January 4, 1999
The Honorable Brian S. Quirk
Black Hawk County Board of Supervisors
316 E. 5th Street
Waterloo, Iowa 50703
Re: Black Hawk County Jail
Dear Mr. Quirk:
On May 8, 1998, we notified you, pursuant to the Civil Rights of Institutionalized
Persons Act ("CRIPA"), 42 U.S.C. § 1997 et seq., that
we were initiating an investigation of conditions of confinement at the
Black Hawk County Jail ("Jail") in Waterloo, Iowa. In June 1998, we conducted
investigative tours of the facility with expert consultants who specialize
in the fields of correctional medicine, correctional psychiatry, and penology.
During our visits we interviewed administrators, corrections officers,
professional staff, contract medical and mental health providers, and inmates.
We also observed conditions and facilities at the Jail, including inmate
housing areas. Further, we reviewed numerous documents, including facility
policies and procedures, intake screening and classification forms, inmate
medical and mental health records, incident reports, records of attempted
and completed suicides, and minutes of the meetings of the Black Hawk County
Correctional Facility Coordination Task Force. Finally, we interviewed
a number of former inmates and family members as well as advocates from
the community. Throughout the investigative process the administrators
and staff of the Black Hawk County Jail have been cooperative and responsive
to our requests. We thank them for their assistance. Consistent with CRIPA's
statutory requirements, we are now writing to inform you of our findings.
The Black Hawk County Jail, a 272-bed facility, opened in September
1995. At the time of our visits, the Jail housed approximately 240 pre-trial
detainees and sentenced misdemeanants, of whom about 160 were from Black
Hawk County, 60 were from other counties, and 20 were from the federal system. According
to Jail personnel, however, ordinarily about half of the Jail's inmates
are from outside Black Hawk County.
The Jail is divided into six housing units, or "pods", each of which
house between 36 and 50 persons. Five of the six pods use direct correctional
officer supervision, where a deputy circulates among the prisoners while
supervising the pod. The sixth pod is a maximum security area that consists
of three sections: a section for inmates who have not yet been classified;
a section for inmates classified as requiring maximum security; and a special
housing unit ("SHU") for inmates in disciplinary or administrative segregation,
including inmates who are determined to pose a suicide risk. This pod is
supervised by an officer in a secure control center.
The constitutional law governing conditions of confinement for inmates
has two sources. With respect to inmates who have been convicted of criminal
offenses, the Eighth Amendment's ban on cruel and unusual punishment governs
all aspects of conditions discussed here. The Eighth Amendment "imposes
duties on [prison] officials, who must provide humane conditions of confinement;
prison officials must ensure that inmates receive adequate food, clothing,
shelter, and medical care, including mental health care, and must 'take
reasonable measures to guarantee the safety of the inmates.'" Farmer
v. Brennan, 511 U.S. 825, 832 (1994) (quoting Hudson v. Palmer,
468 U.S. 517, 526-27 (1984)). Pretrial detainees "retain at least those
constitutional rights . . . enjoyed by convicted prisoners." Id. at 545. With respect
to pretrial detainees, the Fourteenth Amendment prohibits conditions or
practices not reasonably related to the legitimate governmental objectives
of safety, order and security. Bell v. Wolfish, 441 U.S.
520 (1979). Pretrial detainees have not been convicted of anything and
therefore they may not be punished.
Based on our investigation of the Black Hawk County Jail, we have concluded
that conditions at the Jail violate the inmates' federal constitutional
rights with respect to medical and mental health care, suicide prevention,
inmate supervision and protection from harm, and improper use of the restraint
chair. We also have serious concerns about other allegations we have received
regarding excessive use of force, particularly in the intake area of the
Jail. These allegations, which are bolstered by evidence of inadequate
documentation and monitoring of use of force by the Jail, will require
I. INADEQUATE MEDICAL CARE
The Black Hawk County Jail fails to provide adequate medical care services
to inmates. Our investigation revealed serious deficiencies in each major
component of the Jail's system for providing medical care, including staffing,
intake, sick call, emergency care, and infection control. As a result of
these deficiencies, inmates frequently do not receive adequate evaluation
or treatment for their illnesses, and there exists an ongoing potential
for serious harm or death to the inmate population.
A. Inadequate Physician Involvement
An inadequate level of physician involvement underlies many of the problems
in the Jail's medical delivery system. Emergency Practice Associates, a
group of emergency room physicians, provides physician services at the
Jail on a contractual basis. Under the group's current contract with the
Jail, a physician comes on-site once a week for a maximum of one
and a half hours. According to sick call calendars kept by the Jail's nursing
staff, it is not uncommon for the physician to see only one or two inmates
a week. This amount of physician coverage is inadequate to meet the medical
needs of the inmates housed at the Jail. As a result, the Jail's nursing
staff(1) does not receive adequate supervision
and, at times, nurses practice beyond the scope of their licenses. The
physician group is only aware of and involved with the patients the nurses
refer to them, a very small percentage of the inmates requesting services.(2)
Nurses routinely diagnose inmates and decide upon treatment plans, or deny
treatment, without physician supervision or review.(3)
As examples set forth below will demonstrate, this puts inmates at high
risk for misdiagnosis or improper treatment.
The Jail's intake screening procedures are not adequate to identify
inmates with serious medical needs. Intake medical screening is administered
by a civilian booking officer in the Jail's intake area. Inmates in the
booking area stand approximately three feet away from the booking officer
on a designated spot on the floor. Sensitive questions pertaining to the
inmate's medical and mental health, use of medication and suicidal tendencies
are asked and answered from that distance, often in the presence of other
inmates and Jail staff. This lack of confidentiality in the intake screening
process discourages inmates from giving candid answers to health-related
The possibility that inmates will not disclose their medical conditions
at intake is particularly problematic at the Black Hawk County Jail, because
the facility does not provide routine post-admission health assessments
of all inmates who remain at the Jail for extended time periods. Only inmates
who self-report their illnesses or are referred by corrections personnel
are seen by the medical staff. The absence of routine evaluations, together
with the lack of confidentiality in the screening process, creates a significant
risk that inmates with serious illnesses (including contagious diseases
such as tuberculosis) will not be identified at intake or within a reasonable
period of time thereafter.
Morever, even inmates who are identified at intake as having medical
problems are not thoroughly examined by the Jail's medical staff. Ordinarily,
the nurses do not perform physical examinations or even take the vital
signs of the inmates who are seen; rather, "evaluations" consist of asking
the inmates questions and following up with calls to private physicians,
if any, or to family members, in an attempt to obtain medication. The physician
group does not see or even know about these inmates.
One inmate, for example, came into the Jail with a history of hypertension.
Although he was not given a physical examination, the inmate's blood pressure
was taken and found to be high. The nurse did not call the Jail's physician
or do a complete assessment. Instead, she attempted unsuccessfully to get
the inmate's medication from his private doctor and his family. Five days
later, the inmate complained of a headache and again was found to have
high blood pressure. Still, he was not referred to the physician or fully
examined. The nurse continued to seek to obtain the inmate's medication
from his family, and gave him one dose from the Jail's supply until the
inmate's sister brought in the medication. The Jail's delay in treating
this inmate put the inmate at unnecessary risk of serious complications
or even death.
This was not an isolated incident. Our review of inmate medical records
revealed many examples of incomplete examinations, lack of physician involvement,
and delays in treatment for individuals with potentially life-threatening
conditions, including HIV, asthma, and chest pain.
C. Sick Call
Inadequate physician input characterizes the sick call process. For
the most part, the Jail's nursing staff conducts sick call independently
with no physician supervision or review. Fewer than 10 per cent of the
inmates requesting sick call are ever seen by a physician. Moreover, the
nurses providing sick call have no treatment protocols to follow. As a
result, nurses make decisions that they are not qualified to make, placing
inmates at high risk of faulty diagnosis and treatment.
One inmate, for example, came to sick call complaining of an upset stomach.
The nurse did not take the inmate's vital signs or conduct a physical exam.
Two days later the inmate returned, complaining that he had vomited blood.
Again, the nurse failed to examine the inmate. Later that day the inmate
claimed to have vomited blood again. Still, the nurse did nothing. Finally,
the inmate was taken to the hospital for internal bleeding, a condition
that could have been life-threatening.
In other instances, the nurses not only practice medicine without a
physician's supervision, but actually override decisions made by a physician.
For example, an inmate with a history of asthma requested his inhaler,
which had been prescribed by a physician. Without evaluating the inmate
or consulting a physician, the nurse stopped the medication because, according
to nursing notes, she felt he did not need it. Another inmate, who was
HIV-infected, returned from an appointment with a physician with a prescription
for another condition. After reviewing the inmate's record, the nurse refused
to give the inmate the medication ordered because she had previously advised
the inmate to exercise and drink water for the same problem. For nurses
unilaterally to override physicians' orders in this manner poses a serious
health risk to the inmate population.
D. Emergency/Urgent Care
It was difficult to evaluate the Jail's system for providing emergency
or urgent care because inmates' medical encounters outside intake or sick
call are not recorded in a manner that permits tracking or quality control.
No logs are kept of after-hours encounters with on-call nurses or emergency
room physicians. We were told, however, that nurses are the first to be
called in the case of an emergency when there is no medical staff on site.
To assure accurate diagnoses and sound responses in medical emergencies,
physicians should be the first point of contact for emergency care. The
physician can then decide whether it is appropriate for a nurse to handle
E. Absence of Infection Control
The Jail has an inadequate program for infection control. It does not
conduct regular testing for either tuberculosis or sexually transmitted
diseases, even though it is well established that detainees are at high
risk for these diseases. A representative from the Black Hawk County Department
of Health confirmed that the risk of exposure to both tuberculosis and
sexually transmitted diseases exists in Black Hawk County. The absence
of adequate infection control at the Jail seriously threatens not only
the health of inmates, but of the Jail staff and the community at large,
F. Inadequate Documentation/Lack of Quality Assurance/Mishandling of Inmate Grievances
The medical record keeping practices at the Jail are deficient. Inmate
medical charts are poorly organized and fail to provide the documentation
needed to make sound medical judgments and ensure continuity of care. Further,
there is no record review or quality assurance program at the Jail to ensure
that health care is being delivered in a safe, effective and constitutionally
The Jail has established an inmate grievance procedure through which
inmates can have complaints concerning medical care, as well as other types
of complaints, reviewed. Our analysis of incident reports revealed, however,
that in some instances, correctional officers deny inmates access to grievance
forms on the ground that the inmate does not have a valid grievance (e.g.,
"no civil rights were broken"). The withholding of grievance forms defeats
the purpose of a grievance system, which is the independent review of inmate
complaints. A properly-managed grievance system enhances quality assurance
by bringing legitimate complaints and problems to the attention of management,
and may lessen tensions in the Jail.
II. INADEQUATE MENTAL HEALTH CARE
The Black Hawk County Jail fails to provide inmates access to adequate
mental health care. Many of the systemic deficiencies affecting the delivery
of general medical care affect the provision of mental health care as well.
In addition, there are significant issues unique to the Jail's mental health
A. Inadequate Mental Health Staffing
The Black Hawk County Jail contracts with an outside provider to supply
mental health services to inmates. Between July 1997 and July 1998, this
outside provider was a private mental health group, which consisted of
a physician with a background in substance abuse treatment and two licensed
mental health counselors.
The County's arrangement with this private provider did not result in
an adequate level of mental health staffing at the Jail. The group did
not include a psychiatrist and, therefore, could not provide a full range
of mental health services. As a result, between July 1997 and July 1998,
the Jail's nursing staff relied primarily on inmates' outside psychiatrists
or physicians (who had no formal relationship with the Jail) to write orders
for psychiatric medications. Ordinarily, this was accomplished over the
telephone with no face-to-face encounters between the inmates and the psychiatrists.
Further, the psychiatrists who wrote the orders were seldom, if ever, involved
in follow-up or monitoring of the inmates' conditions. As discussed below,
this led to serious inadequacies in medication management, with the nursing
staff operating virtually unsupervised. The Jail's "system" of using outside
psychiatrists also failed to meet the needs of inmates who were not diagnosed
as mentally ill or on medication prior to their incarceration and, therefore,
did not have an outside provider. There was no established procedure for
evaluating these inmates (although on rare occasions, usually in response
to a court order, they would be transported to the local community mental
health center for assessment), and often they would go untreated.
In addition, the Jail failed to utilize the services the private provider
could provide. The counselors had no regular hours at the Jail,
did not provide ongoing counseling or therapy to inmates, and were called
only sporadically to perform evaluations. Although the group had expected
to receive two to five calls a week when it contracted with the County,
this did not occur. During the first six months of the contract, Jail personnel
sought the private provider's services only about five times. All together,
the Jail called the group fewer than 20 times during a one year period.(4)
Black Hawk County has recently taken action to correct these deficiencies,
including contracting with a different mental health provider and significantly
changing the terms of the contract. Under the new contract, approved by
the Black Hawk County Board of Supervisors in August 1998, the community
mental health center will supply mental health services(5)
at the Jail, for a minimum of four hours and an average of no less than
12 hours per week. The contract requires that a board-certified psychiatrist
serve as mental health authority. If this contract is implemented properly,
it will be a significant step toward correcting many of the mental health-related
issues identified herein.
The Black Hawk County Jail does not adequately screen inmates for mental
illness at intake. As discussed previously, the lack of privacy provided
during intake questioning deters inmates from giving candid answers to
medical questions; this is particularly true when it comes to sensitive
questions regarding an inmate's mental health and suicidal tendencies.
In fact, we reviewed a number of screening forms that indicated negative
responses to mental health-related questions despite the conclusion of
our expert that the inmate showed symptoms of an obvious mental illness.
The problems with intake screening are compounded by the fact that only
inmates who self-report or who are identified by correctional staff as
being mentally ill are evaluated by medical staff. There are no routine
mental health assessments of new inmates.
Even when there are reasons to suspect mental illness, inmates are not
always properly evaluated. In one case, an inmate's mother notified the
Jail's nursing staff shortly after intake that her son had a history of
paranoid schizophrenia, and requested that he be evaluated for mental illness.
The nurse, however, reviewed the inmate's intake sheet which (based on
the inmate's own responses) did not indicate any psychiatric problems or
medications, and decided simply to "observe for problems." The inmate was
never interviewed or evaluated by mental health personnel, or even by the
nursing staff, and at the time of our visit, he was receiving no treatment
for mental illness. When we interviewed this inmate at the Jail, he was
very guarded and denied having any psychiatric history. However, our psychiatric
consultant concluded that the inmate was exhibiting symptoms that were
"certainly consistent with the presence of a serious mental disorder."
The nursing staff's response to information concerning this inmate was
inadequate and demonstrated a lack of understanding of relevant psychiatric
C. Sick Call/Treatment
Between July 1997 and July 1998, the Jail's nursing staff routinely
evaluated and dismissed inmates' sick call requests for mental health treatment
with little or no input from qualified mental health professionals, including
the Jail's contracted mental health provider. There was virtually no mental
health counseling or crisis intervention program available at the Jail.
As a result, inmates with serious mental illnesses did not receive adequate
assessment of or treatment for their conditions.
A tragic example of this deficiency occurred when an inmate, who claimed
to have received mental health treatment on the outside, requested to see
mental health personnel. According to nursing notes, a nurse told the inmate
that "we do not routinely have (mental health personnel) come out," and
advised him "to read, exercise and talk with others." Nursing notes indicate
that the nurse called outside providers to determine whether the inmate
was on medication (he was not), but no further follow-up or evaluation
was ordered. Two days later, this inmate hanged himself from a horizontal
window bar in his cell.
D. Medication Management
A lack of psychiatric involvement also contributed to deficiencies in
medication management. Inmate medical charts show that inmates were not
adequately assessed for changes relevant to their medications, even when
they reported changes in their clinical conditions. For example, one inmate,
who had been prescribed Haldol for his psychotic illness complained he was having a heart attack due to his medication. According to nursing notes, the nurse "explained to inmate that he was not having a heart attack and he should not be complaining about things that are not true." Although individuals taking Haldol can experience side effects, including heart symptoms, the nurse dismissed the inmate's complaints without a thorough
medical examination and without any psychiatric input. The inmate thereafter
refused to take his medication, causing his psychiatric condition to deteriorate.
At the time of our visit, this inmate was in the SHU because of out of
control behavior and claimed to have been subject to restraints several
times during the prior week. His chart did not contain an adequate treatment
plan, and he was not receiving treatment for his serious mental illness.
There also has been inadequate psychiatric input into decisions involving
the use of controlled substances, such as Valium. Although it is not an
unreasonable practice to significantly limit and discourage the use of
controlled substances within a correctional facility, the decision to discontinue
medications should be made by a physician based on clinical findings and
not solely premised on correctional policy or practice. At the Jail, however,
the nursing staff often discontinues controlled substances based on the
Jail's "unwritten rule" that such medication is simply not allowed, without
regard to a clinical assessment of the specific inmate in question. For
example, one inmate who was diagnosed with schizophrenia and depression,
had been taking Haldol and Diazepam (a controlled substance) for his mental
illness. While he was incarcerated at the Jail the inmate allegedly was
not given his Diazepam, which had been prescribed by the Jail's own mental
health provider. After the inmate was released from Jail he began experiencing
symptoms of a schizophrenic cycle, which may have been caused by the interruption
in his medication. Terminating inmates' medication without medical consultation
is a dangerous practice that can result in serious side-effects or even
E. Barriers to Access
There are substantial barriers to access to the mental health resources
available at the Black Hawk County Jail. First, inmates are not specifically
informed of the availability of mental health services either in the orientation
video shown to all new inmates or in the inmate handbook. Without clear
notice that the Jail provides mental health services, some inmates will
not seek care for their serious mental illnesses.
Access to mental health care is also impeded by the Jail's fee-for-service
policy. Although charging inmates who have funds available minimal fees
for health services is not per se unconstitutional, such
fees must not significantly inhibit access to care. Because of the nature
of mental illness and the characteristic reluctance of some individuals
with mental illness to seek treatment, charging fees for mental health
care will discourage persons with mental illness from seeking care and
taking the medications necessary to stabilize their conditions.
Although the Jail's written policy regarding fee-for- service appears
to apply to all medical care, the Jail's head nurse informed us that there
is an "unwritten policy" that inmates will not be charged for mental health
services. Notwithstanding this "unwritten policy", there is a perception
among inmates that they must pay for mental health care. For example, during
one of our visits to the Jail, an inmate told us that he was suffering
from depression but that he had not sought treatment because he could not
afford the $5 fee. Another inmate reported that she was not charged a fee
when she visited the nurse to request medication for anxiety (which the
nurse refused); however, she was warned that she would be charged if she
came back again for the same problem.
Even assuming that the Jail's current practice is not to charge inmates
for mental health care, this exception to the Jail's fee-for-service has
not been clearly communicated to inmates. Moreover, it appears that the
decision whether to charge an inmate who visits the nurse with a mental
health related complaint, may depend on the nursing staff's assessment
of whether the inmate's complaint is legitimate (i.e., whether mental health
care is actually needed). As long as this type of uncertainty and subjectivity
exists regarding the Jail's fee-for- service policy, inmates' access to
mental health care will be impeded by their perception that fees may be
charged for mental health services.
F. Improper Restraint and Seclusion of Mentally Ill Inmates
Because it lacks an adequate system for delivering mental health care,
the Jail relies on punitive methods, including segregation and restraint,
to control the behavior of inmates who are mentally ill. During one of
our visits to the Jail, the only inmate in the women's SHU and one of four
inmates in the men's SHU were identified by our psychiatric consultant
as having a serious mental illness. The severe conditions in the SHU, particularly
the almost total isolation imposed, presents a serious risk of harm to
persons with mental illnesses. For this reason, it is unacceptable to house
such persons in the SHU except in emergency situations for a limited period
of time. Acutely mentally ill persons who cannot function in the Jail's
general population must be transferred to a treatment facility as expeditiously
The female inmate we observed in the SHU, for example, was actively
psychotic and unable to explain why she was in segregation. This inmate
had been placed in the SHU related to symptoms of her mental illness including
assaultive behaviors, taking her clothes off and standing on a sink, and
defecating inappropriately while being escorted by deputies. There was
inadequate documentation in this inmate's chart concerning her mental health
history and treatment plan. The chart showed that a psychiatrist had given
telephone orders to administer psychotropic medication. However, the inmate
had not undergone a face to face evaluation and was not receiving an adequate
level of mental health care.
We also identified several inmates who had recently been restrained
in the Jail's restraint chair due to symptoms of their mental illnesses.
Medical or mental health personnel did not appear to be involved in the
decisions to use restraint in these cases, and did not consistently participate
in the monitoring of the individuals restrained. Further, it appears that
the use of the restraint chair was not documented in all cases. These practices
create a serious risk of harm to mentally ill inmates, and violate the
Jail's own policy regarding the use of restraints for medical or psychiatric
purposes. See Policy Number 4.3.2, §VII (requiring that the
use of medical restraints be approved by the Jail Nurse and the Shift Supervisor,
and that all orders for restraints be documented in the inmate's medical
G. Inadequate Identification and Treatment of Suicidal Inmates
The systemic deficiencies in the Jail's provision of mental health care,
including inadequate screening, lack of counseling and crisis intervention,
and lack of on-site mental health personnel, have also led to inadequate
suicide prevention. There is a lack of mental health input into both the
identification and treatment of suicidal inmates.
For example, one inmate who attempted suicide by hanging was restrained
in the restraint chair for an hour and placed on a 30- minute watch for
about 12 hours. The only nursing note regarding this suicide attempt indicated
that the inmate was "just worked up about wife and everything was closing
in." The nursing staff apparently concluded that there was no need for
a mental health evaluation or suicide risk assessment by mental health
personnel. No mental health counseling or crisis intervention services
were sought or provided. Other incident reports involving attempted suicides
similarly revealed an absence of mental health follow-up.
Two suicides have occurred at the Jail (one at the old facility in 1993).
Both appear to be linked to lack of access to mental health services. As
discussed above, the most recent suicide victim had been refused mental
health treatment two days prior to his suicide. The earlier suicide victim
had also attempted to obtain treatment. Found in the inmate's garbage can
after his suicide, were two torn pieces of paper with the following message:
"Hello Mom. Get hold of the doctor. I still haven't gotten my medication
yet. About (half) crazy."
III. FAILURE OF CORRECTIONS AUTHORITIES TO SUPERVISE AND PROTECT
INMATES FROM HARM
Inmates are entitled to incarceration in an environment that offers
reasonable protection from harm. Jail authorities are affirmatively obliged
to provide appropriate inmate observation and remove, whenever identified,
physical conditions that may give inmates an opportunity to attempt suicide.
The Jail does not provide adequate supervision of inmates. Furthermore,
certain physical features in the Jail provide unacceptable opportunities
for inmates to attempt suicide.
The Jail's SHU houses the most troubled and troublesome inmates in the
facility, including suicidal, mentally ill and violent, special control
inmates. The SHU, which consists of eight single cells within a larger
maximum security pod, is monitored with closed circuit television cameras,
by an officer who is assigned to that unit. During our inspection of the
Jail, however, we found that no one monitored the cameras when the officers
assigned to the SHU left their post unattended for meals and breaks for
extended periods of time. These staff absences, are unacceptable for monitoring
a population with severe behavior deficits and pose a substantial threat
to the safety of inmates housed within the SHU.
In addition to inadequate supervision, several design features in the
SHU provide opportunities for inmates so inclined to engage in self-injurious
behavior. Air vents in the cells are large enough to permit an inmate to
tie cloth through the vent aperture. The type of caulking used between
the horizontal window bars and the windows can be removed by inmates, again
providing a means to facilitate hanging. Indeed, this is a known, serious
danger as one inmate at the Jail committed suicide in this manner. This
problem exists throughout the facility, but is of particular concern in
a unit which purports to provide a protective environment.
Showers in the SHU do not permit officer observation. The shower entrance
has a curtain with a metal bar, lightly attached to the top of the doorway.
Even with the curtain removed, the officer is unable to observe the shower
from the officer post, or even the shower room door, as the shower head
is located deeply within the recess of the shower stall. This significant
design deficiency provides special population inmates an unobserved opportunity
to engage in self-destructive behavior.
Other security problems related to suicide prevention at the Jail include
the availability of cleaning items in inmates' cells that could be fashioned
into weapons, and the failure of the facility to provide officers with
an emergency tool in the SHU that would enable officers to promptly cut
down a hanging victim. All the concerns regarding suicide prevention for
male inmates also apply to the smaller female special population unit,
with the exception of the shower curtain fastening problem.
In the general population units, we found similar security problems
relating to suicide prevention. As previously noted, window caulking and
vents were deficient, providing opportunity for hanging attempts. Cells
which were handicap accessible had improperly designed grab bars upon which
cloth or roping could easily be secured. The intake or booking area had
a bathroom in one holding unit with a solid wooden door that when closed
provides a space which is unobservable by sight and sound. Although this
design was apparently intended to provide a "normalizing" environment for
non-combative, recently arrested inmates, it allows persons with suicidal
tendencies an opportunity to hurt themselves without observation. This
"blind spot" is a particular risk at intake, when an inmate's behavioral
history may not be known to staff.
Correctional officer assignment in the general population areas of the
Jail is also deficient. During breaks, correctional officers routinely
lock inmates in their cells and leave duty stations unattended because
officer relief is unavailable. The Jail's failure to have an officer on
duty at all times in all inmate housing areas is an extremely dangerous
and unacceptable practice that compromises institutional security.
IV. EXCESSIVE USE OF FORCE
The Jail utilizes a device called a "restraint chair" (chair) in both
the Jail's intake area and the pods, purportedly to control inmates who
are acting so violently that they pose a significant threat to themselves
or others. We find, however, that the Jail at times uses the chair for
punitive purposes when inmate control is not an issue. For example, the
chair has been used to punish inmates who are verbally disrespectful to
officers and inmates who inappropriately call out to other inmates from
their cells. Use of the chair in this manner constitutes excessive force.
The Jail does not document when the chair is used, how long the chair is
used, or whether the inmate is checked routinely by correctional and medical
personnel. In addition, when inmates are too noisy, the chair is sometimes
moved outside the intake area to a small holding cell near the courtroom.
Inmates cannot be adequately observed in this remote location. Although
there is a video camera in the cell that is monitored in the main control
center, the civilian staff monitoring the screen has other responsibilities
that prevent them from focusing sufficient attention on the individual
the restraint chair.
During the course of our investigation, we heard other serious and seemingly
credible allegations of excessive use of force and physical abuse of inmates.
Due to the limitations of our previous visits, these allegations will require
additional investigation. The alleged abuses include misuse of a stun-gun,
choking, beating and kicking of inmates, and use of force on inmates after
they are already secured in the restraint chair. Many, but not all, of
the allegations involve the intake area of the Jail during the evening
shift. Our concerns about a possible pattern of excessive force at the
Jail were heightened by our consultant's finding of procedural deficiencies
with respect to the Jail's reporting and monitoring of use of force, including
inadequate control of security equipment. For example, Jail authorities
do not follow the generally accepted correctional practice of keeping separate
reports of incidents involving the use of force. Moreover, there is no
documented review within the Sheriff's office of use of force incidents.
In addition, security equipment, which should be under the control of the
shift supervisor, is too readily available to line officers who are not
required to document its use. For example, there is no logbook reporting
associated with the use of the Jail's stun gun, an extremely potent and
potentially dangerous weapon. Access to the stun gun is readily available
to any officer in the intake area without the approval (or knowledge) of
the shift supervisor. This lack of accountability concerning the use of
force increases the risk that force will at times be misused.
V. MINIMAL REMEDIAL MEASURES
In order to remedy the deficiencies we have identified and
to protect the constitutional rights of its inmates, the Black Hawk
County Jail should implement, at a minimum, the following measures:
1. Intake: Establish a method of collecting medical information
on intake that will ensure confidentiality. Develop a standard nursing
intake form, and ensure, at a minimum, that nurses take and record complete
vital signs on all inmates identified as having a medical problem. Provide
a complete health assessment by a physician of all inmates within 14 days
of admission. Ensure that inmates' medications are provided by the Jail
on intake without unreasonable interruption. Ensure that inmates housed
in the intake area of the Jail have access to urgent and emergency health
2. Staffing: Increase the physician presence at the Jail to a
minimum of 20 hours per week. Ensure that the physician supervises all
3. Sick Call: Develop treatment protocols for sick call. Ensure
that nurses take vital signs on all encounters, and that they conduct physical
examinations, and not simply interviews, in response to inmate complaints.
Establish physician review of nursing sick call, which includes at least
random review of medical charts. Ensure physician review of medical charts
in all cases where an inmate's request to see a physician is denied.
4. Emergency Care: Ensure physician participation in the evaluation
of inmate medical conditions that may require urgent or emergency care.
5. Infection Control: Develop an effective infection control
program which would include, at a minimum: testing of all inmates admitted
to the Jail for TB, and testing as appropriate (after consultation with
the County Department of Health) for sexually transmitted diseases; record-keeping
of all testing and development of a tracking log for TB and sexually transmitted
diseases; physician involvement in testing and treatment for TB and sexually
transmitted diseases; and development of a training program for universal
precautions for all staff.
6. Development of Policies and Procedures: Develop formal policies
that clearly set forth the Jail's medical operations, including mental
health services. Clearly delineate in writing the Jail's fee-for-service
policy, and the circumstances under which fees will not be charged, and
provide inmates with notification of this policy. Establish treatment protocols,
including protocols for nursing sick call.
7. Documentation/Quality Assurance/Inmate Grievances: Ensure
that patient medical charts are maintained and organized in a professional
manner. Establish and keep logs of all medical activities, including emergency
responses and referrals to outside specialists. Develop a quality assurance
program that includes review of medical charts, logs and other records,
by a physician to ensure appropriateness of decision-making and documentation.
Ensure that inmates have access to the Jail's grievance procedure for complaints
concerning medical care, as well as for other types of complaints.
Mental Health Care
1. Staffing: Develop a quality assurance plan to ensure that
the level of staffing provided under the County's recent contract for mental
health services is sufficient to identify and treat in an individualized
manner those inmates suffering from serious mental disorders.
2. Intake: Establish a system of collecting mental health- related
information that will ensure confidentiality. The Jail's screening process
should not rely on an inmate self-reporting his or her mental illness in
a group setting.
3. Evaluation: Provide an adequate and timely mental health evaluation,
by a qualified and appropriately trained mental health professional, of
inmates who screen positive for possible mental illness at intake (including
where relatives or other close associates provide information relating
to the inmate's possible mental illness), and of inmates who exhibit symptoms
of mental illness (including suicidal ideation or behavior) at any time
during their incarceration.
4. Sick Call: Ensure that all inmates requesting mental health
care are seen and evaluated by a qualified and appropriately trained mental
health professional. Ensure review of mental health-related sick calls
by the Jail's psychiatrist.
5. Treatment: Ensure that an individual, written, mental health
treatment plan is prepared in a timely manner by a qualified and appropriately
trained mental health professional for every seriously mentally ill inmate.
Changes to and compliance with the treatment plan should be thoroughly
and accurately documented in the inmate's medical/mental health record.
6. Medication Management: Avoid unreasonable interruptions in
inmates' medications upon admission to the Jail. Ensure that the Jail's
psychiatrist is involved in the monitoring and follow-up of inmates on
medications for psychiatric conditions, including cases where there is
inmate noncompliance with medications. Ensure that decisions whether to
prescribe or terminate medications, including controlled substances, are
based on clinical assessments by the Jail's psychiatrist, and that medically-approved
detoxification procedures are utilized.
7. Counseling/Crisis Intervention: Provide adequate counseling
and crisis intervention services for all mentally ill inmates who need
such care, including, but not limited, to inmates who are observed to be
8. Emergency and Acute Care: Ensure that the Jail's psychiatrist
is on-call and consulted in the event of mental health emergencies. Consistent
with security requirements, inmates with acute psychiatric conditions should
be promptly transferred from the Jail to a treatment facility.
9. Barriers to Access: Ensure that inmates are informed in the
Jail's orientation video and in the Inmate Handbook of the availability
of mental health services and of the Jail's exception to the fee-for-service
policy for mental health encounters.
10. Use of Restraint and Isolation: Develop a comprehensive policy
on the use of restraint and isolation on inmates with serious mental illnesses.
Ensure that mental health personnel are involved in decisions to restrain
or isolate mentally ill inmates, and in the monitoring of such inmates
while restrained or isolated. Develop policies and procedures to ensure
that inmates with acute psychiatric conditions, who cannot function long
term in the general Jail population, are transferred or committed to appropriate
treatment facilities as expeditiously as possible.
Inmate Supervision and Protection from Harm
1. Staffing/Supervision: Increase the correctional officer staffing
complement as necessary to ensure that officers are available at all times
to staff designated security posts. Correctional officers must not leave
posts in areas housing inmates suspected of being suicidal or leave posts
in any Special Housing Unit location unless relieved by another officer.
Relief shall mean that the officer is in place at the designated post on
the unit. A correctional officer must observe inmate showers directly in
the Special Housing Unit, with a second officer providing back-up assistance.
2. Physical Features Creating Unacceptable Opportunities for Suicide:
Modify, on a priority basis, all Special Housing Unit areas and the inmate
intake area of the Jail to eliminate physical hazards, thereby lessening
the risk of suicidal behavior. These modifications include: covering air
grille areas in the cells with small diameter mesh or some other material
to prevent inmates from attempting to hang from this fixture; replacing
window caulking in a manner that will prevent its removal; shielding handicap
grab bars to prevent inmates from tying material around the bar; removing
curtains and rods from shower stalls; removing the solid wooden door to
the washroom in the "honor" intake and booking area (a privacy panel may
be installed); and removing cleaning items daily from Special Housing Unit
cells to prevent the fashioning of weapons. Additionally, all inmate housing
units should have properly secured readily available cutting tools (designed
to interrupt suicide attempts).
Use of Restraint
Review and revise, as appropriate, the Jail's policy and procedures
regarding use of mechanical restraint, including the restraint chair. Establish
a policy to ensure that restraint devices are not used for punitive purposes
and that appropriate disciplinary action is taken against staff who violate
this stricture. Absent exigent circumstances, a supervisor should be present
when inmates are first placed in the restraint chair. Inmates in restraint
must be checked by personnel with appropriate training every 15 minutes,
and by medical and mental health staff at appropriate intervals. Proper
measures should be taken to ensure that inmates in restraint have their
limbs exercised to avoid circulation problems, and adequate attention must
be given to food, hydration and bodily functions. Logs should be kept of
placement in and release from restraint, and of all checks made. This log
should be reviewed daily by the Jail Administrator. Inmates should not
be restrained in the courtroom holding cell or in any other area that cannot
be monitored by frequent, direct, personal observation.
We will forward our expert consultants' reports under separate cover.
Although their reports are their work -- and not necessarily the official
conclusions of the Department of Justice -- their observations, analyses, and recommendations provide
further elaboration of the relevant concerns, and offer practical assistance
in addressing outstanding challenges at the Black Hawk County Jail. We
hope that you will give this information careful consideration and that
it will assist in promoting a dialogue aimed at quickly addressing the
problems we noted.
Pursuant to CRIPA, 42 U.S.C. § 1997b(a)(1), the Attorney General
may initiate a lawsuit to correct deficiencies at the Jail 49 days after
you have been informed of the findings of our investigation. We hope to
be able to resolve this matter amicably and cooperatively. We know that
Black Hawk County has already taken significant steps to correct some of
the deficiencies identified herein, and we look forward to discussing these
actions and other actions you intend to take in the near future.
Bill Lann Lee, Acting Assistant Attorney General, Civil Rights Division
cc: Tom Ferguson, Esquire, Black Hawk County Attorney
Mr. Michael Kubik, Black Hawk County Sheriff
1. The Jail has two full-time and one part-time registered
nurses who hold sick call five days a week from 9:00 AM to 7:00 PM.
2. The nursing staff sees approximately 20-25 inmates
a day (over 100 inmates weekly), but refers fewer than 10 inmates (and
frequently as few as one or two) to the physician per week.
3. The nursing staff relies heavily on private, outside
physicians to provide information or advice about inmates (who were their
patients prior to incarceration), and to write orders for medication. However,
these outside physicians have no formal relationship with or accountability
to the Jail and no supervisory authority over the nurses. They do not examine
inmates or monitor the progress of inmates for whom they write orders.
4. This represented a sharp decline in the level
of mental health services provided at the Jail. Prior to July 1997, a community
mental health center funded in part by Black Hawk County, provided approximately
10 hours of inmate services per week, at the Jail's request, out of the
center's own budget. When the community mental health center stopped providing
"free" mental health services for inmates, the Jail drastically reduced
its use of mental health personnel.
5. The services to be provided under the contract
include: assessing requests for mental health services by inmates and Jail
personnel; initiating interventions for acute psychiatric conditions; educating
Jail personnel; maintaining records; and facilitating referrals to other