U.S. Department of Justice
Civil Rights Division

Assistant Attorney General
950 Pennsylvania Avenue, NW - RFK
Washington, DC 20530

May 1, 2006
The Honorable Jim Doyle
Governor
State of Wisconsin
Office of the Governor
115 East State Capitol
Madison, WI 53702
Re:	 Investigation of the Taycheedah Correctional

Institution

Dear Governor Doyle:
I am writing to report the findings of the Civil Rights
Division’s investigation of conditions and practices at the
Taycheedah Correctional Institution (“Taycheedah”), in Fond du
Lac, Wisconsin. On March 25, 2005, we notified you of our intent
to investigate conditions at Taycheedah pursuant to the Civil
Rights of Institutionalized Persons Act (“CRIPA”),
42 U.S.C. § 1997. CRIPA gives the Department of Justice
authority to seek remedies for any pattern or practice of conduct
that violates the constitutional or federal statutory rights of
persons who are served in public institutions such as Taycheedah.
On May 16-18, July 18-21, and October 6-7, 2005, we
conducted on-site inspections of Taycheedah with consultants in
the fields of sexual misconduct prevention and correctional
mental health care. While on-site, we interviewed administrative
and correctional staff, mental health care providers, and
inmates. Before, during, and after our on-site inspections we
received and reviewed a large number of documents, including
policies and procedures, clinical records, and other materials
provided to us by Taycheedah staff. Consistent with our
commitment to provide technical assistance and conduct a
transparent investigation, we provided an extensive debriefing at
the conclusion of each of our inspections, in which our
consultants expressed their initial impressions and concerns. We
appreciate the full cooperation we received from State and

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Taycheedah officials throughout our investigation. We also wish
to extend our appreciation to the administrators and staff at
Taycheedah for their professional conduct and timely response to
our requests.
Having completed our investigation of Taycheedah, we
conclude that sexual misconduct prevention practices meet or
exceed constitutional requirements. We commend Taycheedah for
implementing policies and procedures aimed at preventing,
minimizing, and detecting sexual misconduct, particularly the
facility’s development and dissemination of brochures for staff
and inmates regarding sexual misconduct.
Based on our investigation, however, and as described more
fully below, we conclude that certain conditions at Taycheedah
violate inmates’ constitutional rights by failing to provide for
inmates’ serious mental health needs. We detail our findings
below.
I.

BACKGROUND

Taycheedah is a state-operated, post-conviction facility
that currently houses approximately 600 maximum and medium
security female inmates. In 2002, Taycheedah expanded its
physical plant to include a 64-bed mental health unit, a 64-bed
segregation unit, and a 240-bed minimum security unit. In
December 2004, the State of Wisconsin (“State”) relocated the
female inmates’ Assessment and Evaluation Unit to Taycheedah.
This 75-bed unit provides intake screening for all women entering
the Wisconsin Department of Corrections.
II.

FINDINGS

Prison officials have an affirmative duty under the Eighth
Amendment to ensure that inmates receive adequate food, clothing,
shelter, and medical care. Farmer v. Brennan, 511 U.S. 825, 832
(1994). Inmates’ Eighth Amendment rights are violated when
prison officials exhibit deliberate indifference to their serious
mental health needs. See Estelle v. Gamble, 429 U.S. 97, 100-105
(1976); Maggert v. Hanks, 131 F.3d 670, 671 (7th Cir. 1997).
Deliberate indifference may be inferred when the quality of care
provided to inmates is “such a substantial departure from
accepted professional judgement, practice, or standards as to
demonstrate that the person responsible did not base the decision
on such judgment.” Estate of Cole by Pardue v. Fromm, 94 F.3d
254, 261-62 (7th Cir. 1996).

- 3 -

Taycheedah fails to provide inmates with mental health care
that complies with these constitutional standards. We found that
Taycheedah: 1) fails to timely and appropriately provide
psychiatric treatment, including monitoring of psychotropic
medications and performing laboratory tests; 2) fails to provide
an adequate array of mental health services to treat its inmates’
serious mental health needs; 3) fails to ensure that
administrative segregation and observation status is used
appropriately; 4) fails to ensure that mental health records are
accessible, complete, and accurate; 5) fails to respond to
medical and laboratory orders in a timely manner; and 6) fails to
ensure that an adequate quality assurance system is in place.
A.

Psychiatric Treatment

Taycheedah fails to provide sufficient mental health care
staff to meet the inmates’ serious mental health needs. See
Wellman v. Faulkner, 715 F.2d 269, 274 (7th Cir. 1983)
(understaffing of prison medical personnel and delays in
treatment led to constitutionally inadequate care). Access to a
psychiatrist is a basic constitutional requirement for
correctional mental health care because a psychiatrist is
necessary to address psychiatric emergencies and to provide
ongoing evaluation for and ongoing monitoring of administration
of psychotropic medications. Id.
Psychiatrist staffing at Taycheedah is grossly inadequate.
Taycheedah employs only two part-time psychiatrists who carry a
caseload of more than 400 patients at a time, which is well above
the maximum recommended caseload, according to generally accepted
standards. The care that Taycheedah’s two psychiatrists are able
to provide is further limited by the lack of adequate support
staff, causing them to spend an inordinate amount of time
searching for charts, looking for medication records, and
handling other administrative functions.
As a result, inmates suffer from lack of treatment and are
continually placed at risk of becoming a danger to themselves and
others. For example, there are unacceptably long delays between
the time inmates’ mental health needs are identified and their
initial visit with a psychiatrist. Further, when the
psychiatrist is not at work, there is no one to fulfill her
responsibilities. As a result, inmates with serious mental
health needs are left untreated, sometimes for as long as several
months, which causes them to suffer and puts them at risk of harm
to themselves and others.

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1.	

Failure to Appropriately Evaluate and Monitor
Psychotropic Medications

Taycheedah fails to timely and appropriately evaluate
inmates for the administration of psychotropic medications and
monitor their continued administration. Many Taycheedah inmates
require psychotropic medications to avoid the unnecessary
suffering of acute episodes of mental illness. A physician,
preferably a psychiatrist, is needed to evaluate whether
psychotropic medications should be initiated and to evaluate the
continued administration for proper dosage and effectiveness.
See Wellman, 715 F.2d at 272-73. Generally accepted correctional
mental health care standards require that a physician see a
patient usually before, but clearly shortly after, a prescription
for psychotropic medication is written. Patients who remain
untreated, or who are treated without being seen by a physician,
may suffer from a worsening of their symptoms, including suicidal
and homicidal thoughts, or from the potentially lethal side
effects of medication. Taycheedah consistently fails to follow
this practice. Instead, inmates on psychotropic medications
formerly prescribed by another facility continue to receive the
medications without active monitoring by a physician of the
consequences, effectiveness, or potential side effects.
For example, Inmate #131 was identified upon initial
screening as having bipolar disorder, a mood disorder
characterized by serious mood swings, impulsive behavior,
suicidality and potential psychosis. On December 20, 2004, she
was started on Lithium Carbonate, a mood stabilizer prescribed
for bipolar disorder, by a nurse’s order stating “per County
Jail.” The order was co-signed by a physician, but there was no
indication that the physician ever saw the inmate. On February
23, 2005, the order for Lithium was renewed for three months.
This order specifically stated “not seen,” and was accompanied by
a request for a “new psychiatry appointment,” reflecting that the
inmate had still not been seen by a psychiatrist. Based upon the
date of the first psychiatry report, April 16, 2005, Inmate #13
was prescribed psychotropic medications but did not see a
psychiatrist at Taycheedah until almost four months after she was
admitted.

1


For the purposes of this letter, we identify all
Taycheedah inmates by the number assigned to the inmates by the
United States’ mental health experts in their report. A key with
the inmate names will follow under separate cover.

- 5 

In another case, the intake screen for Inmate #19, dated
February 16, 2005, indicated that she had a history of depression
and anxiety attacks, and had been on numerous psychotropic
medications in the past. Medication orders for Lexapro (an
antidepressant) and Amitryptyline (also an antidepressant) were
written by a nurse, “per health transfer summary,” and co-signed
by someone who might have been a physician. However, there was
no indication that she had been seen by the physician. On
February 22, 2005, the Lexapro was discontinued and Celexa
(another antidepressant) was started. Again, there was no
indication that a physician saw her, nor was there any notation
reflecting why her medication was changed. On April 28, 2005,
both the Amitryptyline and Celexa were renewed, with a note that
clearly stated that she had not yet been seen by a physician.
Based upon the date of the first psychiatry report, June 6, 2005,
Inmate #19 was prescribed psychotropic medications but did not
see a psychiatrist at Taycheedah until almost four months after
she was admitted.
Inmate #15's intake screen, dated March 3, 2005, noted that
she was previously diagnosed with bipolar disorder and had
attempted to commit suicide numerous times. A medication order
for Depakote (a mood stabilizer used for bipolar disorder) was
written by a nurse, “per Racine County Jail.” Again, while the
order was co-signed by a physician, there was no indication that
the physician actually saw the inmate. A doctor’s order, dated
June 6, 2005, stated, “please schedule new psychiatric
evaluation, any psychiatrist,” clearly indicating the physician’s
concern that the patient had not yet been evaluated by a
psychiatrist. The first psychiatric note was dated June 10,
2005, more than two months after Inmate #15's admission to
Taycheedah. While that note stated that she was to be seen for
follow up in two weeks, as of July 2005, there were no further
psychiatric notes in her chart. This indicates that Inmate #15
had been prescribed psychotropic medications but had not seen a
psychiatrist for at least four months after her admission to
Taycheedah.
Patients on psychotropic medications must be seen regularly
by a physician, preferably a psychiatrist. As noted by our
mental health consultants, generally accepted correctional mental
health care practices require that a psychiatrist actively
monitor the consequences, effectiveness, and potential side
effects of psychotropic medications. Our mental health
consultants further noted that gross delays between administering
a psychotropic medication to an inmate and having the inmate see

- 6
a psychiatrist, such as the multiple four-month delays at
Taycheedah, represent a significant departure from generally
accepted correctional mental health care standards.
2.	

Failure to Appropriately Administer Psychotropic
Medications

Taycheedah lacks sufficient nursing staff to meet inmates’
serious mental health needs for long-term maintenance on
psychotropic medications. Wellman, 715 F.2d at 272 (recognizing
treatment of mental disorders, such as with psychotropic
medications, as a serious medical need). Because there are too
few nurses, many nursing functions, such as medication monitoring
and documentation, are relegated to the correctional staff. The
correctional staff is not trained to perform these functions,
placing inmates’ safety in jeopardy from dangerous errors and
omissions.
One of the nursing functions that is being performed by the
correctional staff is the distribution of medication and
monitoring of potential adverse reactions or side effects.
Taycheedah correctional officers informed us that they do not
receive training on the potential adverse reactions or
precautions that should be taken when distributing psychotropic
medications. As a result, they would not be able to ensure that
medication is taken properly or to identify the signs of
potentially dangerous adverse reactions. For example, initial
doses of antipsychotic medications can result in what is referred
to as an oculogyric crisis, in which the patient’s eyes roll back
in her head and are stuck there. If the patient does not receive
immediate treatment, the paralysis can progress down the airway
and possibly lead to death from suffocation.
The nursing staff has also relegated the responsibility for
completion of Medication Administration Records (MARs) to
correctional officers. Nurses receive extensive and specific
training on MARs. Relegating the responsibility for MARs to
correctional officers who do not receive such training falls well
below correctional mental health care standards. This issue is
further explained below in subsection D.
B.	

Mental Health Services

Taycheedah fails to provide adequate mental health services
to meet the serious mental health needs of its inmates. See
Wellman, 715 F.2d at 272 (recognizing treatment of mental
disorders of mentally disturbed inmates as a “serious medical
need”); Balla v. Idaho State Board of Corrections, 595 F. Supp.

- 7 

1558, 1577 (D. Idaho 1984) (mental health treatment must involve
psychiatric and psychological counseling as well as psychotropic
drugs). Taycheedah falls well below these standards through its
failure to provide a minimal array of mental health programming,
crisis services, and specialized treatment for inmates with acute
mental illness.
1.

Screening and Evaluation for Mental Illness

Staffing for psychologists at Taycheedah is insufficient to
provide timely and systematic screening and evaluation for mental
illness among inmates. Generally accepted correctional mental
health care standards dictate that inmates be seen by a
psychologist within 24 hours if they are acutely mentally ill, or
within a week of admission, at the latest. Insufficient staffing
in Taycheedah’s Assessment and Evaluation Unit impedes the
facility from having an adequate systematic intake assessment and
triage process. The psychologist supporting intake assessments
at Taycheedah is unable to see referred inmates for two to four
weeks. Inadequate systemization of the intake and assessment
process and delays in referrals put inmates who are in need of
immediate attention at severe risk of harm to themselves and
others.
2.

Crisis Services

Taycheedah fails to provide adequate crisis services to
adequately manage the psychiatric emergencies that occur among
its inmates. We observed that a large number of Taycheedah’s
inmates are severely psychotic, imminently suicidal, or
physically aggressive, due to decompensation of their conditions.
Their decompensation is no doubt due, in part, to the lack of
programming and use of segregation to control behaviors
associated with their illnesses. We noted a large void in crisis
services available to inmates, resulting in actual harm and
significant risk of harm. As is typically the case where no
other alternative exists, Taycheedah staff resort to the use of
segregation and observation status to control inmates’ dangerous
behavior, which not only fails to solve the problem, but often
exacerbates it.
Staff informed us that there are many instances when inmates
require inpatient psychiatric care but do not receive it. Staff
also stated that some inmates are housed in administrative
segregation solely because their psychiatric symptoms are so
severe that there is simply no other place to put them. Part of
the problem is likely because there is only one psychiatric
inpatient facility in the area where inmates are sometimes sent.

- 8 

Staff acknowledge that this facility, known as the Winnebago
Mental Health Institution (“Winnebago”), is often full to
capacity and ill-equipped to handle the behavioral issues that
arise when housing inmates. As a result, inmates in need of
critical care remain at Taycheedah, where they do not get the
care they need, and end up being placed in administrative
segregation or observation status. This often leads to
decompensation and further dangerous behavior. For example:
•	

On June 19, 2005, Inmate #58 fatally asphyxiated
herself while in administrative segregation. This
inmate was severely mentally ill, exhibiting almost
daily incidents of aggression and self-injurious
behavior, using virtually any property she could access
to harm herself. She swallowed pen inserts and other
solid objects, resulting in numerous trips to the
emergency room. She went on periodic hunger strikes,
during which she would refuse to ingest food and
liquids for days at a time. This inmate had only
recently returned to Taycheedah at the time of her
death, after a long stay at Winnebago. She was
discharged from that facility when it was determined
that she could no longer benefit from the services and
her behavior was too difficult to manage in the less
secure environment.

Inmate #58 clearly needed an intensity of mental health services
that the State was unable to provide given the current options
for incarceration of seriously mentally ill female inmates.
•	

Inmate #51 has a very severe degree of mental illness
and exhibits serious suicidal ideation. She has been
back and forth between Winnebago and Taycheedah for
over a year. Her behavior is difficult to manage in
both facilities because of her serious attempts at self
mutilation. She expressed her ability to manipulate
both institutions when she stated, “I know what to do
to get back to Winnebago.” However, Winnebago staff
members state that after significant attempts, they
have no further treatment options that will improve her
condition; thus, they send her back to Taycheedah. At
the time of our second visit to Taycheedah, this inmate
was under one-on-one supervision, while in observation
status, to prevent her from hurting or killing herself.
None of the staff members we spoke with regarding this
inmate believe that she is receiving appropriate
treatment, yet noted that they had no better
alternative.

- 9
This inmate is also in need of therapeutic treatment, such as
individual and group counseling, that Taycheedah does not
presently offer.
Taycheedah’s failure to provide alternatives to manage
psychiatric emergencies is unacceptable. Not only does it
jeopardize the safety of the inmates, but it creates a strain on
existing resources due to the reoccurrence of dangerous behavior.
3.

Acute Mental Illness

Taycheedah fails to provide adequate treatment to inmates
with acute mental illness. Taycheedah operates its Monarch
Special Management Unit (“Monarch”) to provide specialized
treatment to those inmates at Taycheedah with the most acute
mental illnesses. We found, however, that this unit provides
almost no programming and, as a result, the vast majority of
inmates are unoccupied for most of the day. This lack of active
treatment creates a high risk of exacerbating psychiatric
symptoms and dangerous behavior, especially in inmates who are
already in need of critical care.
Further, inmates in the segregation unit of Monarch receive
no treatment except for medication. The Seventh Circuit has
recognized that there is extensive medical and psychological
literature establishing the harmful effects of isolation and
segregation on mentally ill inmates. Scarver v. Litscher, 434
F.3d 972, 975 (7th Cir. 2006); Davenport v. DeRobertis, 844 F.2d
1310, 1316 (7th Cir. 1988). Despite the increased need for
treatment of mentally ill inmates in segregation, those inmates
do not even receive consistent psychotropic medication
management, a most basic correctional mental health deficiency.
See, e.g., Wellman v. Faulkner, 715 F.2d 269, 272 (7th Cir. 1983)
(defendants’ recognition that the most obvious serious deficiency
of their medical system was the lack of access to psychiatric
care). For example, Inmate #43 told us that when an inmate with
mental illness is sent to segregation, “they are bumped down the
waiting list” to see the psychiatrist. One of the psychiatrists
informed us that visits to segregation are difficult in an
already overwhelming day, as they must work around security
restrictions and rules.
Moreover, correctional officers working in the Monarch Unit
receive little or no specialized training, which falls below
generally accepted correctional practices for such units. It is
critical that correctional officers, especially those working in

- 10
specialized units, be able to recognize the signs of mental
illness since they are generally the first to respond to
behaviors and need to decide whether the behavior warrants
disciplinary measures. In short, inmates at Taycheedah who are
in the greatest need of care are the least likely to receive it.
4.	

Mental Health Programming to Address Serious
Mental Illness

Taycheedah fails to provide adequate mental health
programming to treat the serious mental health illnesses of its
inmates. As a result of the limited number of psychologists,
psychologists are limited to performing initial diagnostic
assessments and managing crises. The significant attention that
these duties require prohibits psychologists from performing
active treatment, such as programming and counseling, which has
been shown to decrease patients’ serious mental health symptoms
and help prevent mental health crises. See Wellman, 715 F.2d at
272 (treatment of mental disorders is a serious medical need).
Counseling for seriously mentally ill inmates is necessary to
prevent serious psychiatric crises, dangerousness to self and
others, decompensation of mental health, and the need to place
inmates in segregation and observation status. Indeed, in the
absence of therapeutic measures, staff resort to managing serious
behaviors with disciplinary, rather than therapeutic, responses.
To address such potential harm, the Seventh Circuit has upheld
court-ordered correctional mental health care staffing that
mandate psychiatric social workers, clinical psychologists, and
behavioral clinicians. French v. Owens, 777 F.2d 1250, 1255
(7th Cir. 1985). In addition, generally accepted correctional
mental health practice is to provide non-medication therapy for
inmates to address self-injurious behavior.
Although Taycheedah’s Annual Report for Fiscal Year 2005
describes an elaborate array of programming, we found that very
little actually exists. In fact, most of the inmates we
interviewed stated that they receive no programming or they wait
as long as three years to receive it. This lack of sufficient
programming falls well below generally accepted correctional
mental health care standards and results in an increase in
psychiatric emergencies.
C.	

Inappropriate Use of Segregation and Observation Status

Taycheedah’s use of administrative segregation and
observation status for inmates with severe mental illness
violates their constitutional rights because Taycheedah imposes

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a significant penalty on inmates whose behaviors are symptomatic
of their mental illness. See Hallett v. Morgan, 296 F.3d 732,
746-47 (9th Cir. 2002) (distinguishing between sanctions that are
minor and intended to deter behavior versus sanctions that punish
inmates for symptoms of their mental illness and upholding the
former); Coleman v. Wilson, 912 F. Supp. 1282, 1320 (E.D. Cal.
1995) (constitutional violation when prison staff punished
mentally ill inmates without regard to what caused inmates’
behaviors or without considering effect of punitive measures on
inmates’ mental illnesses); Arnold v. Lewis, 803 F. Supp. 246,
249-51 (D. Ariz. 1992) (finding that defendants improperly
punished inmates for symptoms of mental illness by placing them
in lockdown). This practice is ineffectual, falls below
correctional mental health care standards, and can be extremely
detrimental for persons with mental illness because it can
severely worsen their symptoms, especially self-destructive
behavior. See Scarver, 434 F.3d at 975 (noting it was “a fair
inference” that conditions including isolation aggravated the
symptoms of inmate’s mental illness); Davenport, 844 F.2d at 1316
(Seventh Circuit’s recognition of ill psychological effect of
solitary confinement or segregation). We found that 44 out of 59
individuals in segregation during our tour in July 2005 had
serious mental illnesses and were observed to be in significant
distress.
We found that many inmates at Taycheedah with mental illness
are placed in administrative segregation due to threats or
attempts to kill themselves. During our review of inmate
disciplinary charges which resulted in segregation, we found
that, as a result of attempting to harm themselves with writing
instruments or parts of mattresses, certain inmates had been
charged with “misuse of state property” (i.e., facility writing
instruments and mattresses). Executive staff corroborated this
finding by informing us that inmates are sometimes charged with
self-abuse as a disciplinary infraction.
Punishing inmates for behaviors that they lack control over
is ineffectual and destructive, but appears to be a practice that
Taycheedah consistently resorts to because of the lack of
appropriate alternatives. For example, we interviewed Inmate #2,
who was housed in segregation, during our visit. She was deemed
to be a danger to herself, having been observed punching herself
in the eye, a clear symptom of psychosis. Her charts revealed
that she has a long history of serious mental illness, exhibiting
symptoms such as eating her feces and drinking her urine. During
our interview of this inmate, she made such comments to us as:

- 12 

“I eat rotworms,” “I see more Gods when I take Haldol,” I
blackened my eye with my fist,” and “I get upset over the melody
that plays in my head.” According to notes, she was in
segregation due to “inappropriate behavior.” However,
correctional staff informed us that she was in segregation
because she received “lots of tickets” for soliciting sex from
numerous male and female staff members, which the officers
described to us as “crazy.” During our interview, Inmate #2 told
us that she had been housed in segregation four or five times
since 2002 for “disrespect.”
Moreover, Taycheedah does not have a “step down” process in
place to allow inmates to earn their way out of segregation by
exhibiting positive behavior. See Hallett, 296 F.3d at 746-47
(noting that acceptable sanctioning system imposed only minor
sanctions on potentially mentally ill inmates who engaged in
self-harm). A system such as this is a necessary component
according to generally accepted correctional mental health care
standards. Without a “step down” process, inmates have no
motivation to change their behavior. Long periods of
segregation, often with no end in sight, are particularly
damaging for persons with mental illness because the lack of
stimulation, active treatment, and social interaction exacerbates
their symptoms. Indeed, several inmates expressed to us that
they had so much additional time added to their segregation
status due to bad behavior that they had no motivation to change.
Our consultants supported this conclusion, based upon review of
the segregation status report prepared by the facility on July
20, 2005. This report indicated that most inmates were sent to
segregation for six months to a year, and in some cases, 18
months or more. Absent a “step-down” process to potentially
reduce such long segregation periods, inmates have little
incentive to improve their behavior while in segregation.
We observed one particular example in which Taycheedah
placed a 15-year-old girl in long-term segregation. This inmate,
Inmate #3, was reportedly placed in administrative segregation on
November 21, 2004. She was adjusted back to segregation on July
14, 2005 and her current release date is June 26, 2006. We
interviewed the inmate through her spit mask since spitting was
reportedly a problematic behavior of hers. She was quite
cooperative and pleasant, but admitted that she felt that she
will “never” get out of administrative segregation because staff
members “just keep adding time.” As of July 2005, she was not
receiving any education services, as she allegedly “refuses” from
the door of her cell. The inmate was diagnosed as suffering from

- 13 

attention deficit disorder and intermittent explosive disorder;
however, she was not receiving any medication as of our July 2005
visit, reportedly because her mother would not consent. Placing
an un-medicated, mentally-ill teenager in segregation, with
little or no stimulation, and no education services causes
psychological damage that may be irreversible. The waiting time
for her release from segregation would feel like a lifetime to a
girl of this age. Punishing inmates for mental health symptoms
that are beyond their control is unacceptable and ineffectual at
modifying the behavior.
D.

Mental Health and Medication Records

Taycheedah fails to keep centralized, complete and accurate
records to adequately provide mental health care to its inmates.
There is no central record-keeping system and the records
themselves contain errors and omissions that jeopardize inmates’
mental health treatment and can have dangerous consequences.
Accessible and up-to-date records are essential for treating
professionals to provide adequate care.
The absence of a centralized record-keeping system inhibits
treating professionals from accessing the necessary information
to provide treatment. For example, psychological notes are kept
by the Psychology Department, and psychiatric notes are kept by
the Health Services Unit. We noted that while the psychiatric
notes are included in the Psychological Services charts,
psychological notes, which contain important information about
the inmate’s history, symptoms, and behavior, were only sometimes
found in the Health Services notes. In fact, one psychiatrist
informed us that important information gathered by psychology
staff was consistently unavailable. Lack of necessary
information can lead to significant mistakes in diagnosis and
treatment.
Moreover, we found that the charts themselves were
inadequately maintained. Oftentimes there were unacceptable
delays, as much as several months, in getting notes into charts,
and some notes were missing altogether. For example, we noted
many errors and omissions during our review of Medication
Administration Records (“MARs”). MARs are critical to patient
care because they contain information on when medications were
ordered, when the orders were filled, whether the patient
actually received the medication, and, if not, the reason the
patient did not receive it. Physicians rely on the accuracy of
this information to make informed decisions regarding patients’
medication regimens.

- 14
The deficiencies we found in these documents were further
supported by our observations of several correctional officers as
they distributed medication to inmates. Even though staff were
aware that we were monitoring them, we noted several errors in
the recording of information, including the failure to note that
inmates received a dose and the failure to record an inmate’s
refusal to take a dose. The correctional staff involved
expressed great discomfort with performing this daily duty
because they felt inadequately prepared. Several staff members
indicated to us that it is frequently unclear whether an inmate
actually received the medication that was ordered. Indeed, the
psychiatrist relayed to us that she has been quite upset over the
MARS because she is unable to determine whether a dosage change
is appropriate due the lack of recorded information. These
omissions in documentation can lead to serious consequences, as
the following examples illustrate.
•	

A medication order for an inmate was placed in her
chart on August 25, 2005. On September 1, 2005, a
nurse removed the order from the chart for filling by
the pharmacy. The medication arrived on September 13,
2005; however, no notation was made in the MAR that it
had been received or whether it had been administered
to the inmate. The physician, who was unaware that the
inmate was not receiving the medication for this long
period of time, saw that the inmate’s symptoms were
worsening, and changed the inmate’s dosage.

This situation put the inmate at serious risk of harm, as this
change in dosage may have been unnecessary or even
contraindicated, and could have resulted in serious side effects.
In another instance:
•	

As discussed earlier, Inmate #58 fatally asphyxiated
herself while in administrative segregation on June 19,
2005. Prior to that, she was ordered several
medications to be taken orally and two others to be
given intravenously, as needed. While the progress
notes intermittently stated that she refused her oral
medications and requested injections, the MARs were
unintelligible as to what she had been given on any
given day. For instance, some entries reflected “R” or
had a circled “R,” which could mean medication
“received” or could reflect the officer’s initials.
The lack of a consistent system for indicating
medication received made it impossible to determine

- 15
from the records what medications the inmate was
actually receiving, as well as what measures were
needed to control her dangerous behavior. Staff
acknowledged to us that they were aware of this
problem.
Some of these documentation deficiencies would likely
be addressed if Taycheedah had an adequate quality assurance
system in place; however, we noted that Taycheedah does very
little, if anything, by way of practices in quality assurance.
E.

Medication and Laboratory Delays

Taycheedah fails to respond to medication and laboratory
orders in a timely manner, preventing inmates from receiving
adequate treatment. See Wellman, 715 F.2d at 274 (significant
delays in providing treatment led to constitutionally inadequate
care). Our investigation revealed significant delays between the
time medication and laboratory tests are ordered and when the
inmates actually receive the necessary medication or test. This
deficiency falls well below generally accepted correctional
mental health care standards and puts inmates’ mental health at
risk.
1.

Medication Orders

Taycheedah fails to provide inmates with the medication
ordered to treat their mental illnesses in a timely manner.
Timely response to medication orders is necessary to provide
accurate and appropriate treatment, and to prevent symptoms from
worsening. We observed significant delays in providing ordered
medications during our review of Taycheedah’s medical records,
which was reinforced during our interview of clinical staff
members. The source of the delays appears to arise from a number
of problems in the process of filling medication orders.
First, psychiatrists often do not write prescriptions until
late in the day. This delays nurses from taking prescriptions
from the charts for processing. Second, the nurses do not
consistently take the prescriptions from the charts in a timely
manner, and, in some instances neglect to do it at all. Next,
all prescription processing is done at a centralized Wisconsin
Department of Corrections pharmacy, where there are only 14
pharmacists serving the entire State correctional system.
Pharmacy staff stated that the average turnaround time is 72
hours; however, Taycheedah staff members strongly objected to

- 16 

that estimate and stated that it often takes much longer,
sometimes even weeks, for the pharmacy to fill prescriptions.
Fourth, once prescriptions are filled, they must be processed by
the Health Services Unit, which creates another opportunity for
delay. Finally, after processing, the medication must be
documented properly in the inmate’s medication chart, which is
yet another opportunity for delay.
As a result of these significant delays in providing
prescription medications, inmates with severe psychiatric
symptoms go untreated or are under-treated for unreasonably long
periods of time, causing them to suffer and putting them at risk
to themselves and others.
2.

Laboratory Orders

Taycheedah fails to respond to laboratory orders in a timely
manner, and sometimes, not at all. Laboratory tests are often
critical for physicians to make accurate diagnoses and to ensure
that psychotropic medications are adequately monitored. Indeed,
a number of medical illnesses have symptoms that are very similar
to psychiatric illnesses and must be ruled out by laboratory
tests to make an accurate diagnosis. For example, low thyroid
function may mimic depression, while high thyroid function may
mimic mania. Thus, a thyroid screening should be performed
before an accurate diagnosis of bipolar disorder can be made.
Morever, certain psychotropic medications require frequent blood
analysis to monitor for side effects, some of which may be
dangerous if undetected. For instance, some psychotropic
medications may cause diabetes; life threatening increases in
cholesterol; pancreatic, liver, or kidney damage; or immune
dysfunction.
Our investigation revealed serious delays and omissions in
completing laboratory orders. For example, Inmate #13 was
diagnosed with bipolar disorder and prescribed Lithium Carbonate,
a mood stabilizing medication. A lithium level and thyroid
stimulating hormone test (necessary to monitor any potential
thyroid problems caused by the lithium) were ordered on April 16,
2004. As of July 2005, no results from those tests were in the
inmate’s chart, and it was unclear whether the tests were
actually ever done.
Taycheedah is not providing adequate mental health care
because it fails to ensure that inmates are receiving prescribed
medications and necessary laboratory tests. Significant delays
and omissions such as those described cause inmates to suffer and
their symptoms to worsen.

- 17 

F.

Quality Assurance

Taycheedah’s quality assurance system is grossly inadequate.
See Coleman, 912 F. Supp. at 1308 (requiring quality assurance
program for correctional mental health system). Quality
assurance programs are necessary in a correctional mental health
setting to identify basic minimal individual and systemic issues
that need to be addressed in the delivery of mental health
services. Lack of quality assurance leads to focusing efforts
and resources on problems and issues that may not be critical or
compelling. A quality assurance system is especially necessary
in a system struggling with insufficient resources to ensure that
its limited resources are channeled in the most efficient manner
possible.
We found very little, if any, practices to ensure quality
assurance at Taycheedah. Further, the formal efforts that are in
place are severely undercut by Taycheedah’s totally inadequate
data systems. For instance, when the Mental Health Director’s
office attempts to monitor prescribing practices, this can only
be done by a hand count of the medications listed on a several
hundred page printout. The absence of an adequate quality
assurance system results in errors or omissions left undetected
that put inmates at risk of serious harm. For example:
•	

The medication records for Inmate #19 reflect that her
Celexa (an antidepressant medication) was discontinued;
however, there was no notation in her chart as of the
following week to reflect whether she had been seen by
a physician or why this medication change had occurred.

The absence of any clinical documentation made it unclear whether
Inmate #19 no longer had the diagnosis of depression, whether she
had some untoward effects or allergy, or whether she was simply
refusing to take it. In another case:
•	

Inmate #20 was seen by a psychiatrist on March 17,
2005, and a follow up appointment was ordered in six
weeks. Four months later, there were no further
psychiatrist notes in the chart, although orders for
medication changes were written three months after the
appointment was ordered.

Again, without any notes, it is impossible to determine the
reason for the medication change. Review of these charts to
ensure that they are completed properly is necessary to ensure
that inmates are receiving adequate treatment and are not put at
risk from medical errors.

- 18
III. RECOMMENDED REMEDIAL MEASURES
In order to address the constitutional deficiencies
identified above and to protect the constitutional rights of
inmates, Taycheedah should implement, at a minimum, the following
measures with respect to mental health care:
A.	

B.	

Psychiatric Treatment
1.	

Provide adequate on-site psychiatry coverage for
inmates’ serious mental health needs. Ensure that
psychiatrists see inmates in a timely manner and
that psychotropic medication orders are reviewed
by a psychiatrist on a regular, timely basis.

2.	

Ensure that medications are provided to inmates in
a timely manner and that they are properly
monitored.

3.	

Provide nurse staffing adequate for inmates’
serious mental health needs. Ensure that nursing
functions, such as distribution of medications,
are performed by nurses or other properly trained
staff.

Mental Health Services
1.	

Provide adequate on-site psychology coverage to
ensure that psychologists see inmates in a
systematic and timely manner to evaluate inmates
for their serious mental health needs. Provide
adequate staffing to ensure timely and appropriate
mental health screening and referrals.

2.	

Provide an adequate array of mental health
programming, including individual and group
therapy, to meet inmates’ serious mental health
needs and prevent decompensation and mental health
crises.

3.	

Ensure that adequate crisis services are available
to address the psychiatric emergencies of inmates.

4.	

Provide adequate programming in the Monarch Unit
to meet inmates’ critical mental health needs.

- 19 


C.	

Segregation and Observation Status
1.	

D.	

Mental Health Records
1.	

E.	

Ensure that Taycheedah’s mental health records are
centralized, complete, and accurate.

Medication and Laboratory Delays
1.	

F.	

Ensure that administrative segregation and
observation status are not used to punish inmates
for symptoms of mental illness and behaviors that
are, because of mental illness, beyond their
control.

Ensure timely responses to orders for medication
and laboratory tests and prompt documentation
thereof in inmates’ charts.

Quality Assurance
1.	

Ensure that Taycheedah’s quality assurance system
is adequate to identify and correct serious
deficiencies with the mental health system.
* * * * * * * * * * * * * * * * *

We hope to continue working with the State in an amicable
and cooperative fashion to resolve our outstanding concerns
regarding Taycheedah’s mental health care. Assuming that our
cooperative relationship continues, we will be sending you under
separate cover our consultants’ evaluations. Although their
evaluations do not necessarily reflect the official conclusions
of the Department of Justice, their observations, analysis, and
recommendations provide further elaboration of the issues
discussed in this letter and offer practical assistance in
addressing them.
We are obligated to advise you that, in the entirely
unexpected event that we are unable to reach a resolution
regarding our concerns, the Attorney General may initiate a
lawsuit pursuant to CRIPA to correct deficiencies of the kind
identified in this letter 49 days after appropriate officials
have been notified of them. 42 U.S.C. § 1997b(a)(1).

- 20 


We would prefer, however, to resolve this matter by working
cooperatively with you and are confident that we will be able to
do so in this case. The lawyers assigned to this investigation
will be contacting the facility’s attorney to discuss this matter
in further detail. If you have any questions regarding this
letter, please call Shanetta Y. Cutlar, Chief of the Civil Rights
Division’s Special Litigation Section, at (202) 514-0195.
Sincerely,

Wan J. Kim
Assistant Attorney General
cc:	 The Honorable Peggy A. Lautenschlager
Attorney General
Wisconsin Department of Justice
Matthew J. Frank

Secretary

Wisconsin Department of Corrections

Ana Boatwright
Warden
Taycheedah Correctional Institution
Steven M. Biskupic
United States Attorney
Eastern District of Wisconsin