U.S. v. Cal.

U.S. Department . Justice
Civil Rights Division

PC-CA-013-002

Office of the Assistant Attorney General

Washington. DC. 20530

JAN 6 1??.?
Honorable George Deukmejian
Governor of the State of California
State Capitol
Sacramento, California 95814
Re:

Investigation of California Medical Facility

Dear Governor Deukmejian:
Pursuant to the Civil Rights of Institutionalized Persons
Act, 42 U.S.C. 1997b, I am writing to inform you of the findings
of the United States Department of Justice in its investigation
of the California Medical Facility (CMF) in Vacaville, California.
In the course of our investigation, staff attorneys from
our Special Litigation Section conducted tours of CMF with outside expert consultants. During these tours, the consultants
examined inmate medical records and interviewed inmates and
staff. In addition, they reviewed numerous documents provided
by staff such as institutional policies and procedures, schedules
of specialty clinics, staffing rosters, and minutes of infection
control and other clinical staff committee meetings.
The California Medical Facility, situated adjacent to
the Northern Reception Center and the California Medical
Facility-South, serves a unique function within the California
Department of Corrections (CDC) insofar as its primary purpose
is to provide medical and/or psychiatric evaluation and treatment
to those male inmates whose condition requires acute, chronic or
recuperative care not available elsewhere within the CDC system.
Thus, the great majority of the roughly 3,300 inmates at CMF have
serious medical or psychiatric needs. In addition, CMF must
provide general medical care to more than 1,000 support service
prisoners and to hundreds of prisoners who are undergoing initial
classification and evaluation at the Northern Reception Center
(NRC) yet, due to severe overcrowding at NRC, are housed within
CMF. CMF staff also occasionally perform medical/psychiatric
evaluations and prescribe psychoactive medications for inmates
at California Medical Facility-South.

_ 2 —

Based upon our extensive investigation, we believe that
conditions exist at CMF which deprive inmates of their right to be
free from deliberate indifference to their serious medical needs.
Estelle v. Gamble, 429 U.S. 97 (1976). Set forth below are our
findings and recommendations. We will discuss only those areas
which in our opinion are violative of the constitutional rights of
inmates confined to the facility.
General/Acute Medical Care
Staffing
In numerous areas CMF requires additional professional staff
to meet the medical needs of the facility's burgeoning inmate
population with serious and acute medical conditions. Staff
shortages at the primary care outpatient clinic and various
specialty clinics result in the failure to provide timely
diagnoses and treatment for serious medical conditions.
Members of the CMF medical staff freely stated that many
inmates with serious medical conditions experience substantial
and undue delays in access to the sick call clinic. Due to lack
of staff and limited hours of operation many inmates fail to
receive timely evaluation, diagnosis, and treatment of serious
medical needs. Finally, security staff often fail to release
inmates seeking medical attention from work assignments and
arbitrarily deny access to sick call. Inadequate access to
medical services due to lack of staff has resulted in deliberate
indifference to the serious medical needs of CMF inmates.
Staffing in CMF clinics designed to provide specialized
services for the most serious medical problems of CMF inmates is
likewise inadequate. Inmates afflicted with chronic renal
failure, diabetes, cancer, bone/joint/muscle injuries, serious
infections, and other acute illnesses and conditions fail to
receive adequate medical care. In brief, there is insufficient
staff to evaluate, diagnose, and treat serious illnesses and
acute medical conditions.
Staffing on the evening shift and weekends is grossly
inadequate. Only one medical doctor is on duty during these time
periods. This individual is the only physician on duty to
provide medical coverage to over 3,300 CMF inmates, including
those in acute\surgical hospital units, as well as more than
1,000 NRC overflow inmates. Such inadequate medical coverage in
a facility such as this one amounts to deliberate indifference
to the serious medical needs of the inmates.

- 3 In the operating room and elsewhere at CMF, inmates are
regularly entrusted to perform direct patient services.
These
inmates also have direct access to inmate medical records. There
is no evidence of formalized training of these inmates or that
they possess the qualifications necessary to perform these
medical duties. Moreover, staff shortages do not permit adequate
supervision of inmate attendants by properly qualified
professional staff. While inmates may be used to perform minor
incidental medical tasks, the system of using inmate medical
attendants, as currently administered at MF, is unconstitutional.
At a minimum, there must be a showing that nonprofessionals can
perform the tasks assigned, have been trained to do so, and are
properly supervised.
In conclusion, lack of adequate professional staffing at CMF
prevents the facility from providing medical care and services
sufficient to avoid deliberate indifference to inmates' serious
medical needs.
Psychiatric Care For The Seriously Mentally 111
Professional psychiatric staff at CMF is grossly inadequate.
The shortage of trained, competent psychiatric staff was
acknowledged by CMF administrators. Due to lack of staff and
space in the acute psychiatric care units, CMF is unable to
provide psychiatric care necessary to address the medical needs
of inmates who are seriously mentally ill.
In the acute care units, our consultant noted a near-total
absence of psychiatric care except for sporadic efforts to handle
"crisis" cases. Further, due to the constant pressure to make
housing space available for new admissions into the psychiatric
units (including the admission of inmates without legitimate
psychiatric diagnoses but requiring protective custody and
inmates who are merely disruptive), inmates are quickly discharged
to outpatient units where care is inadequate. Untreated, these
inmates with serious mental illnesses are exposed to undue risks
to their personal safety. Decisions to release inmates from acute
care units often appear to be based primarily upon a shortage of
space and other custodial, rather than medical, consideratons.
Moreover, inmates on psychotropic drug regimens are not adequately
monitored by medical or psychiatric staff. There are no or
inadequate efforts to evaluate inmates for adverse drug side
effects or toxicity. Finally, our consultants concluded that the
number of suicides and suicide attempts within the psychiatric
care units at CMF indicate a failure to identify or to monitor
properly suicide-prone individuals.

- 4 In sum, the professional psychiatric staff and other
resources at CMF are so deficient as to constitute deliberate
indifference to the needs of inmates with serious mental
illnesses.
Medical Records
Medical recordkeeping at CMF is grossly inadequate. Our
review of medical recordkeeping at CMF revealed a pattern of
failures to perform or document necessary diagnoses, treatments
and monitoring.
Medical records frequently do not indicate either a patient's
course of treatment or any treatment planning. Due to shortages
in clerical staff, dictated medical notations, the results of
physical examinations and other information frequently are not
incorporated into inmates' medical charts in a timely manner.
Minutes of staff committee meetings confirm that medical records
often fail to contain psychiatric nursing notes. In one internal
audit, CMF staff found that as many as 400 nursing charts were
incomplete and noted that failures to incorporate necessary
treatment records into inmates' medical files result in "inconsistent medical therapy with multiple, conflicting orders on some
patients." Finally, medical records on many outpatients are not
available to the medical doctor on duty in the evenings,
nights, and on weekends. The obvious importance of available,
accurate and minimally complete medical records in the treatment
of serious medical needs renders their absence "deliberate
indifference" in the constitutional sense.
Environmental Conditions
Serious deficiencies exist with regard to environmental
conditions at CMF. These conditions have a direct, adverse
impact upon the provision of medical care at the facility.
Several housing units visited by our consultant were extremely
crowded and were poorly ventilated and lighted. In one unit
housing more than 80 inmates, many of whom were in wheelchairs,
there were two toilets, three communal shower heads (without
operable temperature controls), and one bathtub without special
fittings for the handicapped. Several inmate treatment and
housing areas also were unsanitary. In the acute medical/surgical
hospital unit, provisions for medical isolation were grossly
inadequate. General provisions for infectious waste disposal were
also inadequate. These deficiencies endanger inmates by
subjecting them to serious risk of infectious diseases.

- 5 Overcrowding
Due to overcrowding, CMF's capacity to render adequate
chronic and acute medical care as well as psychiatric care is
strained beyond reasonable limits. The serious medical needs of
prisoners for access to sick call, specialty clinics, and to
basic care for continuing medical impairments are not being
adequately met. Overcrowding also exacerbates deficiencies
present with respect to sanitation and infection control.
Further, overcrowded conditions and lack of resources also
undermine CMF's ability to provide adequate psychiatric care to
inmates who are seriously mentally ill. The impact of crowding
on the provision of medical services is so great as to constitute
a constitutional violation.
Minimally Necessary Remedies
Remedial measures must be taken to ensure that prisoners
confined to California Medical Facility are not deprived of
rights guaranteed to them under the Constitution of the United
States. We propose to enter into a legally binding and judicially
enforceable agreement with the State of California designed to
provide constitutionally adequate conditions at CMF and to provide
a means by which compliance with said agreement may be verified.
The following minimum measures are those that may be necessary to
remedy the conditions described above:
1) Professional medical staff must be increased, as
necessary, to ensure that inmates have reasonable and prompt
access to care and treatment necessary to respond to their
serious medical needs, including psychiatric care sufficient to
address the medical needs of seriously mentally ill inmates.
2) CMF must expand and improve the operation of its sick
call clinic and procedures for general health surveillance
to ensure that serious medical conditions are identified and
treated in a timely fashion.
3) Sick call procedures must be established and implemented
to ensure timely access by inmates, irrespective of classification
or work status, to medical services.
4) CMF must expand the availability of specialized medical
services (e.g., urology, physiotherapy, orthopedics) in order to
meet the most serious medical needs of inmates confined at the
facility.

- 6 5) Housekeeping, infectious waste disposal, and general
sanitation procedures must be improved.
6) The use of inmates as medical attendants providing
direct health care must be discontinued or permitted only
after training and under supervision, with respect to such
incidental medical tasks as nonprofessionals are able to
provide.
7) Steps must be taken to ameliorate and eliminate the
effects of overcrowding.
We would be pleased to consult with you regarding ways in
which we might be able to assist you in correcting the deficiencies described. For example, we would be pleased to provide you
with copies of our experts 1 reports. You may also wish to
consult with the National Institute of Corrections and/or the
Federal Bureau of Prisons. We would be pleased to assist you in
any inquiries you may wish to make about the possibility of
obtaining technical and other assistance through programs they
administer.
We appreciate the cooperation that the California Attorney
General's Office and the staff and administration at CMF have
extended us. We hope that a cooperative spirit will continue to
prevail so that this matter can be concluded promptly and
amicably. My staff will contact you shortly to arrange a meeting
to discuss this matter further.

Wm. Bradford Reynolds
Assistant Attorney General
Civil Rights Division
Enclosures
cc:

John K. Van De Kamp
Attorney General

- 7 Eddie Ylst
Superintendent
California Medical Facility
Peter A. Nowinski
United States Attorney
Norman Carlson
Director
Bureau of Prisons
Raymond Brown
Director
National Institute of Corrections