day.

While an inmate is on a five-minute or fifteen-minute watch, he is placed in a cell without a mattress or blanket and is given a paper hospital gown to wear. The cells in C-Wing consist of a toilet, a sink and a concrete slab for the inmate to sleep on. Inmates are given their food on a tray through a slot in the door of the cell. Once the inmate is upgraded to lockdown status, he is given a mattress, a blanket and a prison uniform.

Medication

Eleven of the inmates interviewed stated that if they did not take their medication they were placed on lockdown. The policy of CPTU is that to move from C-Wing into the program, the inmate must agree to mental health treatment, including prescribed medication. It was reported by many mental health staff, correction officers and inmates that if an inmate does not take his medications for three days, then the inmate is placed on lockdown until he takes the medication.

The lockdown can last until the inmate begins to take his medication, which could be days or even up to a year in one instance. P&A learned during this investigation that an inmate at CPTU stayed on C-Wing in segregation for a year because he refused to take his medication. This inmate served out his sentence in CPTU. At the time of his serve out, the staff of CPTU petitioned the District Court to commit him involuntarily for sixty days to a psychiatric hospital. The District Court expressed concern that the staff chose to place the individual in segregation on C-Wing for a year rather than go through due process procedure for forced medication.

In November 2001 in CPTU, three inmates were placed in lockdown for not taking their medication. In March 2000 in CPTU, 11 inmates were placed in lockdown for medication noncompliance. Five inmates in CPTU were placed in lockdown for medication noncompliance in February 2000. In January 2000 in CPTU, six inmates were placed in lockdown for medication non-compliance.

The Chief of Psychiatrists explained that this procedure is utilized when the criteria for forced medication are not present. In order to meet the criteria for forced medication, the inmate must be found to be a danger to himself or others. Often, the inmate's behavior does not meet this criteria; however, the behavior may be odd or suggest that the inmate is becoming unstable. In an effort to balance the safety interests of the other inmates and the staff of CPTU and the inmate's right to refuse treatment, safety is given greater weight. The inmate who refuses to take his medications and exhibits odd behavior or behavior that indicates that the inmate is deteriorating may be placed on lockdown until the inmate begins to take his medicine again.

The Administration of CPTU made it clear that a team comprised of both mental health and correction staff meets daily to evaluate the inmates in an effort to determine whether they can stay in the program without medication. The team also observes the inmates to make a determination that their behavior indicates that they need to be placed on lockdown for failure to take medications. CPTU staff is mindful of the balance of safety and the inmate's right of refusal to take medication. CPTU staff stated that there are a few inmates not taking medication who remain in the program not on lockdown. The Administration and Chief of Psychiatrists further stated that they have measurable criteria for the odd behavior that would cause an inmate refusing medications to be placed in lockdown.

Access to Psychiatrists

Many of the inmates stated that they refused to take their medication because they felt that it either was not working or they were experiencing unpleasant side effects from the medication. Several of the inmates interviewed were prescribed neuroleptic medication, such as thorazine and haldol. Many described side effects such as dizziness, drooling and feeling nauseous.

Ten of the inmates stated that they made repeated requests to see the psychiatrist regarding their medication and alleged that they may go several months before they see their psychiatrist.

DOC employs three psychiatrists who cover five correctional facilities located throughout the Commonwealth. In April 2002, the population of the five correctional facilities in Kentucky was as follows:

• Eastern Kentucky Correctional Complex, West Liberty—1,605
• Kentucky State Reformatory, LaGrange—1,507
• Luther Luckett, LaGrange—1,056
• Green River Correctional Complex, Central City—898
• Kentucky State Penitentiary, Eddyville—783

Each of the three psychiatrists may treat the inmates housed in CPTU. There is not one particular psychiatrist assigned to CPTU.

The State Psychiatric Director for DOC and the Mental Health Director for DOC both stress that the inmates housed in CPTU are provided with psychiatric care that meets the Community Standard. Persons living in the community would not be able to access their psychiatrists more frequently. In addition, they explained that some psychotropic medications take months of use before their benefit in a patient can be measured.

Cell Entries

A cell entry consists of a team of correction officers entering a cell either to subdue an inmate or to prevent self-injurious behavior. Most, if not all, cell entries are videotaped. Some, but not all cell entries utilize electric shields and a taser gun. Several of the allegations of abuse and injuries for both inmates and staff occured during cell entries

The cell entry is supposed to occur after other interventions have been attempted to stop the inmate from the behavior. Unless it is an emergency, a psychologist will meet with the inmate prior to the correction officers conducting a cell entry. This may not be true on 2^nd and 3^rd shift, since a psychologist is not on staff during this time.

There are certain situations where the safety of the inmate requires a cell entry. However, P&A believes that, as the result of this investigation, the numbers of cell entries could be greatly reduced if inmates were not ignored and verbally antagonized by a few correction officers. The end result of the verbal abuse is that the inmates become more agitated, become more verbally abusive to staff, and are provoked more into banging on their doors which results in a cell entry, always a forceful procedure.

Most cell entries occur on C-Wing and this is also the wing where most mechanical restraints are used.

Extraordinary Occurrence Reports

An Extraordinary Occurrence Report (EOR) is a document that all correctional facilities within the Commonwealth of Kentucky generate to record deaths, illnesses, escapes, assaults, contraband, accidents, suicide attempts, self mutilation, destruction of property, riots, fires, fights and the use of force by staff.

The EORs reviewed by P&A were well documented. The EOR contains the factual information and a narrative of the events written by the highest-ranking officer. The EOR may also contain statements from the other staff involved in the incident. Our review of EORs revealed that the reports contained information explaining why the reports were necessary and were very descriptive of the behaviors necessitating the report. All of the EORs reviewed contained necessary documentation justifying the actions taken. Some of the EORs included behaviors by inmates such as smearing feces, fighting with officers and self-abuse.

P&A reviewed 102 EORs generated in CPTU from the year 2001 (53% of the total EORs for that year). Forty-six inmates generated those EORs. Eighty-three of the 102 EORs (81%) described the use of restraints on inmates. Of the 102 EORs, thirty reports involved the initial behavior of an inmate striking the cell door.

The Captain and Lieutenant Captain of correction officers have the authority to place an inmate in restraints[19] with the authorization of a psychologist. The psychologist can authorize the use of restraints for up to 3 hours. If more time is needed, then a psychiatrist must be called. If chemical restraints are used, the psychiatrist must be called by nursing staff. Anytime a restraint is used, an EOR must be completed. The nurse examines the inmate once he is placed in restraints and after he is released from restraints.

Lack of Cohesion and Role Differences between Mental Health Staff and Correction Officers

Some poor relationships and philosophical differences between correction officers and mental health staff hinder the mental health treatment of some of the inmates housed in CPTU. The KSR policies state that DMH and KSR shall cooperate to ensure that the Treatment Program in CPTU provides a safe and secure environment to assigned inmates and staff and the Treatment Program provides a therapeutic benefit to the participating inmate. Finding a balance between these two missions has been difficult.

Chain of Command

Two supervisory chains seem to add to the lack of cohesion. The correction officers in CPTU report to a Captain who reports to a Senior Captain of KSR. The mental health staff reports to the Program Director of CPTU who reports to the Director of the DMH. When there is a difference of opinion regarding an inmate, this reporting mechanism becomes problematic.

Philosophical Differences

During the interviews with mental health staff and correction officers, most agreed that a difference in philosophy existed between mental health staff and correction officers and that this difference often resulted in a territorial struggle. These philosophical differences between mental health staff and correction officers prevent each of them from fully appreciating the other's role.

Correctional Staff View

More than one correction officer pointed out to the P&A interviewer the fact that the unit was called the "Correctional" Psychiatric Treatment Unit and not the "Psychiatric Treatment" Correctional Unit, emphasizing that the word correctional came before psychiatric.

Four correction officers stated that mental health staff takes unnecessary risks with inmates. These risks include: a report that an art therapist brought a hot glue gun for a project; a psychologist meets with inmates in an unsecured office; a psychologist was locked in an office with and by an inmate, once locked, the psychologist was unable to unlock the office door from the inside; a mental health staff person who wants to hold group therapy sessions in unsecured locations.

In interviewing correction officers, it was clear that they take their job of protecting all staff and visitors very seriously. It does not help their morale when they notice that some mental health staff place themselves in vulnerable, dangerous situations with inmates and the correction officers are charged with the duty to risk their life and health in order to rescue the mental health staff from those potentially dangerous situations.

Three of the correction officers interviewed intimated that they felt unappreciated by mental health staff and also not valued by other correction officers working in the general population.

Mental Health Staff View

Some mental health staff interviewed stated that the verbal abuse and philosophical view of a few of the correction officers interfere or hinder the mental health treatment of the inmates. Some of the mental health staff interviewed gave specific instances of verbal abuse that they had witnessed or been told about by inmates. Mental health staff stated that although they had not witnessed physical abuse, inmates had alleged a few instances to them.[20]

Three mental health staff stated that they were somewhat apprehensive and afraid to speak out against the correction officers. The staff did not state that they were fearful of the administration's reaction to the information, but rather of the reaction of the few correction officers.

All staff interviewed were in agreement that the correction officers in CPTU maintain a secure and safe environment in which to be employed and that the correction officers are very responsive in a crisis situation. Most of the mental health staff stated that because of the secure and safe environment provided by the correction officers, they were able to move freely on the unit and this made it easier for them to perform their job.

Administration's Role

CPTU is approximately four years old and has demonstrated through its leadership that it is working to find the balance between the mission and philosophy of KSR and the unique purpose of CPTU. This is a difficult balance to strike. The leadership of DMH and KSR has shown throughout this investigation that they are aware that this is an issue within CPTU and they reported to P&A that they are committed to working to find the balance in order to accomplish both missions with all deliberate speed.

Conclusions

• The majority of the staff (correction officers, administration, mental health staff and nursing staff) is comprised of competent, caring, dedicated individuals who are committed to the mental and physical health and well being of the individuals housed and receiving treatment in CPTU.
• A few correction officers, who by their authority or by their influence due to their personalities perpetuate a climate which is hostile to mental health treatment at CPTU. (KSR and DOC have taken action to remove abusive staff from CPTU).
• At the time of this investigation, inmates of CPTU were experiencing verbal abuse by correction officers. Due to the actions and words of a few correction officers, much of the climate was hostile to the inmates and to their receiving mental health treatment.
• Several inmates interviewed made allegations of physical abuse by correction staff. P&A was unable to corroborate any of the allegations of physical abuse. However, circumstantial evidence, such as scrapes on one inmate's chin with no accompanying medical report, as well as the environment of verbal abuse by a few officers were of great concern to investigators.
• The mentally ill inmates of CPTU endure isolation on C-Wing.
• CPTU is providing mental health treatment but is not a licensed mental health treatment facility. No independent regulatory entity certifies or monitors the treatment being provided at CPTU.
• The confusion about roles and tension among correction staff and mental health staff hinder the mental health treatment of the inmates. Dual lines of authority exacerbate this problem.
• Inmates of CPTU are placed on lockdown if they refuse to take their medication despite their right to refuse treatment.
• Correction staff needs more training to work with inmates who have serious mental illnesses.
• CPTU, which can house as many as 150 individuals with serious mental illness, does not employ a psychiatrist whose time is solely dedicated to CPTU.
• Inmates are placed on lockdown at the discretion of the staff. Some stay in lockdown "pending investigation" which, sometimes, can take several weeks.

Recommendations

Protection and Advocacy recommends the following:

• A number of allegations of abuse and injuries for both inmates and staff occur during cell entries. Training and technical assistance should be provided to correction officers to avoid situations that result in cell entries. There are certain situations where the safety of the inmate requires a cell entry. However, P&A believes that, as the result of this investigation, the numbers of cell entries could be greatly reduced if inmates were not ignored and verbally antagonized by a few correction officers. The end result of the verbal abuse is that the inmates become more agitated, become more verbally abusive to staff, and are provoked more into banging on their doors which results in a cell entry, always a forceful procedure.
• CPTU should adopt its own policy regarding excessive force, physical and verbal abuse. The policy should include a clear "no tolerance" mandate for excessive force, physical or verbal abuse by staff.
• CPTU should provide more training:
  • It is apparent that correction officers should be provided with more mental health training than the standard two hours provided during orientation for new officers. Last April, all day training was provided to all of the staff at CPTU. This is a good start; however, it should be continued on a regular basis. The correction officers working in CPTU need more mental health training, including more extensive training in suicide prevention.[21]
  • It is recommended that CPTU provide its staff extensive training on de-escalation techniques and other methods that would substantially reduce and work towards eliminating the use of restraints.
  • It is also recommended that the Federal Consent Decree of 1981 be included in the training. While many employees know that it exists, not many know why a class action lawsuit was filed on behalf of the inmates at KSP and the outcome of the lawsuit. To include and recognize this piece in the training and allow employees to read it, would help staff to be able to appreciate the positive reforms that have taken place in the penal system in Kentucky, but also to understand that an environment of abuse of a prison population with mental impairments precipitated this class action.
  • Mental Health staff employed in CPTU should receive minimal training on security measures, rules and responsibilities while being employed in a prison.
• The Correction Officer positions in CPTU should be reclassified to Psychiatric Correctional Officers. The position should require some background in mental health training or experience working with persons with mental illness. Protection and Advocacy acknowledges that the needs of the inmate population are complex and that interacting with the inmates is challenging. Many of them have assaulted staff and other inmates, thrown feces and urine, destroyed property, flooded cells and threatened staff. P&A recommends that correction officers who work with this population be given a pay differential. The position should have higher pay due to the requirements of higher qualifications and greater responsibilities. It is also suggested that officers who want to rotate off this unit to other units be allowed to do so.
• Currently correction officer staff and mental health treatment staff have separate chains of command. This unit is unique in that there are as many clinical staff as there are security staff. All CPTU staff should report to the director of CPTU. Since this unit opened, the division between correction officer staff and mental health treatment staff has existed. It is evident that the reporting mechanism for all staff should be streamlined under one person. The "us vs. them" mentality undermines the mission of the unit. The competing expectations of correction staff and mental health staff cannot be managed without professional leadership, which adheres to the mission of the program. Clinical leadership needs to keep the focus on the mission of providing mental health treatment and allow all staff of all interdisciplinary levels to discuss and work on differences.
• The Correction Officers' chain of command should be changed so that all shift Lieutenants assigned to CPTU report to the Captain of correction officers for CPTU. The Captain employed in CPTU should report to the Director of the Unit. This Director should be supervised by Department of Correction' Mental Health Staff.
• CPTU should be licensed as a Psychiatric Hospital. This unit is performing medical and psychiatric practices used in licensed psychiatric hospitals. An outside licensing agency needs to monitor the use of these practices.
• At least two more psychiatrists should be hired and assigned to CPTU. Several inmates stated that they are not able to meet with psychiatrists as often as needed to discuss their medication. With only three psychiatrists employed to cover five facilities in the entire state, the need for more psychiatrists is very real. In addition, much of the psychiatrists' time is, understandably, used in travel time to and from the five facilities. Applying a "community standard" of access to psychiatric professionals to a 150-bed psychiatric treatment unit does not seem reasonable.
• Inmates are held on hold ticket status for several weeks during which they stay in isolation without any programming. The classification process is very slow. P&A recommends that this procedure be examined so that inmates can move into the program without staying in isolation for weeks.
• Contact information, including address and telephone numbers, for Protection & Advocacy should be posted in a location accessible to inmates housed in CPTU.
• Every staff person working in CPTU should receive a copy of this report.

Conclusive Summary

A few correction officers are perpetuating incidents of verbal abuse, and there are allegations of physical abuse, within CPTU. Any abuse of an inmate should not be tolerated. Any incidents of abuse, whether verbal or physical, create an atmosphere that is in direct contradiction of the stated mission of CPTU to provide psychiatric treatment. From this investigation and interviews, it is evident that the majority of the staff (correction officers, administration, mental health staff and nursing staff) are competent, caring, dedicated individuals who are committed to the mental and physical health and well being of the individuals housed and receiving treatment in CPTU. Many of the inmates interviewed stated that they feel that all staff of CPTU care about their welfare and are trying to help them. However, the action of a minority of correction officers, who are influential because of their authority or their personalities, perpetuates a climate of abuse.

In the past months, P&A has met with the Warden of KSR, the Director of DMH for DOC, the Chief Psychiatrist for DOC, and the Director of CPTU to discuss these findings and recommendations. These meetings were productive. Since the initiation of the investigation, CPTU has undergone some correctional staff changes.

P&A is aware that many, if not all, of the recommendations it makes in this report require additional funding, legislation and/or the promulgation of regulations and policies. However, these factors should not be used to compromise the mission of CPTU to provide mental health therapeutic benefit to the inmate. P&A strongly urges that funding for these necessary mental health programs in DOC and more specifically CPTU be increased to ensure a high quality and effectiveness.

In six to eight months, P&A will complete a brief follow-up to this investigation to observe and evaluate the changes made at CPTU.