When Leland Workman's heart faltered while he was imprisoned at McNeil Island Correction Center, the nurses couldn't find the IV equipment needed to ease his chest and arm pain.

They couldn't find standing orders for managing emergencies when there's no doctor on duty at the island prison.

They knew they had to get Workman to a mainland hospital, but staffers couldn't figure out how to start the boat, according to state records. And when the prisoner suffered cardiac arrest in the ambulance, they didn't have equipment on board to help him.

They rushed him back to the prison clinic, where Workman nearly died amid a series of medical failings from clinicians who couldn't run the defibrillator to useless trauma equipment.

The events of that day in December 1999 reflected broader problems of poor training, unreliable equipment and inadequate staffing, a state Health Department inspector found.

They are failings that had been documented before, yet lingered for years saddling prisoners with uneven treatment and taxpayers with legal costs, according to dozens of state inspections and reports.
Such failings continue, at McNeil Island Corrections Center and elsewhere.

System Problems

In Washington prisons, wardens not doctors have the final say in medical administration.
Each prison interprets state policy with its own field instructions within a bureaucracy wrought by inconsistent quality and standards of care, according to a recently completed independent study. Managers offer little accountability or guidance.

The entire system, supervising more than 15,000 prisoners, employs just five full-time staff doctors and relies heavily on additional, part-time physician help. Health workers, often making do in ill-equipped clinics, warn that critical staff shortages force them into taking risky shortcuts.

The state never opened an infirmary recently built at the Clallam Bay Corrections Center because officials couldn't recruit enough workers. McNeil Island, in Pierce County, never managed to staff and clean up its infirmary enough to reopen it after it was closed three years ago in the wake of a scathing Health Department report.

Health Department inspections of five of the state's largest prisons last year found that:
* All failed to meet standards for infection or communicable disease controls;
* Staffers at all five of the prisons, including McNeil, kept illegible, incomplete or inaccurate patient records, missing critical information such as patient diagnoses, medical histories and whether prescriptions were ever actually administered;
* Three lacked proof that staff had been properly trained in CPR and infection control and two prisons couldn't verify first aid training;
* Two had critical" shortages of nurses;
* Two failed to verify that clinicians held professional licenses; and
* Two stocked expired medications and supplies.
In addition, there were other problems at each of the prisons. The prison complex in Monroe left a cabinet of drugs unlocked and administrators there gave staff no standards for how to care for dying prisoners and infirmary patients.

Airway Heights Corrections Center near Spokane failed to get medications to prisoners quickly enough after it had to close its own pharmacy for lack of staffing.

Staffers at the Washington Corrections Center in Shelton did not follow up when prisoners with tuberculosis missed doses of their medication putting the prisoners at risk for developing resistance to the drugs.

The Washington Corrections Center for Women near Gig Harbor failed to give its staff guidelines for caring for prisoners in the infirmary.

And McNeil couldn't show that it provided staff with direction in distributing drugs to patients more than three years after the investigation into Workman's care.

Workman's story, told in state records, illustrates what happens when officials ignore warnings given by the Health Department.

Neither of the two nurses who treated him both outside agency nurses could operate the defibrillator, which applies an electric shock to the heart to return it to a normal rhythm.

The health workers didn't have cardiac medications the doctor requested and said they weren't supposed to mix IV, or intravenous, solutions. One employee promised an IV solution, but came back from the pharmacy with a pill in a paper cup.

Staffers used the wrong kind of oxygen mask, and the first oxygen bottle they found was outdated and unusable, state records show. No one could figure out how to operate the emergency suction equipment, and when it was finally turned on, it didn't work right.

It was chaos perpetuated by a lack of guidance or direction officials had left no orders instructing the temporary nurses how to handle an emergency without a doctor or physician assistant on hand.

There were a number of staff members that were doing their own thing, and it appeared there was (no) one in charge," the unidentified health worker who'd been paged that morning wrote in an incident report.

Fortunately for Workman, the worker who wrote the report knew how to shock Workman's heart back to life.

Workman, 57, who was serving time on a child-rape conviction, is now at a prison assisted-living facility in Yakima.

Warnings Continue

Although it's legally charged with regularly surveying prison health systems and investigating complaints, the state Health Department can't do much about the problems it finds.

The agency cannot issue fines or order that clinics be shut down. Its enforcement rests in the reports it produces and any political pressure it can bring.

Prisons respond to the Health Department's reports by submitting plans of how they intend to correct the problems. Because of limited resources, Health Department inspectors usually cannot verify whether the prisons actually corrected the problems until the next annual survey.

When they do find problems, we continue to write reports, which are publicly disclosable," said Bliss Moore, who heads the department's facility inspection division. It's in (the prison system's) best interest to work with us and for the most part it has tried to work with us well.

Still, despite annual warnings from Health Department inspectors, some front-line deficiencies in prison health care come up time and again.

In part, that's because each prison exists under a system lacking resources, oversight and accountability, according to a recent independent study commissioned by the Department of Corrections.

In a report finalized in June, Pulitzer/Bogard & Associates of New York and a Seattle firm called the DLR Group found: Washington prison health services provide inconsistent access to and quality of care, partly because the system lacks guidance that a medical director would provide."

That puts taxpayers at risk for lawsuits because it leads to wide variation in patient outcomes and missed diagnoses, they said. Based on projections expected of Washington's prisoners, the analysts estimated that prison health workers here miss diagnoses by 30 percent for asthma, 17 percent for diabetes and 28 percent for hypertension.

And Washington prisons have only a crude information infrastructure," leaving them unable to determine whether their health services are poor, they said.

Without such information, policy decisions and clinical supervision are also seriously compromised," the consultants wrote.

Washington prisons suffer a statewide personnel shortage, forcing several prisons to rely heavily on overtime and temporary workers, which creates a significant concern for consistency of services delivery and ongoing quality of care," the consultants wrote. Understaffing also creates poor morale and a lower ratio of doctors to offenders than is found in other states and suggested in professional guidelines.

Above all, the consultants said, the system lacks accountability, leadership and standards. Someone with medical knowledge and authority needs to set some basic ground rules, they wrote.
Health clinics in the Department of Corrections operate like a loose federation" with little oversight, they said. The small headquarters office in Olympia has virtually no clinical direction and very little authority.

And they found that Washington prisons need a system for managing chronic diseases, a communicable disease program and policies for when prisoners should be hospitalized.

Reviews to determine whether prisoners should get specialized care, such as wheelchairs or cardiology treatment, fall short of nationally accepted guidelines, they said.

No Medical Director

Prison officials say many of those problems boil down to one missing element: the lack of a medical director to oversee the state's prisons. And administrators at the Corrections Department say they hope to hire a statewide medical director soon.

That's what this department has been missing the capacity to monitor and evaluate and direct clinical issues in the health care program," said Joseph Lehman, secretary of the prison department. Unless you have that, you really don't have the capacity to make judgments about whether or not the care is adequate.

Lehman said, however: For the most part ... this is a very credible health care system.
Lehman said he'd like to fill the director position with a medical doctor. Several candidates have applied. The state advertised the position last year but did not think any of the four candidates met the state's needs, said the state Corrections Department's health care administrator, Beth Anderson. Any medical director would have the authority to hire and fire, Lehman said, and perhaps also have budgeting authority as the consultants suggested.

As it is, Anderson oversees and answers to the public for the medical care of prisoners. But her role is little more than advisory. Prison health care managers answer to prison administrators, and each facility develops its own policy decisions.

Anderson holds no budget authority and cannot hire or fire staff.

In a recent interview, Anderson repeatedly turned to the potential improvements a medical director could make when asked why prison health programs can't comply with many of the operating standards that it developed with the Health Department years ago. Such standards include CPR training, properly sterilizing medical equipment and keeping accurate patient charts.

After running down a list of the most commonly cited problems, Anderson finally shrugged and shook her head slightly when asked why Washington prisons often fail to verify that their doctors, physician assistants and nurses even hold professional licenses.
It's a relatively straightforward issue," Anderson said. I don't know why it hasn't been done accurately.

A statewide medical director could be a major step forward for Washington's prison services, prisoner advocates say.

We've been saying that to them for years," said Pat Arthur of Columbia Legal Services.
I'm hopeful that this time it happens.

Infirmary closed in 1999 by state remains shut; problems have never been corrected prison relies on clinic

Years of inspection reports and internal memos documenting shoddy health care including a final blistering health-inspection report led state officials to finally shut down the infirmary at McNeil Island in the spring of 1999.

Despite commitments from officials in the subsequent months, they've never been able to correct the problems there adequately to reopen it.

And inspectors continue to find some of the same problems in the medical clinic that McNeil uses today for scheduled visits and some trauma care.

These days, McNeil officials say, they've learned to get by mostly without the skilled-nursing infirmary. McNeil transfers prisoners who need round-the-clock nursing care to other prisons, they say.

Beth Anderson, health care administrator for the state Department of Corrections, acknowledged that it is better for public safety and taxpayer dollars to have an infirmary in the prison.

Asked whether the infirmary's closure affects patient health care, Anderson said it depends on who is staffing the health clinic down the hall. That's hard to say, as a generality," she said.

In April 1999, the state Health Department issued a 46-page report listing dozens of deficiencies under operational standards that the two agencies had developed years earlier. They included: inadequate staffing, training and verification of licensing; inadequate and inaccurate documentation of patients' conditions; poor equipment maintenance; violation of infection control standards; uneven monitoring of pharmaceuticals; and insufficient guidance for frontline health workers.

And, backed by the Cabinet-level state Secretary of Health, the report urged the prison to close the infirmary. Corrections complied.

An internal follow-up memo written by the Department of Corrections warned that the problems, including failures to meet standard nursing practices because of inadequate staffing, could hurt patients and expose the state to lawsuits.

In the following months, the prison submitted to the Health Department plans for correcting the deficiencies and status updates. For a while, both sides saw progress.
Yet at the same time, according to some, the prison continued to use the infirmary despite its agreement.

Prisoner Phillip Montgomery spent some of his dying hours there in September 1999 several months after it had been ordered closed, according to records in a lawsuit.

Weeks later, a Health Department investigator found that at least two prisoners had been cared for there. The facility failed to abide by the agreement to keep the infirmary closed until such time as there is qualified health care staff to provide safe care," according to the inspector's report.

These days, McNeil uses the infirmary as a secure wing of a half-dozen cells where officials can observe and house prisoners for several hours at a time while they wait to be ferried off the island for shoreside health care. Prison officials say they do this as a custodial function and do not provide infirmary or skilled nursing care there.

Health care services at McNeil today are largely limited to scheduled office visits and occasional trauma care. As such, McNeil Island's medical clinic fares somewhat better in Health Department surveys than the beleaguered infirmary did.

Still, Health Department inspectors continued to document serious problems there. For example:

* In January 2000, an investigator found that working emergency equipment, including defibrillators and oxygen tanks, was not available; standing orders for emergency care instructions were not available to staff; and the facility failed to follow policies for sterilization.
* In April 2000, an inspector found that medical records missed significant diagnoses; records were spotty on whether prescriptions were actually administered; and, again, emergency care policies were lacking. The inspector also found that the prison failed to adequately verify that employees were licensed, certified in cardiopulmonary resuscitation and first aid, trained in communicable diseases and complying with facility rules on hepatitis vaccination and prevention.
* In April 2001, a health inspector again found poor records of patient conditions. The surveyor also found spotty documentation of whether treatment orders were implemented; failure to give staff written directions; and failure to properly clean and sterilize equipment.

McNeil's health-services area resembles a typical government-run medical clinic with white walls, florescent lights and linoleum floors but also with guard stations, ultra-thick window glass and locks on every door. It has an X-ray room, a pharmacy with a window counter and a dental suite that smells of fluoride and plastic dust.

A sign taped to the window tells clinic staff and visitors: Only positive attitudes beyond this point.

Health Care Manager Jane Robinson says the prisoners get better care than many folks on the outside especially people battling managed care. This is the only facility where I can guarantee good care," said Robinson, a registered nurse. We're organizing and restructuring our delivery of health care really focusing on how to deliver health services in a meaningful way.

For example, Robinson said, each week a McNeil clinician instructs peers in a topic. Also, the clinic plans a health-education program for the staff and prisoners, partially funded by donations collected by staffers.

Operating health services today in this world wherever you are is a challenge," Robinson said, citing shrinking budgets and more expensive health care. In a prison population, you have people who maybe prior to their incarceration had not been caring for themselves very well.

For example, hepatitis infection is a huge issue in prison populations, she said. Prisoners need to be trained on how to manage it and prevent spreading it.

These inmates are only here for a short period of time," Robinson added. They're going to go back on the streets.

RED FLAGS

Reports and investigations indicating problems at McNeil Island Correctional Center:
August 1997: State Health Department inspector finds poor training; faulty medical equipment; poor patient record keeping; outdated medical supplies; and lack of treatment policies to guide staff.

October 1997: At state's request, a University of Washington doctor studies McNeil health services and finds unprofessional and inefficient discord among staffers for at least two years. The UW doctor also reports complaints of nursing medication errors and found that physician's assistants work with too little supervision.

April 1998: Grievance from Teamsters Union claims that because of poor management and a lack of staffing, the infirmary is a ticking time bomb." The grievance also says it is a dangerous place to work for staff and a dangerous place for inmates."

May 1998: Health Department survey concludes there is a failure to provide prison medical staff with policies for care; also finds outdated supplies and inadequately maintained equipment; poor record keeping; failure to meet standards for infection control. Also finds frequent incidents of multiple dosing and delays of medication administration of two to four days.

December 1998: In a memo from McNeil nurse Carol Hoke to her supervisors, she claims the clinic can't meet its own standards for minimal staffing. Hoke says nurses are being forced to take shortcuts. This scares me; it is extremely unsafe," she writes.

March 1999: In another memo, Hoke complains of lack of staffing and ridiculous" working conditions." All of us are about at wits' end at being pushed past our max," she writes.

April 1999: Health Department survey leads to the closure of the infirmary. A 46-page report lists dozens of deficiencies, many of them repeats. It says McNeil lacks adequate staff, proper training and verification of clinician licensure. Also, the report says McNeil fails to document medications or lab tests, perform infection control, provide staff with standing orders and maintain working equipment.

May 1999: A Department of Corrections internal memo says the prison's written plans to correct problems identified in 1997 and 1998 were either insufficient or never actually implemented. The memo also says that significant staffing shortages lead to skeleton crews" and failure to comply with nursing standards.

Sept. 7, 1999: Phillip Montgomery dies.

Dec. 17, 1999: Health Department investigation into cardiac emergency finds failure to keep accurate staffing and patient records; inadequate training; inadequately maintained equipment; and failure to abide by agreement to keep the infirmary closed.

April 2000: Health Department survey finds inaccurate medical records; lack of training and verification of clinician licensure; inadequate infection control; and failure to ensure a policy on emergency care.

March 2001: Phillip Montgomery's family files wrongful-death lawsuit against the state.

April 2001: Health Department survey finds inadequate patient health records; failure to provide staff with care policies; failure to monitor medications; and inadequate infection control.

Reprinted with permission from the Seattle Post-Intelligencer.

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