NEW YORK STATE COMMISSION OF CORRECTION In the Matter of the Death FINAL REPORT OF THE NEW YORK STATE COMMISSION of Quanell Offley, an inmate of : OF CORRECTION the Otis Bantum Center TO: Commissioner Joseph Ponte NYC Department of Correction 75-20 Astoria Blvd, Ste. 100 East Elmhurst, NY 11370FINAL REPORT OF QUANELL OFFLEY PAGE 2 GREETINGS. WHEREAS, the Medical Review Board has reported to the NYS Commission of Correction pursuant to Correction Law, section 47(1)(d), regarding the death of Quanell Offley who died December 3, 2013, as a result of circumstances which occurred while an inmate in the custody of the New York City Department of Correction, the Commission has determined that the following final report be issued. FINDINGS: 1 Quanell Offley was a 31-year-old black male who died of suicidal hanging on 12/3/13, at 3:11 p.m., at Elmhurst Hospital while in the custody of New York City Department of Correction (NYC DOC) at the Otis Bantum Corrections Center. On 11/30/13, Offley while in punitive segreg ered in his cell suspended from by a sheet form theFINAL REPORT OF QUANELL OFFLEY Offley was admitted to NYC DOC through the Bronx Criminal Court. Officer h_noFINAL REPORT OF QUANELL OFFLEYFINAL REPORT OF QUANELLPAGE 6FINAL REPORT OF QUANELL AGIFINAL REPORT OF QUANELL OFFLEY PAGE 8 29, 30. 31 32. The Department of Health and ‘Mental Hygiene Correctional Health Hygiene; Correctional Health Services Policy #5 entitled: Refusal of Mental Health Treatment and/or Medication states: “An inmate, housed in general population, who directly refuses treatment by mental health staff shall be asked to sign the Refusal of Treatment Form. If the inmate refuses to sign the Patient Refusal of Treatment Form, a correction officer shall be asked to sign as witness to the refusal.” In the course of the investigatign it was reported by the mental staff that they were not “— a the housing tier 33. On 9/22/13, at 1:15 p.m., Offley was involved in a physical altercation with another inmate. He was served a disciplinary infraction notice for fighting. Both Offley and the other inmate suffered minor injuries. Offley received 25 days of punitive segregation gFINAL REPORT OF QUANELL OFFLEY PAGE 9 36. (On 10/22/13, Offley received an infraction notice for having an institutional phone in his clothes. On 14/7/13, while in general population, Offley became verbally belligerent and was swearing when he was told he had to wait to use the telephone after dinner. He threw a broom causing it to break and also refused to pick up the broom as ordered by the correction officer. Offley was issued a disciplinary infraction ticket which resulted in 20 days in punitive segregation.FINAL REPORT OF QUANELL OFFLEY PAGE 10 43, On 11/29/13, at 11:40 p.m., Officer R. observed Offley blocking his cell window with a sheet of paper. Officer R. stated that she told Offiey to remove the paper, and he complied. She wrote Offiey a disciplinary ticket for this action. The officer stated that Offley did not ask for any mental health assistance during the interaction. 44,FINAL REPORT OF QUANELL OFFLEY PAGE 11 45. 46. 47. 48. 49. On 11/30/13, at approximately §:00 a.m., Offigers R. and S.M. were passing out the breakfast trays. In the process of the NYC investigation, inmate voluntary statements were taken: Witness D.M. stated *. This moming | woke and an argument with a CO and 2 cell (Offfey), he was saying he gonna kill himself and someone said (that same CO) "Do it! Do it if you got the balls” This was at approximately 5:00 am Witness R.R. stated "Two cell (Offley) also told C EEE while sho was doing chow for the bottom tier, and she said ‘If you got the balls then do it" | don't care it ain't my life. He told her to get someone that does care and she walked away.” Witness R. B, stated “Offley did respond morning when CO arrived to serve him breakfast. Offley told CO i ‘have been trying to get out of here. | am going to kill myself.” She replied "If you have the balls, go ahead and doit.” On 11/30/13, at approximately 8:00 a.m., Officer L.R. completed a mental health referral which indicated that Offley was showing radical changes in his behavior and was depressed. Officer LR. stated he remembered Offley stating that he would not handle being locked in a cell for extended periods of time.” Officer L. R. stated the only thing he remembered was Offley stating “he could not be in the call” At approximately 9:00 a.m., Captain D. M. was made his supervisory round with another officer on the housing unit. Officer L. R. stated Captain D. M. received the mental health referral while he was on 2 South. There were no further supervisory rounds completed on Offley’s housing corridor before he was discovered. (On 11/30/13, at 9:30 a.m., PA S.W. signed the 2 South Punitive Segregation Log Book. He started his sick calll rounds in the unit. On 11/30/13, at approximately 9:30 a.m., Officer L.R. stated that he observed Offley standing at his cell window (cell #2). Offiey then asked Officer L.R. the location of the sick call officer who was in the housing unit (2-South). According to NYC DOC videotape on 11/30/13, at 9:42 a.m., the PA S.W. inthe process of ‘conducting sick call rounds, looked through the cell window. At 9:43 am., the PA S.W. waved Officers LR. and J.V. over to the cell. At 9:43 a.m., both officers went to Offley's cell and tured sideways looking through the cell window. Officers LLR. and J.V. stated that they observed Offley in standing position directly to the left side of the door. The two officers observed he had a sheet tied around his neck attached to a metal vent grid over the toilet, Officer L.R. immediately reported to the control station where he verbally notified Officer S.M. in the control room. Officer E.S. stated she notified Captain D.M. that there was an inmate hanging. Officer S.M., who was also in the Control Room, stated since she was the officer with more seniority, Officer LR. asked her to go to the cell. Officer S.M stated that she did not have anyone immediately enter the cell because Offley was in the standing position with his feet on the floor, and he could be playing “possum.” Within one minute, at 9:46 a.m., Captain D. M. arrived at the cell and the cell was opened. It was reported to Commission staff that a cell door in the punitive cell units can be opened without a captain present. The four officers entered the cell. Officer LLR. used the cut down tool to release the ligature. Officers LR., S.M, and Captain D. placed Offley on his bunk. At 9:48 a.m., Sgt. H. arrived and entered the cell. Captain D. called for medical staffFINAL REPORT OF QUANELL OFFLEY PAGE 12 50. 51 62. 53. and instructed Officer J.V. to obtain the AED and code pack. Captain D.M. started CPR after noting that Offley was not breathing and had no pulse. Captain H. ordered that leg shackles be obtained. Once the leg shackles were retrieved Officer S.M. applied them to Offiey. It was reported that the face mask was missing in the first-aid kit. An officer left the unit fo obtain another mask. At 9:45 a.m., PA S.W. leaves the unit. ‘At 9:52 a.m., medical documentation reported that an emergency was called for 2 South. At 9:55 am., PA G.C. was at Offley’s cell before other medical staff arrived on the scene as he was completing sick call rounds on a different punitive segregation unit. He stated he saw the gurney going down the hall and followed it. PA G.C. stated he observed staff actively completing CPR on Offley in which he assisted the officers. PA G.C. stated that this was the first time that he was on 2 South, and he did not complete medical sick call rounds on this housing unit. At 10:00 a.m., Dr. M.L. arrivey Offiey At 10:12 am. Urgi-care Dr. F.F. arrived at ce| ‘was pronounced at 3:11 p.m. by Dr.P. In the course of the NYC DOC investigation, Inmate N.A. was interviewed. Inmate N.A. was employed as a Suicide Prevention Aid (SPA) in the punitive segregation new admission area on the night shift on 11/29/13 to 11/30/13. He stated upon arrival he toured the housing area. N.A. stated the inmate in cell #2 (Offley) requested his night light to be turned on. After completing his initial tour, Inmate N.A. did not make any additional ones ‘on the unit but reported that he passed a book to one inmate to another as instructed by an officer. After that, N.A. reported that he went into the interview room and fell asleep with his head phones on. The correction officers in the housing unit are responsibility to supervise the SPAs. According to NYC DOC Directive #4017B entitled Inmate Observation Aide Program (IX, 1) states: “Observation Aides shall conduct a minimum of six (6) vigilant heir assigned areas, pre-hour, at irregular hours.”FINAL REPORT OF QUANELL OFFLEY PAGE 13 Since Offley’s suicide, NYC DOC correctional staff have placed a housing tour log book for the SPAs to sign at the completion of their rounds. 54, The NYC DOC Preliminary Report, dated 12/13/13, incorrectly states that PA G.C. was completing the sick call rounds on 2-South on the morning of 11/30/13. It was verified that PA S.W. was completing sick call rounds. RECOMMENDATIONS: TO THE COMMISSIONER OF THE NYC DEPARTMENT OF CORRECTION: 4 The Commissioner shall direct an investigation as to the reasons Offley was not produced numerous times for mental health clinical encounters by correctional staff. A corrective plan of action will be developed and initiated. The results of this investigation and the corrective plan will be forwarded to the Commissioner of the NYS Commission of Correction by February 15, 2015. The Commissioner in conjunction with the Division of Health Care Access and Improvement, NYC Department of Health and Mental Hygiene will review the current: practice of prohibiting mental health staff on the inmates’ housing tiers to obtain a Refusal of Care and ascertain the inmatefpatient’s reasons for declining clinical encounters. The Commissioner shall direct the continued enforcement with NYC DOC Directive #40178 entitled Inmate Observation Aide Program. The Commissioner shall investigate the actions of Officer S.M. in regards to her encounter with Offley in the early hours of 11/30/13, and the directions she gave other correction officers in an emergency situation, ‘The Commissioner shall direct correction officers to complete supervisory rounds every thirty minutes in the punitive segregation. The Commissioner shall direct an amendment of any investigation records or written reports that incorrectly state that PA G.C. was completing the sick call rounds on 2-South on the morning of 11/30/13. The Commissioner shall direct a review of the Department's current policy and procedures for the administration emergency medical aide by correction officers in the punitive segregation housing units and revise it as necessary. ‘The Commissioner shall direct that emergency response equipment in inmates’ housing is accounted and supplied according to the existing NYC DOC Directive. TO THE DEPUTY COMMISSIONER, DIVISION OF HEALTH CARE ACCESS AND. IMPROVEMENT, NYC DEPARTMENT OF HEALTH AND MENTAL HYGIENE AND TH! DIRECTOR OF NYC HEALTH AND HOSPITAL CORPORATION: 1 The Deputy Commissioner in conjunction with the New York City Department of Correction will review the current practice of prohibiting mental health staff on the inmates’FINAL REPORT OF QUANELL OFFLEY PAGE 14 housing tie to obtain a Refusal of Care form and ascertain the inmate/patient’s reasons for declining clinical encounters. The Deputy Commissioner will direct a review of mental health records of Physician Assistant K.C. with attention to mental health diagnostic assessments in conjunction with her supervising physician The Deputy Commissioner will direct a policy and procedure for mental health clinicians have a physical encounter to evaluate the inmate for suicidal risks and indicators who are receiving their services before admission to punitive segregation housing The Deputy Commissioner will direct an investigation in Physician Assistant S.W.'s actions concerning Offiey's life-threatening emergency during the sick call rounds on 11/30/13, WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner, NYS Commission of Correction, 80 South Swan Street, 12" Floor, in the City of Albany, New York 42210 this 17" day of March, 2015. is Harrison-Ross, MD Commissioner PH-JJ:ams, 413-M-181 315 ce: Eric Berliner, Deputy Commissioner, Health Services Unit Heidi Grossman, General Counsel/Acting Chief of Staff Sonia Angell, MD, Deputy Commissioner Correctional Health Services, NYC Department of Health & Mental Hygiene George Axelrod, Deputy Executive Director, NYC Department of Health & Mental Hygiene Homer Venters, Assistant CommissionerNEW YORK STATE COMMISSION OF CORRECTION In the Matter of the Death FINAL REPORT OF THE NEW YORK STATE COMMISSION of Carlos Mercado, an inmate of OF CORRECTION the Anna M. Kross Center Commissioner Joseph Ponte NYC Department of Correction 75-20 Astoria Blvd, Ste. 100 East Elmhurst, NY 11370RLOS MERCAI WHEREAS, the Medical Review B has reported t Commission of Correction pursuant to Correction Law, e 47(1)(d), regarding the death of Carlos Mercado who died on Augus , 2013 while an inmate in the custody of the Department of Correction at the Anna M. Kross Center, the Commission has determined that the following final report be issued. arlos Mercado was a 45-year-old Hispanic male who died of Diabetes Mellitus with Ketoacidosis on 8/24/13, at 9:36 a.m. while in the custody of New York City Department of Correction (N¥C DOC) at the Anna M. Kros x (AMKC). On 8/24/13, at approximately at 8:25 a.m., he was discovered in the AMKC New Admission Pen in the Main Clinic by a correction officer conducting a supervisory round. On 8/23/13, Mercado was admitted to Brooklyn Criminal Court and transferred to AMKC on the same day. According the inmate witnesses, Mercado reported he had diabetes to several correction officers. He was observed by videotape to have an unbalanced gait and extreme vomiting. Mercado was also observed falling out of the pen onto the floor when the pen door was opened. Had Mercado received adequate and appropriate medical care, h: death would likely have been prevented CenFINAL w S MERCAI REPORT OF CARL On 8/23/13, at 4:06 a.m., Mercado was admitted to the custody of NYC DOC at Brooklyn Criminal Court. According to the Suicide Prevention Screen completed at Brooklyn Criminal Court, Officer A. scored Mercado with a “one” for the question “Detainee has history drug or alcohol abuse,” with no mment lis There al mad mental health services. is no refe. review of do did not state he had diabetes cide Prevention Screen reported that Merc mellitus. Officer A. completed an Arraignment and Classification Risk S Form in which Mercado stated he had no immediate medical needs. Mercado’s Securing Order also icate he needed immediate medical attention. did not ind Mercado stated to Officer A. that he was “okay.” The DOC correction officers that appeared in the NYC DC videotape were on duty in the AMKC Intake area on 8/23/13 for he evening shift (3:00 p.m. to 11:31 p.m.) and on 8/24/13 for the following night shift (11:00 p.m. to 7:31 a.m.) while Mer: processing. The AMKC videotape DOC Investigative Di was in this area fc reviewed omission of Correction . Identification the s later made by requeste: their mortality investigatior ion officers cited in this videota: sonnel during the Commission’s interviews at leotape was recorded at the AMKC intake areaFINAL REPORT OF CARLOS MERCADO PAGE 4 where Mercado was housed. Due to NYC DOC regulations, there was no videotape surveillance of Mercado while he was in the AMKC Main Medical Clinic pen awaiting his admission medical intake. On 8/23/13, at 6:54 p.m., Mercado entered the AMKC facility. At 7:03 p.m., Mercado, who was wearing a white shirt, left AMKC intake pen #1 carrying his belongings and a clear trash bag and was transferred to AMKC intake pen #3. He was observed ambulating on his own. According to the NYC videotape on 8/23/13 at 9:10 p.m., the inmates from intake pen #3 were released and ordered to start lining up for an inmate count. Mercado does not appear to be in the line-up. Later, at 10:45 p.m., Officer E. J. approached pen #3 and opened the door. Mercado fell out of the pen on to the floor in front of Officer E.J. Mercado was lying initially face down on the floor and was observed briefly rolling back and forth. At 10:46 p.m., Officer E.J. was observed stepping over Mercado while he was on the floor. Mercado then placed his shirt under his head while he was lying on the floor. At 10:47 p.m., another officer also walked over Mercado’s legs. Several officers looked and talked to Mercado who was still on the floor. Mercado stayed on the floor for approximately three minutes. Mercado was assisted to his feet by Officer M.B. who then guided him to the AMKC intake pen #3. Mercado appeared to have an unstable gait. At 10:50 p.m., Officer M.B. and Officer R.F. returned to pen #3 and opened the gate. Officer M.B. handed a water bottle inside pen #3. There were several inmates in pen #3 where Mercado was located. Officer M.B. later retrieved the water bottle from pen #3. At 10:50 p.m., Captain M.G. walked into the AMKC intake area near holding pen #3 where Mercado was confined. Captain M.G. spoke to the two officers and then went behind the desk. Captain M.G. did not recall the officers who were on duty during this time period or the officers reporting that any of the intake area inmates needed medical attention. At 10:54 p.m., Officer M.B. returned to pen #3 and handed the water bottle inside the pen. At 11:09 p.m., Officer M.B. opened pen #3 and partially stepped into the pen #3. At 11:15 p.m., the pen #3 inmates were brought out of the pen and made a line for feed-up. They obtained trays and food from the table in the intake area. Mercado was not observed to be with them.FINAL REPORT OF CARLOS MERCADO PAGE 5 10. 1. 12. 13. According to the NYC DOC videotape, on 8/24/13 at 12:31 a.m., Mercado walked out of the pen #3. He dragged a bag behind him, and according to four inmate witnesses, Mercado’s bag contained vomit. These statements were taken from the NYC ID Preliminary Investigative Case Report and are recounted in the NYC DOC’s report in part as follows: Witness H.B. stated “at some point (Mercado) started throwing up into a garage bag.” Witness R.S. reported.“at some point he was given a plastic bag to throw up in.” Witness M.R. stated “When the inmate (Mercado) was finally taken out of the pen, he was wobbly and not stable on his feet. The other inmates told him to take his bag of throw up With him.” Witness B.J. reported “staff gave the inmate a bag so he could throw up in it.” According to the NYC DOC ID videotape, Mercado placed his hands on the table in AMKC intake area and bends at the waist. He appeared to be vomiting into his plastic bag. Mercado does this action in front of an officer whose back was to the camera. Mercado appeared to be staggering and shuffling his feet with an impaired balance. At 12:32 a.m., Mercado returned to pen # 3 after a conversation with an officer. On 8/24/13, at 12:36 a.m., Mercado left the pen for processing, which included having his photo taken, completing forms, and having his finger prints done. Mercado’s ambulation appears to have improved as his gait and balance were better during this process. Mercado returned to pen #3 at 12:38 a.m. At 1:54 a.m., Mercado left pen #3. He appeared to be unsteady, staggering, and had poor balance with his ambulation. He was observed breathing heavily and rapidly. He guided himself to what appears to be a bench and sat down there. Officer R, F. was sitting at the desk but stood and walked over to Mercado. Officer B.C, walked down the hallway and joined Officer R.F. A conversation took place between Mercado and the officers. At 1:56 a.m., Mercado returned to pen #3 ambulating on his own. At 2:00 a.m., Officer B.C. opened the door of pen #3 and Mercado, along with two other inmates, left the pen. Mercado was dragging the plastic bag with liquid vomit. He put the bag in the garbage bin. He was noted to be staggering slightly.FINAL REPORT OF CARLOS MERCADO PAGE 6 14. 1s. 16. On 8/24/13, at 2:01 a.m., Mercado was moved to another AMKC intake pen at the end of the hallway. Mercado and other inmates were escorted there by Officer B.C. At 2:11 a.m., Mercado was placed in the pen at the end of the hallway, and he was noted to be extremely unsteady on his feet. At 2:39 a.m., five other inmates were placed by Officer B.C. in the same pen where Mercado was housed. At 2:58 a.m., Officer B.C. stopped at the pen and briefly spoke with the inmates located there. Another inmate was placed in Mercado’s pen. At 3:17 a.m., Captain M.G. stopped at Mercado’s pen and spoke to the inmates until 3:21 a.m., and then leaves. Shortly afterwards, another officer stopped at the cell and spoke to the inmates in the pen briefly. At 3:24 a.m., Officer B.C. placed another inmate in Mercado’s pen. Officer B.C. spoke to the inmates inside for approximately four minutes. At 3:47 a.m., Captain M.G. spoke to the inmates in Mercado’s pen for about three minutes. on 8/24/13, at 4:33 a.m., Officer R.F. approached Mercado’s pen and conversed with the inmates. At 4:36 a.m., Captain M.G. joined Officer R. F. in the conversation outside Mercado’s pen. At 4:38 a.m., Officer R.F. left the area, but Captain M. G. stayed by the pen. At 4:40 a.m., Captain M.G. removed herself from Mercado’s pen but appeared to be summoned back and conversed with the inmates again for approximately 2 minutes. At 4:43 a.m., Captain M. G. walked away from pen #3. She came back shortly and had a mop and bucket with her. She first entered the pen next to where Mercado was placed. At 4:45 a.m., Captain M.G, entered pen #3, where Mercado was, with the mop and bucket, and then she came back out with the cleaning equipment. on 8/24/13, at 5:00 a.m., Captain M.G. opened pen #3 and the inmates crossed the hallway and obtained either water or food. Mercado was not observed to be with them. At 5:26 a.m., the inmates (fourteen total) were seen exiting the intake door and at 5:30 am entering the Main Clinic area. At 6:28 am an officer opened the intake door and the inmates exited the pen. Mercado was included in this group. At 6:31 am Mercado leaned against the opposite wall and placed a clear plastic bag that contained vomit against the wall. At 6:34 am Mercado entered the corridor and was swaying as he walked. The inmates entered the clinic area and were placed in the main clinic holding pen awaiting an admission medical evaluation.FINAL REPORT OF CARLOS MERCADO PAGE 7 a7. There were several inmates who were interviewed in the course of the NYC DOC ID Preliminary Investigative Case Report. Three inmate witnesses Teported that Mercado stated that he had diabetes to the correction officers located at the AMKC intake area, These statements were taken and recounted in the NYC DOC’s report in part as follows: Witness H.B. stated that he and the other inmates saw Mercado “start throwing up in a garbage bag. He was sick. He told the officers in intake that he was (an) diabetic, that he wasn’t feeling good and needed methadone. There were a lot of officers around in the intake. He threw up ten or twenty times.” Witness M. R. stated to NYC DOC ID’s investigators that: “In the intake pen, the one in front of the receiving xoom, there was a Hispanic inmate (Mercado) who was sick and throwing up into a paper bag. He was telling the officer that he was sick, that he was a Diabetic. The officer told him “no, you're withdrawing.” Witness M.R. identified the officer as Officer B. Mercado did tell Witness M.R. he was withdrawing from drugs. Witness M.R also stated “The inmate (Mercado) continued to throw up into the bag, to the point where the other inmates in the pen were complaining to the officer. At one point when the officer opened the gate to the pen to let another inmate in (the pen), the inmate (Mercado) fell out of the pen onto his face.” Witness J. M. also stated to NYC DOC ID’s investigators that: “The inmate was asking to see medical numerous times. The inmate (Mercado) said he needed to see the doctor because he was diabetic.” ‘These failures to refer a sick inmate to the medical unit is a violation of the NYC DOC Operations Order 22/91, which is entitled Emergency Health Care Log which states: “It will be the policy of the Department to ensure that all inmates are afforded prompt medical attention when required. To ensure compliance, this Operations Order is established to delineate the procedures necessary to effect emergency health care by in-house medical staff, as required by the Board of Correction, NYC Correctional Health Care Minimum Standards. A situation requiringFINAL REPORT OF CARLOS MERCADO PAGE 8 18. 19. 20. emergency health care is defined as any circumstance, other than the standard sick call or follow-up that necessitates a face to face encounter between medical staff and inmate patient, to prevent loss of life, disfigurement, and/or the placing of an inmate in imminent danger. Upon being informed that an inmate requires emergency medical attention, either as a result of an injury, the Correction Officer being notified shall immediately: Notify the facility medical staff of the inmate’s illness or injury. Notify the area supervisor of the inmate’s illness or injury.” According to the NYC DOC Operation Order entitled Processing and Monitoring New Admissions # 16/89, (K) which is summarized as: From the time of admission to (the) Department (‘s) custody to the time housed in a Rikers Island facility. Timeframe (for) DOC/ Medical processing - 4 hours Housing assignment- 4 hours On 8/23/13, at 6:54 a.m., Mercado was admitted to Riker’s Island and was not taken to the Main Clinic until 6:34 a.m., on 8/24/13, a time span of almost 12 hours. The New Admission Log Book reported that Mercado went to the AMKC Main Clinic on 8/24/13, at 5:30 a.m., arriving there at 5:45 a.m., and his examination started at 6:00 a.m. However, the NYC videotape shows that Mercado did not report to the AMKC Main Clinic until 6:34 a.m. The Commission of Correction, for purposes of this investigative report, had requested the Main Clinic Medical Expediter Log Book to verify the times of the inmate count, determine when administrative rounds were made, when the medical staff were notified about Mercado, and any additional information documented on him while he was in the clinic holding pen. At the time of composing this report, the Main Clinic Medical Expediter Log Book has not been received. on 8/24/13, at the AMKC medical clinic, Officer K.J. was the assigned medical expeditor for the hours 7:00 a.m. to 3:30 p.m, At 8:15 a.m., Officer K.J. ordered the new admission (N/A) inmates out of the medical holding pen for the purpose of conducting an inmate count. Officer K.J. documented that Mercado refused to step out of the N/A holding pen. Officer K. J. observed Mercado lying on the floor. Officer K.J. then notified RN A.D. to come to the N/A holding pen to evaluate Mercado. The officer documented the statement: “0825; NotifiedREPORT OF CARLOS MERCADO PAGE 9 medical staff that Inmate Carlos Mercado did not look right” in the medical expeditor log book. Officer K.J. A.D. came and completed a visual ins Mercado. fteen minutes later icer K.J. stated that approximately mpleting an administrative round, she observed Mercado lying on the floor in the same position as when she completed the inmate count earlier. Officer K.J. called the medical area a second time and asked LPN A.P. to come to the holi and evaluate Mercado 22. in the AMKC Main Clinic A Post security logbook that at 9:45 a.m., notification was made to the AMKC administrative staff that Mercado had expired. However, there was no documentation which reported a medical emergency was called for him. There was an e' Case Report of Mercado’s death has ID investigator reported that n delayed due to 24; The ID Final Investiga not been completed. The NYC DO the Final Investigative Case Report had be the inability to interview the Corizon Correctional Healthcare medical personnel involved in rcado’s dea‘ There were no officers’ statements obtainec by ID or identification mpleted on those who worked in the AMKC intake area fromFINAL REPORT OF CARLOS MERCADO PAGE 10 25. 8/23/13 to 8/24/13. Security statements were obtained from Officers K.J. and S.M. who were the principle witnesses in the AMKC Main Clinic area when Mercado was discovered to be unresponsive. Mercado did not report his diabetes in the Bronx Criminal Court which most certainly delayed his medical treatment. However, inmate witnesses reported he did tell some of the officers in the AMKC intake area of his diabetes. The inmate witnesses would have had no knowledge of Mercado’s diabetes unless he reported it. Additionally, there were several incidents when Mercado displayed extreme vomiting, staggering, and shuffling his feet with an impaired balance. He was also observed falling on his face when a cell door was opened. It was the responsibility of the NYC DOC officers to alert the facility medical staff regarding of these difficulties. RECOMMENDATIONS To The Commissioner of the NYC Department of Corrections: 1. The Department shall direct correctional staff to comply with the NYC DOC Operations Order 22/91, entitled Emergency Health Care Log which states: “It will be the policy of the Department to ensure that all inmates are afforded prompt medical attention when required. To ensure compliance, this Operations Order is established to delineate the procedures necessary to effect emergency health care by in-house medical staff, as required by the Board of Correction, NYC Correctional Health Care Minimum Standards. A situation requiring emergency health care is defined as any circumstances, other than the standard sick call or follow-up that necessitates a face to face encounter between medical staff and inmate patient, to prevent loss of life, disfigurement, and/or the placing of an inmate in imminent danger. Upon being informed that an inmate requires emergency medical attention, either as a result of an injury, the Correction Officer being notified shall immediately: Notify the facility medical staff of the inmate’s illness or injury. Notify the area supervisor of the inmate’s illness or injury.”FINAL REPORT OF CARLOS MERCADO PAGE 11 2 The Department shall direct correctional staff to comply with the NYC DOC Operation Order entitled Processing and Monitoring New Admissions #16/89, (K) which is summarized as: From the time of admission to (the) Department ('s) custody to the time housed in a Rikers Island facility. Timeframe (for) DOC/ Medical processing - 4 hours; Housing assignment - 4 hours. The Department shall instruct correctional staff to document inmates’ medical emergencies and document the correct times of AMKC Main Clinic inmate arrivals on the New Admission Log Book. 4. The Department shall direct that the Final Investigative Case Report on Mercado’s death to be completed and the direct disciplinary actions be instituted against the correction officers who ignored Mercado’s statements of diabetes and did not refer him to medical staff. Some of signs that indicated Mercado’s physical distress were his extreme vomiting, shortness of breath, and an unsteady gait with poor balance which at one point caused Mercado to fall out of a cell. To the Deputy Commissioner, Division of Health Care Access and Improvement, NYC Department of Health and Mental Hygiene and the Director of NYC Health And Hospital Corporatiot ‘The Deputy Commissioner shall direct the private contractor vendor, Corizon Correctional Healthcare, Inc. to cooperate with the NYC DOC Investigator Division for the purpose of completing the investigation of Mercado’s death. To the New York State Department of Education, Office of Professional Discipline (OPD): The Department shall investigate of actions of Registered Nurse A.D. regarding the failure to conduct a nursing assessment of Carlos Mercado when summoned by a correctional officer and failure to make a medical record of such encounter.PINAL REPORT OF CARLOS MERCADO PAGE 12 WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner, NYS Commission of Correction, Alfred E. Smith Office Building, 12" Floor, in the City of Albany, New York 12210 this 16‘ day of ser OE ote thsie Ln Mo, phéliis Harrison-Ross, Commissioner PH-JJ:ams 13-M-125 12/14 cc: Eric Berliner, Deputy Commissioner, Health Services Unit Heidi Grossman, General Counsel/Acting Chief of Staff Sonia Angell, M.D., Deputy Commissioner Correctional Health Services, NYC Department of Health & Mental Hygiene George Axelrod, Deputy Executive Director NYC Department of Health & Mental Hygiene Homer Venters, Assistant CommissionerNEW YORK STATE COMMISSION OF CORRECTION In the Matter of the Death of Mark Perlov, an inmate of the Anna M. Kross Center 70: Commissioner Dora Schriro NYC Department of Correction 75-20 Astoria Blvd, Ste. 100 Bast Elmhurst, NY 11370 FINAL REPORT OF THE NEW YORK STATE COMMISSION OF CORRECTIONFINAL REPORT OF MARK PERLOV PAGE 2 GREETINGS: WHEREAS, tho Medical Review Board has reported to the NYS Commission of Correction pursuant to Correction Law, section 47(1) (a), zegarding the death of Mark Perlov who died on August 25, 2010 while an inmate in the custody of the NYC Department of Correction at the Anna M. Kross Center, ‘the Commission has determined that the following final report be issued. FINDINGS: 1 Mark Perlov was a 43 year old male who died on 8/25/10 from suicidal hanging while in the custody of the New York City Department of Correction (N¥CDOG) at the Anna M. Kross Center (AMKC) Mark Perlov was born in Manhattan, NY. His mother was déceascd and his father reportedly lived in Westchester County. He was a high school graduate with some college completed. He was not married and had no children. Perlov did not roport any racent work history and was reported to be honeless at the tine of hie arrest. on 6/8/10, Mark Porlov was arrested by the New York Police Department (PD) for Burglary, Criminal Possession of stolen Property, and Possession of Burglary Tools. He was arraigned in New York City Criminal Court Part F and remanded to the NYCDOC on $35,000 bail. He. was transferred to AMKC on 6/9/10.FINAL REPORT OF MARK PERLOV PAGE 3 12. n 7/8/10, Perlov was involved in a fight with another inmate. Perlov reportedly punched the innate in the eve |3 3 i 3 5 EI i FFINAL REPORT OF MARK PERLOV PAGE 5 an. 32. on 8/24/10, Perlov was transferred from Quad 4 to Quad Lower 11, coli #18 in AMKC, On 6/25/10, Officer E.M. was assigned supervision of Quad Lower 9 and 11 for the 3:00 a.m. to 12:00 p.m. tour. Officer E.M. reported seeing Perlov in his cell at approximately 6:30 a.m. lying on his bed. Officer B.M. then was relieved for a break at approximately 7:00 a.m. At approximately @:00 a.m., Officer E.M. returned to the Quad Lower 9 and 11 post. At 8:30 a.m., she reported conducting a tour of the 9 side of the unit. Rounds for the 9 side were signed for in the logbook by Officer E.M, at 8:30, 9:00, and 9:30 a.m, stating “tour of the area, all appears normal." It was reported to Commission staff during the investigation from Officer E.M. that she was monitoring an inmate situation on the 9 side and was not able to conduct a round on the 11 side, however, there is no notation of such in the logbook. A review of the 11 side logbook shows a tour logged in by Captain K.L. at 8:58 a.m. and then tours completed at 8:45, 9:15, 9:45 a.m. stating “tour of area, all appears normal.” OfficerFINAL REPORT OF MARK PERLOV PAGE 6 33. 34. 35 36. 37 38. 39 E.M. stated to Commission staff during the investigation that she did not begin a tour of the 11 side until approximately 9:30 a.m. There was no reported round made on the 11 side between 8:00 a.m. and 9:30 a.m, by Officer E.M. indicating that false logbook entries were made between 8:30 a.m. and 9:30 a.m. These cited instancos are in violation of 9 NYCRR 87003.2(c) (2) and $7003.3(5) (6) (-4v). At approximately 9:45 a.m., Officer B.M., while conducting the tour of Quad 11, approached Perlov’s cell and cbserved he had bed sheets covering the cell door. Officer B.M. pulled the sheets away and then observed Perlov was lying on the floor of his cell face down with towels and sheets wrapped around his neck. Perlov was positioned under the cell desk and had affixed the ligature to the desk frane. Officer E.M, notified the A post officer, Officer M.R., to open the cell door. Officer E.M. entered the cell to try and remove the sheets fron Perlov’s neck with the 911 tool but could not. Officer E.M. told Officer M.B. to notify the area supervisor and medical staff. Officer M.B. made the notifications at approximately 9:31 a.m. and respondad down to assist Officer E.M. Officer MB. took over removing Perlov’s ligature. Officer E.M. took the A post key to let responding medical staff in the unit. Captain K.L. and Captain K.N. both responded to the report of a medical jmergency in Quad Lower 11. Captain K.L. entered cell #18 and found Perlov on the floor with a towel around his neck. Ofsicer M.B. was in the process of trying to get Perlov turned over and the ligature renoved. Captain K.N. entered the coll, turned Perlov over, and began CPR, Captain K.N. performed chest comprogsions while Officer M.B. conducted rescue breathing. A radio transmission was received by the Main Clinic Post officer at approximately 9:43 a.m. that there was a medical emergency in Quad Lower 11. Medical staff consisting of Dr. Y.P. and PA F.N. departed the clinic to the emergency. Drs. A.H. and J.R soon followad afterwards A search of Porlov’s cell revealed a suicide note addressed to his father and two other fonales. RECOMMENDATIONS: TO THE COMMISSIONER OF THE NYC DEPARTMENT OF CORRECTION: The Department shall conduct an inquiry into the conduct of the officer (E.M.) who failed to conduct a supervisory tour of the housing unit in ‘compliance with 9 NYCRR §7003.2(c) (2) and who falsified the housing area log in violation of §7003.3(3) (6) (i-iv)FINAL REPORT OF MARK PERLOV PAGE 7 ‘the Department should conduct a joint review with Prion Health Sexvices, Inc. of instances in which patients are not produced for appointments to identify the xeasons therefor and to identify procedures that will minimize innate production for appointments. 7O__THE DEPUTY COMMISSIONER, DIVISION OF HEALTH CARE ACCESS _AND TMPROVEMENT, NYG DEPARTMENT OF HEALTH AND MENTAL HYGIENE: 1. The Division should conduct 2 quality assurance roviow with the eychiatrist (Dz D.C 2. The. Division should conduct @ joint review with NYCDOC of instances in which patients are not produced for appointments to identify the reasons therefor and to identify procedures that will minimize inmate production for appointments. WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner, NYS Commission of Correction, 80 Wolf Road, 4" Floor, in the City of Albany, New York 12205 this 20" day of Decauber, 2011. 4 Bhyfiis Warcison-Ross, M.D. Conmissioner PH-Rim} 10-4121 9/at cc: Eric Berliner, Executive Director of Health Services Thomas Bergdall, General Counsel Sara Taylor, Chief of staff Amanda Parsons, Deputy Commissioner Correctional Health Services, N¥C Department of Health & Mental Hygiene George Axelrod, Deputy Executive Director, NYC Department ef Health & Mental HygieneNEW YORK STATE COMMISSION OF CORRECTION In the Matter of the Death : FINAL REPORT OF THE NEN YORK STATE COMMISSION of Bradley Ballard, an inmate of OF CORRECTION the Anna M. Kross Center TO: Commissioner Joseph Ponte NYC Department of Correction 75-20 Astoria Blvd, ‘Ste. 100 East Elmhurst, NY 11370FINAL REPORT OF BRADLEY BALLARD PAGE 2 GREETING WHEREAS, the Medical Review Board has reported to the NYS Commission of Correction pursuant to Correction Law, section 47(1)(d), regarding the death of Bradley Ballard who died on September 11, 2013, while an inmate in the custody of the NYC Department of Correction at the Anna M. Kross Center, the Commission has determined that the following final report be issued. SUMMATION FINDIN 1 Bradley Ballard was a 39-year-old African-American male who died on 9/11/13, at 1:31 a.m., while in the custody of the New York City Department of Correction (NYC DOC) at the Anna M. Kross Center (AMKC). Ballard was discovered in the evening on 9/10/13, to be lying in his cell naked, unresponsive, covered with urine and feces, and in critical condition. Ballard went into his cell and was pronounced dead at Elmhurst Hospital. Ballard died from diabetic ketoacidosis (DKA) (serum glucose 1,200mg%)due to withholding of his diabetes medications complicated by sepsis due to severe tissue necrosis of his genitals as a result of a self-mutilation. Between 8/7/13, and 9/5/13, Ballard should have been encountered for finger sticks 58 times but was actually seen on only ten (10) occasions. The medical and mental health care provided to Ballard by NYC DOC’s contracted medical provider, Corizon Inc. during Ballard’s course of incarceration, was so incompetent and inadequate as to shock the conscience as was his care, custody and safekeeping by NYC DOC uniformed staff, lapses that violated NYS Correction Law and were directly implicated in his death. Had Ballard received adequate and appropriate medical and mental health care and supervision and intervention when he became critically ill, his death would have been prevented. The events that lead to Ballard’s death were directly caused by the compounded failures of NYC DOC and its contracted medical provider, Corizon Inc., to maintain care, custody, and safekeeping of this inmate in accordance with New York State Correction Law, NYS Minimum Standards and Regulations for Management of County Jails and Penitentiaries, and Ballard’s civil rights. Bradley Ballard was keeplocked in his cell for six days prior to his death and was denied access to his life-supporting prescribed medications, denied access to medical and psychiatric care, denied access to essential mandated services such as showers and exercise periods, and denied running water for his cell. Ballard’s deteriorating health and mental status was observed over the course of this six day period by many NYC DOC officers, supervisors, and administrators, together with clinicians employed by Corizon Inc., who showed deliberate indifference to Ballard’s serious medical needs by collectivelyGE T OF BRADLEY ide the very basics of medical care and failing to take approp tion in a timely manner to a medical emergency which resulted in Ballard’s death. The assertion by the NYC Department of and Mental Hygiene in its response to the Medical Revie ninary Report to the effect that Ballard acidosis secondary to genital stricture is associated with DXA, and in this extreme as to have 1 stricture having h not contributory to es the New York xd’s manner of failing to p: ong. lactic acidosis is cor case, the deceased’s blood unquestionably resulted from DKA, Ba been isolated from his circulation and as su nis lacti is. The Medical Review Board coi City Me iner’s ruling that Bradley Ball death is ar level was si lard!'s ger DINGS RE: BRADLEY BALLARD’ S COUR IN dley Ballard was born in Houston, TX. father is deceased and still resides in Houston. Ballard was the Ballard reported having an abusive childhood m his biological father and stepfather. Ballard had no spouse and no children. Ballard had a from 1990 but no steady work history. Ballard reported alcohol and cocaine use, the most recent use in March, 2013. 1. B his mother reporte: ungest of three boyadley was from Ha County, Texas by NYS poccs - Division of Parole and directly admitted to Otis Bantum Correctional Center on 6/13/13. Ballard was housed in 3-West as a new admission/general population erred to el Vierno Centera tht 1 sa 5 m at clinic to determin th or to accordingly. This repres ard me: nd 11. Ballard was involved with a use of force by DOC officers in the evening on 6/30/13. Ballard had begun to display radical changes in his behavior and became assaultive. At 7:00 a.m., on 7/1/13, Ballard was seen in the medic. an injury assessment.personne Kross Center's (Jocumenté i n fo of the current me a regimen SUuprThe lack of follow up for known chronic condition after Ballard had nissed appgigtmentc and was present in the clinic for a benign complaint |, constitutes uncoordinated and incompeten medical care /13, Ballard was involved in a fight whereby to have thrown hot water on two other innates. J on 8/2 reported13, Ballard was involved in fight with an inmate in his lard and his assailant refused to stop fighting ficers and chemical agents (OC) was S nousing area orn contrary, comprehensive c r assessm s medic efficacy was documented by any psychiatric provider in relation to changes in behavior in the face of subtherapeutic and otherwise ineffective therapy not authorized by a physician. This represents inadequate psychiatric care by Corizon, Inc. a7. icici? Be rel a placed in an individual cel hadence that view of ica. rE was completed prior to renewing his medica’ a ropresents inadequate medical care. NYC DOH-MH’s asse was appropriate for this patient tion that Mr. Ballard d from being di J of ne for 11 days, a severe Which there is no explanation and for which no defense is 40 The lack of coordinated care for anc the mrsnanagenen Bariarc’s MMMM vepresents y negligent medical care Corizon, Ines eneangered Ballara’s Life and subsequently cause death. The Medical Review Board found evidence that LPN A.D. created a false entry in Ballard’s medical chart. Recorded video camera footage for the 24 hour period covering 9/6/13 (as cited in Finding # 18 in Part II of this report) revealed no med: staff were present at Ballard’s cell, and Ballard was not from the cell at any time. NYC Department of Health Hygiene in its response to the Medical Review Board's Report offered that LPN A.D. had taken a written data from another patient, and in error, entered it in Ballard’s chart completely inconsistent with Ballard'sFINAL REPORT OF BRADLEY BALLARD PAGE 12 history and is apparent that a proper and thorough chart review was not completed by Dr. N.G. 43. There were no further documented encounters for Ballard with medical or mental health staff from 9/3/13 through the terminal event, eight (8) days later. RECOMMENDATIONS OF THE MEDICAL REVIEW BOARD RE: BRADLE: OF INCARCERATION: BALLARD! $ COURSE S_AND TO_THE DEPUTY _COMi IMPROVEMENT, NYC DEPARTMENT STONER, DIVISION OF HEALTH CARE AC F HEALTH AND MENTAL HYGIENE: 1. That the Division shall conduct a quality assurance review of the pegchistric care provided by NP RA. to Ballard on 8/15/13. The Fetus gf che zesiew should inch therapeutic. dosage of 1 aie ec cscscs Nailin” 3° S800 Oe Ero wt adcunented supporting clinical inareaeron,, counte soto the reported efficacy of the current medication and contrary to a prior order of a reviewing psychiatrist. 2, That the Division shall conduct an inquiry with the AMKC clinic director as to why Ballard did not receive the laboratory study as ordered for 8/12/13. A comprehensive review Shall also be undertaken to examine the laboratory requisition procedure to determine the frequency and circumstances of dropped laboratory orders by Corizon, Inc. Ballard was dropped on 8/30/13, and was not renewed without c. inical 4, The Division shall conduct an inquiry with the AMKC clinic director as to why Ballard was not produced for five sepapay outs for specialty clinics for purpose of managing his and why follow up explanation by senior Corizon, Inc. and DOC staff did not occur. Further inquiry shall include how providers failed to recognize Ballard was in need of being seen in a specialty clinic when Ballard was readily available at the medical clinic on 8/26/13 for a non-acute complaint The Division shall conduct an inquiry into the psychiatric care provided to Ballard by Dr. A.G. to include the failure to review Ballard’s course of changing behavior, his having been referred for causing self-injury, and the failure to correlate this to his change in medication two weeks prior. The Division shall conduct a quality assurance review with Dr. ¥.P. who failed to thoroughly review Ballard’s medical chart prior toFINAL REPORT OF BRADLEY BALLARD PAGE 13 renewing a medication on 9/4/13 where g the fact that Ealiard’was without @ curren order oil The Division shall conduct @ quality assurance review with Dr. N.6. who conducted a transfer chart review of Ballard on 9/10/13 and failed to properly mote his mental health history and current medieations. A representative sample of patient chart reviews by Dr. NG. shall be conducted to illuminate his practice pattern in this regard. 8 The Deputy Commissioner shall complete all recommended inquiries and quality assurance reviews and provide a comprehensive report to the Medical Review Board with findings and corrective actions taken on before November 21, 2014 The Deputy Commissioner shall conduct an investigation into the conduct of LPN A.D. who entered incorrect medical data for Ballard on 9/6/13. Administrative action should be taken at the completion of the investigation if found to be in violation of policy and procedures. FINDINGS RE: TERMINAL EVEN’ 14. on 9/3/13, Ballard vas transferred to AMKC’s Quad tover + SM IS cc ecco into coll #23. On 88/4, Dallard was lee owe of his cell for programming and social interaction on the housing unit. 45. Video Footage of Quad Lower 4 on 9/4/13, revealed the following: * At 12:15 p.m., Ballard is in the day room for Quad Lower 4 socializing with other inmates. * At 1:35 p.m., Ballard is observed dancing in the day room. Ballard stops and stands still holding his hands upward as if he were praying. * At 1:50 p.m., Ballard is observed again dancing in the day room. * At 1:54 p.m., Ballard is observed removing his shirt. * At 1:56 p.m., Ballard is observed twisting his shirt into a phallic symbol and making a lewd gesture. The gesture was reported to have been done toward a female correction officer. * At 1:57 p.m., Ballard puts his shirt back on. + At 2:24 p.m., Ballard is observed holding his hands upward again as if in prayer. * At 2:50 p.m., officers confront Ballard in the day room.FINAL REPORT OF BRADLEY BALLARD PAGE 14 46. aq. * At 2:53 p.m., Ballard is secured in handcuffs by two officers and a captain and escorted back to his cell © At 2:55 p.m., Ballard is secured in his cell. There is no notation in the housing area logbook about Ballard being keeplocked in his cell pending disciplinary action or any entry about any disciplinary infraction. This in violation of 9 NYCRR §7003.3 (3) (6) (i - iv) that requires “any significant events and activities occurring during supervision” be properly documented in the Logbook. There is no written misbehavior report -documenting for what infraction Ballard was being administratively segregated and no documentation authorizing Ballard’s administrative segregation pending a disciplinary hearing. These are in violation of 9 NYCRR § 7006.4 (a) (b) (1-5) Misbehavior reports which states: (a) When a staff member has a reasonable belief that an inmate has committed an offense that constitutes a violation of the facility's rules of inmate conduct, and such violation is not informally resolved, such staff member shall prepare a written misbehavior report. (b) Each misbehavior report shall include: (2) the name(s) of the inmate(s) charged with the misconduct; (2) the date, time and place of occurrence; (3) a description of the incident or behavior involved and the rule(s) allegedly violated; (4) the date and time the report is written; (5) the reporting staff member's printed name and signature. and §7006.7 (a) (b)(c) Administrative segregation pending a disciplinary hearing which states: (a) An inmate who threatens the safety, security, and good order of the facility may be immediately confined in a cell or room pending a disciplinary hearing and may be retained in administrative segregation until the completion of the disciplinary process. (b) Within 24 hours of such confinement, the inmate shall be provided with a written statement setting forth the reason(s) for such confinement. Upon receipt of the written statement, the inmate shall be provided with an opportunity to respond to such statement orally or in writing to the chief administrative officer.FINAL REPORT OF BRADLEY BALLARD PAGE 15 48. 43. 50. 51. (c) The chief administrative officer shall review the administrative confinement within 24 hours of such confinement in order to determine if continued confinement is warranted Video Footage of Quad Lower 4 on 9/4/13, revealed the following: * At 4:57 p.m., a meal tray is delivered to Ballard’s cell. * At 5:01 p.m., a beverage container is delivered to Ballard’s cell. © At 11:57 p.m., garbage is observed being pushed out from underneath the cell door by Ballard. Video Footage of Quad Lower 4 on 9/5/13, revealed the following: * At 12:08 a.m., Ballard is flooding his cell as water is seen coming out from under his cell door. No notation is made in the logbook regarding this incident. * At 1:03 a.m., a captain is observed at Ballard’s cell. * At 5:57 a.m., the breakfast meal is served but not delivered to Ballard. There is no notation in the logbook that Ballard refused the meal. This is in violation of NYS Correction Law Article 20 $500 - K Treatment of Inmates that applies Article 6 $137 (6) (a) and states: The inmate shall be supplied with a sufficient quantity of wholesome and nutritious food, provided; however, that such food need not be the same as the food supplied to inmates who are participating in programs of the facility. :50 p.m., Ballard appears to be banging on his cell door. An officer stops at his cell and speaks to him. At 1:03 p.m., Ballard receives a lunch meal tray. At 4:48 p.m., a mental health clinician appears to stop at Ballard’s cell and speak with him. The clinician is at Ballard’s cell for less than one minute. At 6:59 p.m., a dinner meal tray is delivered to Ballard’s cell. © At 7:24 p.m., a mental health clinician is observed making rounds on the unit. The clinician does not stop to speak to Ballard. In the 24-hour period covering 9/5/13, Ballard did not receive any medications delivered to his cell despite current orders for Metformin and Seroquel. During the same 24-hour period of 9/5/13, Ballard was not provided with access to a shower in violation 9 NYCRR §7005.2 (a) Showers which states:PINAL REPORT OF BRADLEY BALLARD PAGE 16 52. 53. 94. Hot showers shall be made available to all prisoners daily. Consistent with facility health requirements, the chief administrative officer may require prisoners to shower periodically. During the 24-hour period covering 9/5/13, Ballard was not afforded any access to exercise in violation of 9 NYCRR §7028.2 (b) (1,2) Exercise periods which states: All inmates who have completed the classification process pursuant to sections 7013.7 and 7013.8 of this Title, except as otherwise provided in subdivision (c) of this section or section 7028.6 of this Part, shall be entitled to exercise periods which, at the discretion of the chief administrative officer, shall consist of: (1) at least 1-1/2 hours during each of five days per week; or (2) at least one hour seven days a week. No specific written determination was made to deny Ballard’s exercise access based on any threat to the safety and security of the facility or of others in violation of 9 NYCRR 7028.6 (a) (b) which states: (a) The exercise periods of a prisoner may be denied, revoked, or limited when it is determined that such exercise period would cause a threat to the safety, security, or good order of the facility, or the safety, security, or health of the prisoner or other prisoners. (b) Any determination to deny, revoke, or limit a prisoner's exercise period pursuant to this section shall be made by the chief administrative officer in writing, and shall state the specific facts and reasons underlying such determination. A copy of this determination shall be given to the prisoner. During the 24-hour period covering 9/5/13, Ballard was not seen by a mental health clinician. This is in direct violation of NYC Department of Health and Mental Hygiene Correctional Health Services Policy: MH 26 Mental Observation Unit which states: The Mental Health Unit Chief or their designee shall maintain a daily account of the inmates on the mental observation unit and shall track visits to each patient. Mental health staff shall conduct rounds on the MO Unit seven (7) days a week. The rounds conducted will be documented in the “Rounds Logbook”. Ballard was also not seen by any staff from medical during the 24FINAL REPORT OF BRADLEY BALLARD PAGE 17 55. 56. 57. hours covering 9/5/13, which is in violation of N¥S Correction Law Article 20 §500 ~ K Treatment of Inmates that applies Article 6 $137 (6) (c) which states: Where such confinement is for a period in excess of twenty- four hours, the superintendent shall arrange for the facility health services director, or a registered nurse or physician's associate approved. by the facility health services director to visit such inmate at the expiration of twenty-four hours and at least once in every twenty-four hour period thereafter, during the period of such confinement, to examine into the state of health of the inmate, and the superintendent shall give full consideration to any recommendation that may be made by the facility health services director for measures with respect to dietary needs or conditions of confinement of such inmate required to maintain the health of such inmate. Video Footage of Quad Lower 4 on 9/6/13, revealed the following: It is noted at At 2:49 a.m., an officer and a captain are at Ballard’s cell. At 3:23 a.m., Ballard is at his cell door and an officer responds. At 3:24 a.m., the officer leaves from in front of Ballard’s cell. At 4:47 a.m., an officer is at Ballard’s cell. :30 a.m. that an officer stationed at a constant supervision post at cell #14 for inmate M.H., abandons his post until 6:22 a.m, This is in violation 9 N¥CRR §7003.2 (d) (1,2) Security and Supervision which states: Constant supervision shall mean the uninterrupted personal visual observation of prisoners by facility staff responsible for the care and custody of such prisoners without the aid of any electrical or mechanical surveillance devices. Facility staff shall provide continuous and direct supervision by permanently occupying an established post in close proximity to the prisoners under supervision which shall provide staff with: (2) a continuous clear view of all prisoners under supervision; and (2) the ability to immediately and directly intervene in response to situations or behavior observed which threaten the health or safety or prisoners of the good order of the facility. Video Footage of Quad Lower 4 on 9/6/13, revealed the following:FINAL REPORT OF BRADLEY BALLARD PAGE 18 58. 59. 60. * At 6:13 a.m., the breakfast meal is delivered to Ballard’s cell. © At 7:34 a.m., the constant supervision post at cell #14 is abandoned until 8:46 am in violation of 9 NYCRR §7003.2 (4) (1,2). * At 9:31 a.m., Ballard is observed to be flooding his cell © At 9:33 a.m., an officer is at Ballard’s cell At 10:24 a.m., Ballard is still flooding his cell. Maintenance staff is observed shutting off the water to Ballard’s cell. There is no notation in the logbook as to Ballard’s water being shut off in violation of 9 NYCRR §7003.3 (J) (6) (i — iv). Additionally, there is no documentation as to who authorized the water deprivation order, how long it was to be in effect, and who was to review it to see if it was still warranted. Although it may be necessary to shut off water to an occupied cell when an inmate is becoming disruptive and flooding the cell, affecting the safety and order of the facility, it must be periodically turned back on for the purposes of flushing the toilet, access to drinking water, and otherwise providing proper sanitation. Ballard’s water remained turned off and unchecked for over four and half days through the terminal event. This is in blatant violation of NYS Correction Law Article 20 §500 - K Treatment of Inmates that applies Article 6 §137 (6) (b) which state Adequate sanitary and other conditions required for the health of the inmate shall be maintained. Video Footage of Quad Lower 4 on 9/6/13, revealed the following: * At 1:14 p.m., the lunch meal was delivered to Ballard's cell. © At 1:25 p.m., an officer opens Ballard’s cell door. Ballard tosses out food trays and a cup * At 5:48 p.m., the dinner meal tray was delivered to Ballard’s cell. * At 7:00 p.m., a mental health clinician conducts rounds on the unit. The clinician looks in Ballard’s cell but does not engage in any conversation with him. * At 7:22 p.m., rounds were conducted by an Assistant Deputy Warden (ADH; name illegible in logbook). The ADW makes motions that indicate that the area near Ballard’s cell was malodorous. There were no orders documented in the logbook to address the situation. The ADW failed to make a command decision and take proper action of an obvious health and safety situation with Ballard’s cell which had water shut off to it for over 24 hours. During the 24-hour period covering 9/6/13:FINAL REPORT OF 61. 62. BRADLEY BALLARD PAGE 19 Ballard did not have any medications delivered to his cell nor was he seen by any staff from medical which is in violation of N¥S Correction Law Article 20 §500 - K Treatment of Inmates that applies Article 6 §137 (6) (c). b. Ballard was not provided with access to a shower in violation 9 NYCRR §7005.2 (a). Ballard was not afforded any access to exercise in violation of 9 NYCRR §7028.2 (b)(1,2). Also, no specific written determination was made, to deny Ballard’s exercise access based on any threat to the safety, and security of the facility or others in violation of 9 N¥CRR 7028.6 (a) (b). Ballard was not actually seen by a mental health clinician during mental health rounds. This is in direct violation of NYC Department of Health and Mental Hygiene Correctional Health Services Policy: MH 26. Video Footage of Quad Lower 4 on 9/7/13, revealed the following: * At 5:54 a.m., it appears that Ballard refuses his breakfast meal tray. No tray is delivered. * At 8:17 a.m., an officer is seen utilizing a deodorizer spray in front of cell #23. Nothing more is noted or documented to address the problem. © At 12:22 p.m., Ballard’s lunch meal tray is delivered. © At 12:59 p.m., a mental health clinician stops by Ballard’s cell and speaks with him briefly. The clinician leaves the area within the minute. * At 5:00 p.m., Ballard’s dinner meal tray is delivered. During the 24-hour period covering 9/7/13: Ballard did not have any medications delivered to his cell nor was he seen by any staff from medical which is in violation of N¥S Correction Law Article 20 §500 - K Treatment of Inmates that applies Article 6 $137 (6) (c). Ballard was not provided with access to a shower in violation 9 NYCRR §7005.2 (a). Ballard was not afforded any access to exercise in violation of 9 NYCRR §7028.2 (b)(1,2) Also, no specific written determination was made to deny Ballard’s exercise access based on any threat to the safety and security of the facility or others in violation of 9 NYCRR 7028.6 (a) (b). Although Ballard was seen by a mental health clinician, the roundFINAL REPORT OF BRADLEY BALLARD PAGE 20 63. 64. conducted was observed to be a “drive-by” assessment that took less than one minute. This is insufficient to properly assess the daily status of a patient with serious persistent mental illness. The water to Ballard’s cell remained shut off continuously in violation o£ NYS Correction Law Article 20 $500 - K Treatment of Inmates that applies Article 6 §137 (6) (b) which states: Adequate sanitary and other conditions required for the health of the inmate shall be maintained. Video Footage of Quad Lower 4 on 9/8/13, revealed the following: © At 12:22 a.m., an officer is seen speaking to Ballard at his cell. © At 5:28 a.m., a breakfast meal tray is delivered to Ballard’s cell. eat 4 a.m., an officer is observed at Ballard’s cell speaking to him. * At 7:53 a.m., an officer is observed at Ballard’s cell speaking to him. * At 8:31 a.m., an officer delivers a drink carton to Ballard’s cell. * At 9:58 a.m., a captain is observed at Ballard’s cell speaking to him. * At 1:00 p.m., the lunch meal is delivered to Ballard’s cell. * At 5:04 p.m., the dinner meal is delivered to Ballard’s cell. * At 7:23 p.m., a mental health clinician was at Ballard’s cell. The Clinician leaves the area by 7:24 p.m. During the 24-hour period covering 9/8/13: Ballard did not have any medications delivered to his cell nor was he seen by any staff from medical which is in violation of NYS Correction Law Article 20 $500 - K Treatment of Inmates that applies Article 6 §137 (6) (c). a Ballard was not provided with access to a shower in violation of 9 NYCRR §7005.2 (a). c. Ballard was not afforded any access to exercise in violation of 9 NYCRR $7028.2 (b)(1,2). Also no specific written determination was made to deny Ballard’s exercise access based on any threat to the safety and security of the facility or others in violation of 9 NYCRR 7028.6 (a) (b) d. Although Ballard was seen by a mental health clinician,FINAL 65. 66. 67. PORT OF BRADLEY BALLARD PAGE 21 the round conducted was observed to be a “drive-by” assessment that took less than one minute. This is insufficient to properly assess the daily status of a patient with persistent mental illness. e. The water to Ballard’s cell remained shut off continuously in violation of NYS Correction Law Article 20 §500 - K Treatment of Inmates that applies Article 6 $137 (6) (b) which state: Adequate sanitary and other conditions required for the health of the inmate shall be maintained. Video Footage of Quad Lower 4 on 9/9/13, revealed the following: © At 2:15 a.m., an officer is observed at Ballard’s cell with a flashlight looking in. The officer is there until 2:17 a.m. The officer does not enter the cell. There is no notation in the logbook as to what the officer was observing. * At 5:37 a.m., an officer delivers a small container (unknown) to Ballard. No actual breakfast meal tray was delivered to Ballard’s cell. * At 6:00 am an officer is at Ballard’s cell with an inmate porter. An item (unknown) is tossed into Ballard’s cell. * At 8:12 a.m., an officer is observed at Ballard’s cell speaking to him. © At 8:19 a.m., food items were delivered to Ballard by Officer c. © At 10:33 a.m., a Captain and an ADW are at Ballard’s cell. Ballard’s cell door is opened and they are speaking to Ballard. Ballard’s cell door is re-secured at 10:34 a.m. There is no notation in the logbook about the visit with Ballard. No action was taken on Ballard’s continued deprivation of running water in his cell by the Captain or ADW in violation of N¥S Correction Law Article 20 $500 ~ K Treatment of Inmates that applies Article 6 §137 (6) (b). * At 12:40 p.m., a lunch meal tray is delivered to Ballard’s cell. While viewing the activity around 12:40 p.m. of meal trays being delivered, the neighboring inmate to Ballard in cell 24 is observed to run out of the cell when it is opened to deliver his food. It was noted from viewing the prior 72 hours of video footage that this inmate had also not been provided access out of his cell for exercise, programs, or a shower. It is indicative from the video footage that the violations noted of 9 N¥CRR §7028.2 (b) (1,2) Exercise, and 9 NYCRR §7005.2 (a) Showers were not specific to Ballard but are pervasive violations in the management of the housing area. Video Footage of Quad Lower 4 on 9/9/13, revealed the following:FINAL REPORT OF BRADLEY BALLARD PAGE 22 68. 69. * At 5:06 p.m., a mental health clinician is observed doing rounds in the unit but Ballard is not seen. + At 5:18 p.m., a dinner meal tray is slid underneath Ballard’ s door to him. + At 6:18 p.m., an officer and an innate delivering what appears to be paperug Re 7:48 pomey, the ADWA and Captain fil are seen touring the unit. At 9:04 p.m., it is observed that medications are delivered to cell 24 next’ door to Ballard. No medications were delivered to Ballard. ° At 10:36 p.m., an officer is observed at Ballard’s cell speaking to him. At 11:56 p.m., an officer is observed at Ballard’s cell speaking to him. at Ballard’s cell During the 24-hour period covering 9/9/13: Ballard did not have any medications delivered to his cell nor was he seen by any staff from medical which is in violation of NYS Correction Law Article 20 $500 - K Treatment of Inmates that applies Article 6 $137 (6) (c)- b. Ballard was not provided with access to a shower in violation of 9 NYCRR §7005.2 (a). Ballard was not afforded any access to exercise in violation of 9 NYCRR §7028.2 (b) (1,2). Also, no specific written determination was made to deny Ballard’s exercise access based on any threat to the safety and security of the facility or others in violation of 9 NYCRR 7028.6 (a) (b). Ballard was not actually seen by a mental health clinician during mental health rounds. This is in direct violation of NYC Department of Health, and Mental Hygiene Correctional Health Services Policy: MH 26. The water to Ballard’s cell remained shut off continuously in violation of N¥S Correction Law Article 20 $500 ~ K Treatment of Inmates that applies Article 6 $137 (6) (b) which states: Adequate sanitary and other conditions required for the health of the inmate shall be maintained. Video Footage of Quad Lower 4 on 9/10/13, revealed the following: Review of the video footage beginning on 9/10/13, revealed that the constant supervision post at cell #14 for inmate M.H. is abandoned multiple times. From 1:29 a.m., to 1:37 a.m., (8 a minutes), from 1:37 a.m. to 2:13 a.m. (36 minutes), and fromFINAL REPORT OF BRADLEY BALLARD PAGE 23 70. nn. 72. 2:14 a.m. to 2:58 a.m. (44 minutes). These are all violations of 9 NYCRR §7003.2 (4) (1,2) Security and Supervision. b. Between 2:15 a.m. and 3:15 a.m., no general supervisory tour of the housing area was conducted by the assigned officer Officerf was assigned as the “C" post officer for the 11:00 p.m. to the 7:31 a.m. tour. Officer [J made false entries into the housing logbook by signing as having conducted tours at 2:30 a.m. and 3:00 a.m. This is also in violation of 9 NYCRR §7003.2 (a) (1,2) (b) which states: (a) Supervisory visit shall mean: (2) a personal visual observation of each individual prisoner by facility staff responsible for the care and custody of such prisoners to monitor their presence and proper conduct; and (2) a personal visual inspection of each occupied individual prisoner housing unit and the area immediately surrounding such housing unit by facility staff responsible for the care and custody of prisoners to ensure the safety, security and good order of the facility. (b) General supervision shall mean the availability to prisoners of facility staff responsible for the care and custody of such prisoners which shall include supervisory visits conducted at 30-minute intervals. At 2:30 a.m., Captain J signed the logbook for the “Cc” post indicating a tour of the area was completed; however, the video revealed that no officers walked through the unit for at least an hour. Captain |) made a false entry in the “Cc” post logbook. At 3:29 a.m., the constant supervision officer left his post and walked down to cell #23 to check on Ballard. The officer remained there until 3:32 a.m. Video Footage of Quad Lower 4 on 9/10/13, revealed the following: + At 3:30 a.m., the ADH toured the area and signed the log book. + From 3:35 acm. to 4:11 a.m, the officer conducting the Constant supervision at cell #14 abandoned his post + Re 3:45 avm. and 4:00 a.m., Officer fil nade two more false entries in the logbook for conducting wounds of the © post. No rounds were observed being conducted on the video. + At 4:55 a.m., a secondugacurity inspection is documented as being done by Officer This is also a falsified logbook entry as no security inspection is observed having been Conducted on the housing area video. © At 5:25 m., the breakfast meal begins being delivered and Captain ff ccaducted @ tour of the area.FINAL REPORT OF BRADLEY BALLARD PAGE 24 73. 74. 15. At 5:29 a.m., Ballard’s cell is opened to deliver a breakfast meal tray. The inmate delivering the tray pulls his shirt up over his nose and mouth indicating that the conditions in Ballard’s cell were grossly unsanitary and malodorous. The meal tray was not taken by Ballard. There was no notation in the logbook about the unsanitary conditions. in Ballard’s cell. Both officers and a supervisor (Captain) were in the immediate area to observe this but took no action. This is a violation of NYS Correction Law Article 20 $500 ~ K Treatment of Inmates that applies Article 6 §137 (6) (b). Video Footage of Quad Lower 4 on 9/10/13, revealed the following: © From 5:14 a.m. to 5:55 a.m., the officer conducting the constant supervision at cell #14 abandoned his post. * From 6:10 a.m. to 7:00 a.m., the officer conducting the constant supervision atecell #14 abandoned his post © At 9:22 a.m., Officer I delivers what appears to be a towel to Ballard’s cell. * At 9:49 a.m., a mental health clinician is seen on the unit but Ballard is not seen. * It is observed that officers walking by Ballard’s cell keep reacting to the malodorous condition coming from it; however, no action is taken. © At 12:46 p.m., an officer and a civilian are observed at Ballard’s cell. * At 12:57 a.m., a lunch meal tray is delivered to Ballard’s cell. + at 3:00 p.m., Officer assumed supervision of the ¢ post for the 3:00/p.m., to 11:00 p.m. tour. ¢ At 4:18 p.m., an inmate standing near Ballard’s cell is observed to be covering his mouth and nose with his shirt. * At 5:28 p.m., a mental health clinician conducts rounds in the unit but does not see Ballard * At 5:35 p.m., an officer opened Ballard’s cell and delivered a dinner meal tray. * At 5:45 p.m., a mental health clinician was observed doing rounds on the unit. Psychiatrist Dr. N. is documented as leaving the housing area at 6:45 p.m. Ballard was not seen by the clinician. Ballard had not had a therapeutic clinical encounter with mental health or psychiatry since 9/2/13. © At 8:21 p.m., an officer is at Ballard’s cell checking on him. An inmate standing nearby can be seen covering nis nose. At 8:25 p.m., an officer and ADW[MJ are observed at Ballard’s cell. The AD kicks at Ballard’s cell and is covering his nose. There was no notation of the obvious unsanitary conditions of Ballard and his Gell in the ADW 8:30 p.m. logbook entry. There were no orders orFINAL REPORT OF BRADLEY BALLARD actions taken to address the situation by the ADW. This is in flagrant violation of NYS Correction Law Article 20 §500 - K Treatment of Inmates that applies Article 6 $137 (6) (b) d’'s cell door. ing at Bal. At 8:35 p.m., an officer is seen kic 77. Re 9:47 pam. while being let out of nis cell for medications, the inmate in cell #24 runs out of the cell and begins to immediatel assault another inmate who was standing in the hallway. officer lll Separates the two inmates and secures them in their individual ells 18. Officer documented in a report that he ‘observed Ballard laying m. and naked in his cell and having difficulty breathing at 9:30 made notification to the A post officer to contact the clinic. The documents that they were not notified until 10:52 clinic, p-m. 79. Dr. A.H. and LPN A.D. responded from the clinic to Quad 4 Lower along with Officer D.C. and two inmate clinic workers. They arrived at Ballard’s cell at 10:56 p.m. -At 10:57 p.m., Ballard’s cell is opened. Neither the medical staff nor the correction officers enter documented he asked Ballard if he could get up on mis own. Ballard tempted to get up but then lay back down and said “I need help.” 80. At 11:01 p.m., two inmate workers entered the cell and wrapped ‘din a blanket. Ballard is then carried out and placed on a gurney. At 11:02 p.m., Dr. A.H. is observed doing a brief assessment, and then Ballard is escorted on the gurney out to the clinic. Inmates should never be employed to assist in med: emergencies. — It incumbent upon responding clinicians to encounter and handle the patient gl. 82.FINAL REPORT 0 BRADLEY BALL 86. During the day on 9/11/13, video footage revealed inmates and staff entering into Ballard’s cell to conduct cleaning. A mattress that appeared to be covered in feces was removed from the cell. The water exved being turned back on in Ballard’s cell at approximately 0 pam. RECOMMENDATIONS RE: TERMINAL EVENT: 10 THE ASSISTANT ATTORNEY GENERAL FOR CIVIL RIGHTS, U.S. DEPARTMENT OF JUSTICE That the Assistant Attorney General for Civil Rights take official notice of the findings of the Medical Review Board in the case cited herein and initiate both individual criminal civil rights investigations and a CRIPA investigation into the New York City Department of Correction’s Anna M. Kross Center and their contracted medical provider, Corizon Inc. TO THE COMMISSIONER OF NYC DEPARTMENT OF CORRECTION: 1. ‘The Commissioner should remove Warden[{l assigned to aMKC during Ballard’s terminal event from all command duties due to failing to maintain a correctional facility in a safe, stable, and humane manner and in violation of NYS Correctional Law and NYS Minimun Standards and Regulations for Management of County Jails and Penitentiaries. 2. The Commissioner shall conduct an investigation into the conduct of the Assistant Deputy Warden who conducted rounds of Ballard’s housing area on 9/6/13, at 7:22 p.m. who failed to take administrative action regarding Ballard’s water beii the completion of the investigation, administra taken for any identified misconduct. 3. The Commissioner shall conduct an investigation into the conduct of the Assistant Deputy Warden and Captain present at Ballard’s cell on 9/9/13, at 10:33 a.m., who violated NYS Correction Law by failing to take administrative action regarding Ballard’s water being turned off. At the completion of the investigation, administrative action shall be taken for any identified misconduct. 4, The Commissioner shall conduct an investigation into the conduct of the Assistant Deputy Warden who was present at Ballard’s cell onFINAL REPORT OF BRADLEY BALLARD PAGE 28 9/10/13, at 8:25 p.m., who failed to take any administrative action regarding Ballard’s obvious unsanitary living conditions and deteriorating health. The Medical Review Board opines that the AD@ should be removed from all supervisory capacity for failing to properly maintain a correctional facility in a safe, stable, and humane manner in accordance with NYS Correction Law and should be the subject of administrative action. 5. The Commissioner shall conduct an investigation apge take administrative action regarding the misconduct of Captain wn: * Made a false entry in the Quad Lower 4 “C” post logbook on 9/10/13, at 2:30 a.m., when video evidence showed no tour was completed. * Violated NYS Correction Law by failing to take appropriate action on 9/10/13 at 5:29 am when the captain was present to observe conditions in Ballard’s cell that were grossly unsanitary and inhumane. 6. The Commissioner shall conduct an investigation and take administrative action regarding the official misconduct of Officer assigned to supervision of Quad Lower 4 housing area on 9/10/13, from 11:00 p.m. to 7:31 a.m., who made false logbook entries for completing supervisory tours when video evidence shows no tour was completed. 7. The Commisgioner shall conduct an investigation into the actions of Officer fi on 9/10/13, who failed to notify the medical clinic Sn a timely manner when Ballard was observed to be in severe distress, At the completion of the investigation, administrative action shall be taken for any identified misconduct. 8 The Commissioner shall immediately revise and implement procedures for water deprivation orders in special housing situations. Revised procedures must include the following: * All deprivation orders must be authorized by an Assistant Deputy Warden or higher ranking official. * Each deprivation order must be reviewed on a daily basis by a Deputy Warden or an Assistance Deputy Warden who is assigned as a watch commander. The review shall be documented by the reviewing Warden. * Deprivation orders may only be in effect for seven (7) days and must be re-authorized and approved by the Warden. * Any deprivation order for “mental health” reasons must be approved by an appropriate clinical professional. * During an active water deprivation order, an inmate’s in cell water must be turned on minimally for ten (10) minutes five (5) times a day as follows: approximately 30 minutes prior toFINAL REPORT OF BRADLEY BALLARD PAGE 29 10. a. 12) 13. 14. To the service of each meal; once during the night shift and once during the evening shift. * All times water is turned on and off must be appropriately documented in the housing area log book. The Commissioner shall review policy and procedures and take administrative action to assure that staff are in compliance with 9 NYCRR § 7006.4 (a) (b) (1-5) Misbehavior reports and §7006.7 (a) (b) (c) Administrative segregation pending a disciplinary hearing. The Commissioner shall review policy and procedures and take administrative action to assure that staff are in compliance with 9 NYCRR §7003.3 (J) (6) (i — iv) that requires “any significant events and activities occurring during supervision” be properly documented in the logbook. The Commissioner shall review policy and procedures and take administrative action to assure that staff are in compliance with 9 NYCRR §7005.2 (a) Showers; in that inmates who are administratively segregated are given access to showers in accordance with the standard requirements. The Commissioner shall review policy and procedures and take administrative action to assure that staff are in compliance with 9 NYCRR §7028.2 (b) (1,2) in that all inmates are provided with daily access to outdoor exercise periods and in compliance with 9 NYCRR 7028.6 (a) (b) in that any determination to revoke or deny an inmate access to exercise must be made by the chief administrative officer with documented justification why such order is in effect. The Commissioner shall review policy and procedures and take administrative action to assure that staff are in compliance with 9 NYCRR §7003.2 (d) (1,2) Security and Supervision in that constant supervision posts are continuously occupied until properly relieved as required by the standard. The Commission shall provide the Medical Review Board with a comprehensive report on all administrative and corrective actions taken on or before November 21, 2014. THE DEPUTY COMMISSIONER, DIVISION OF HEALTH CARE ACCESS AND IMPROVEMENT, NYC DEPARTMENT OF HEALTH AND MENTAL HYGIENE: 1 The Deputy Commissioner should consider and determine whether Corizon, Inc., a business corporation holding itself out as a medical care provider, is fit to continue as a New York City service contractor in light of delivery of flagrantly inadequate, substandard and dangerous medical and mental health care to Bradley Ballard.FINAL REPORT OF BRADLEY BALLARD PAGE 30 The Deputy Commissioner shall review the conduct of all clinic staff assigned to conduct rounds in the mental health observation housing area between 9/4/13, and 9/10/13. The review shall focus on: a. Failure to make daily or adequate contact with mental health clinicians did not occur with Bradley Ballard. b. Failure of clinicians to observe, make notification, and otherwise take appropriate action of a patient who obviously was in extremis. At the completion of the review administrative, action shall be taken for any identified misconduct. The Deputy Commissioner shall conduct a review with the AMKC mental health unit chiefs as to why Ballard was not scheduled clinical appointments as part of his approved treatment plan between 9/3/13, and 9/10/13. At the completion of the review, administrative action shall be taken for any identified misconduct. 4, The Deputy Commissioner shall conduct an inguiry as to the failure to deliver medical and/or psychiatric medications to Ballard between 9/3/13, and 9/10/13. | The Deputy Commissioner shall make administrative changes necessary to assure that patients who are administratively segregated are provided prescribed medications. At the completion of the review, administrative action shall be taken for any identified misconduct. 5. The Deputy Commissioner shall conduct a review of the professional conduct of Dr. A.H. and LPN A.D, who both failed to immediately attend to and remove Ballard. from his cell and inappropriately ordered inmates to perform said rescue measures in their place. The practice of utilizing inmate workers in the medical clinics or at medical emergency scenes to perform work tasks beyond routine sanitation and cleaning or porter duties shall cease immediately. At the completion of the review administrative, action shall be taken for any identified misconduct. 6. The Deputy Commissioner shall conduct a review of the delivery medical services to inmates who are placed in punitive or administrative segregation to assure that inmates are seen by medical staff daily in compliance with NYS Correction Law Article 20 §500 - K Treatment of Inmates that applies Article 6 $137 (6) (c)- The Deputy Commissioner shall provide the Medical Review Board with a comprehensive report of the review findings and corrective actions taken. 7. ‘The Deputy Commissioner shall conduct a thorough review of delivery of mental health services to patients in mental health observation units in AMKC, and throughout the Department's institutions. The Deputy Commissioner shall implement administrative changes necessary to assure compliance with NYC Department of Health and MentalFINAL REPORT OF BRADLEY: BALLARD PAGE 31 Hygiene Correctional Health Services Policy: MH 26 that requires clinicians to conduct daily rounds in the mental health observation units. The Deputy Commissioner shall provide a comprehensive report to the Medical Review Board with findings and corrective actions taken on or before November 21, 2014. WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner, NYS Commission of Correction, Alfred E. Smith Office Building, 80 South Swan Street, 12 Floor, in the City of Albany, New York 12210 this 16" day of December 16, 2014. - lis Ha¥rison-Ross, M.D. Commissioner PH-Co: ams 13-M-142 12/14 cc: Eric Berliner, Deputy Commissioner, Health Services Unit Heidi Grossman, General Counsel/Acting Chief of Staff Sonia Angell, M.D., Deputy Commissioner Division of Prevention and Primary Care Department of Health & Mental Hygiene George Axelrod, Deputy Executive Director, NYC Department of Health & Mental Hygiene Homer Venters, Assistant Commissioner Stuart Delery, Assistant Attorney General For Civil Rights, US Department of JusticeNEW YORK STATE COMMISSION OF CORRECTION In the Matter of the Death PINAL REPORT OF THE NEW YORK STATE COMMISSION OF CORRECTION of Arie Hiraldo, an inmate of the George R. Vierno Center "0: Commissioner Dora Schriro NYC Department of Correction 75-20 Astoria Blvd, Ste. 100 East Elmhurst, NY 11370FINAL REPORT OF ARIS HIRALDO PAGE 2 GREETINGS WHEREAS, the Medical Review Board has reported to the NYS Commission of Correction pursuant to Correction Law, section 47(1)(d), regarding the death of Aris Hiraldo who died on February 3, 2011 while an inmate in the custody of the NYC Department of Correction at the George R. Vierno Center, the Commission has determined that the following final report be issued FINDINGS: 1 Aris Hiraldo was a 24 year old Hispanic male who died on 2/3/11 at 11:22 a.m, from a suicidal hanging while in the custody of the NYC Department of Correction (NYCDOC) at the George R. Vierno Center (GRVC). At 10:25 a.m., Hiraldo was found hanging in his cell by two correction officers after they observed and removed a sheet from his cell window. While incarcerated in the NYCDOC, Hiraldo was under the medical and mental health care of Corizon, Inc., a business corporation holding itself out as a medical care provider on 12/7/10, Hizaldo was admitted to the custody of NYCDOC at the Queens Criminal Court. He was arraigned on an Assault 2 charge with bail set at $10,000 cash or bond. He was additionally charged with a violation of parole, On 12/7/10 at 7:56 p.m., Officer W. completed a Suicide Prevention Screening Form giving Hiraldo a score of one. This was for an affirmative anewer to the question: “Inmate has a history of drug or alcohol abuse.” The officer listed comments of “alcohol” and “appears OK." on 12/8/10, Hiraldo was transferred to the Vernon C. Bain Center (VCBC)FINAL REPORT OF ARIS HIRALDOFINAL REPORT OF ARIS HIRALDO PAGE 4 9 10 on 12/15/10, Hiraido was transferred from VCBC to GRVC and on 12/16/10, he was placed in GRVC General Population cell housing. n 12/27/10 at 3:00 p.m., Hiraldo was observed by security staff going from cell to cell when he was ordered to return to his cell for lock-in for the count. He ignored the officer who ordered him back to his cell. Hiraldo received a disciplinary ticket for his actions and was placed in GRVC, Bldg. 13 in punitive segregated cell #17 as a disciplinary sanction for not following 2 direct order. Hiraldo was given 22 days of punitive housing placement in GRVC. on 1/7/11, Capt. L. was notified by Officer C. that Hiraldo was complaining he was unable to sleep, was depressed, and had demonstrated a radical change in his behavior. A mental health roferral for Hiraldo was completed by Officor C on 1/11/11, Capt. W. was notified by Officer L. that Hizaldo had requested to see mental health bacause of “family issues.”FINAL REPORT OF ARIS HIRALDO 12, 0n 1/19/11, Hixaldo was placed in GRVC Bldg. 11, Bunit) the Mental health Assessment Unit for Infracted Inmates (MHAUII) .FINAL REPORT OF ARIS HIRALDOFINAL REPORT OF ARIS HIRALDO Presently the pharmacy technicians’ practice an New York regulated by license or certification by the NYS Department of Education.FINAL REPORT OF ARIS HIRALDO PAGE 8 21. 22 On 2/3/11 at approximately 10:25 a.m., Officers J.J. and E.F. were en route to another cell when they observed that the window of Hiraldo’s cell door was covered with a sheet. Both officers ordered Hiraldo to uncover his door window to which he did not respond. Officer J.J. opened the door slot and removed the sheet. Both officers stated that they observed Hiraldo standing upright againet the back coll wall suspended, Hiraldo was unresponsive, Officer J.J. called to Officer 0.J., escort officer, to have Officer T.U., the control officer, open Hiraldo’s cell. Officer 0.5 did instruct Officer T.U. to complete such. When the cell door was opened, Officers J.J. and E.F, stated they entered the cell. Officer B.F held up Hizaldo’s body and Officer J.J. cut the nylon-type drawstring from the water sprinkler and from Hiraldo’s neck. This drawstring matched the material used for inmates’ sweat pants, Officer 0.J. arrived and cut the ligature from Hiraldo’s neck. Officer J.J. stated he immediately began chest compressions on Hiraldo. Officer E.¥. obtained and applied the AED The AED ordered CPR which was continued by Officers E.F. and J.J. Capt 8.D. arrived on the scene and ordered the officers to let PAN.P_ in the coll where he assumed CPR. ‘A suicide note was later found in Hiraldo’s cell to notify his mother and girlfriend in the event of his denise. According .to N¥CDOC documentation completed by 1.M., Forensic Investigator, following Hiraldo’s suicide, it was discovered that his nylon sweat pante drawstring was attached to the overhead fire sprinkler water pipe instead of the actual sprinkler head itself. The sprinkler head iteelf is designed to be difficult to attach anything to it and will break off if more than 40 pounds of weight is applied to it. ‘The end of the water pipe the sprinkler is attached to usually has a metal plate (a.k.a, escutcheon plate) covering it to make it flush against the cell wall. This eacutcheon plate covers the water supply pipe to make its access almost impossible. However in this case, the escutcheon plate was tampered with. exposing the water pipe. Hiraldo tied the ligature to the small exposed water pipe, not the sprinkler itself. It was reported to the Commission that NYCDOC has replaced the escutcheon plates in GRVC to RECOMMENDATIONS THE_DEPUTY COMMISSIONER, DIVISION OF HEALTH CARE ACCESS _AND IMPROVEMENT, NYC DEPARTMENT OF HEALTH AND MENTAL HYGIENE AND THE DIRECTOR OF THE NYS HEALTH AND HOSPITAL CORPORATION: ‘The Deputy Commissioner should inquire into Corizon Health's fitness to conduct prescription medication administration and directly observed therapy with needed psychotropic medications at Rikers Island Specifically, the Division should inquire into the current medication delivery/administration credentialing and qualification systen used by Corizon Health, Inc. focusing attention on the use of pharmacy techniciansFINAL REPORT OF ARIS HIRALDO PAGE 9 in directly observed thorapy and other medication administration, generally recognized a nursing care function 2. The Deputy Commissioner should direct NYC Department of Health and Mental Hygiene mental health clinicians employed at the Vernon C. Bain Center to review inmates’ admission/screaning documentation, specifically in the arcas of mental health and social history prior to the completion of a mental health referral. WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner, NYS Commission of Correction, Alfred E. Smith State Office Building, 80 South Swan Street, 12" Floor, in the City of Albany, New York 12210 this 17‘ day of April, 2012 ‘3 Harrison-Ross, Commissioner PH-Rimj asia co: Erie Berliner, Executive Director of Health Sorvices ‘Thomas Bergdall, General Counsel Sara Taylor, Chief of Staff Ananda Parsons, Deputy Commissioner Correctional Health Services, NYC Department of Health & Mental Hygiene George Axelrod, Deputy Executive Director, NYC Department of Health ¢ Mental Hygiene Homer Venters, Assistant CommissionerNEW YORK STATE COMMISSION OF CORRECTION In the Matter of the Death of Jesse Raiirez, an inmate of the Anna M. Kross Center 70: Commissioner Dora Schrizo NYC Department of Correction 78-20 Astoria Blvd, Ste. 100 East Elmhuret, NY 11370 FINAL REPORT OF THE NEW YORK STATE COMMISSION OF CORRECTIONFINAL REPORT OF JESSE RAMIREZ PAGE 2 GREETINGS: WHEREAS, the Medical Review Board has reported to the NYS Commission of Correction pursuant to Correction Law, section 47(1)(d), regarding the death of Jessa Ramirez who died on August 5, 2009 while an inmate in the custody of the NYC Department of Correction at the Anna M. Kross Center, ‘tho, Commission has determined that the following final report be issued. FINDINGS: 1. Jesse Ranizer vas a 34 year old male inaate who died on 8/5/09 from suicidal hanging vhile in the custody of the MYC Department of Correction (srrcooc) av the Anna M. Kease Conver Sanives vas under the wental health Ente of Prigon Haalth Soreisce, Iné.. (PHS, Ino.) a bobinase corporation holding iteal? cut as a medical care ‘provider: Ranires received inedequate mental health care, without continuity of care chacacterized mine (3) conslicting diagnoses, none of which nA oc sosporces by cainten eee —— fantres did aot receive an adequate suicide risk assessuent fron a ental health clinician after belag soferrod by correction staff on the dave of his death Jesse Ramirez was born and raised in the Brooklyn, NY area. He completed the 10 grade but obtained his GED during a prior incarceration | Ramirez was engaged to bo marriod and had ono child. mad ‘a recent family loss when hie father died on 1/18/09. | po esse Ramirez was admitted into NYCDOC custody at AMKC on 2/8/09. He was initially housed on 2/10/09 in Dorm 4 Main for new admissions. On 2/17/09, he was reassignod to Quad 6 Uppor, general population. His last move was to Quad 15 Upper cell #3 on 4/29/09. Ramirez had an uneventful incarceration with no unusual incidents. or disciplinary infractions. iiiFINAL REPORT OF JESSE RAMIREZ 6.FINAL REPORT OF JESSE RAMIREZ PAGE 4 12. his represents an inadequate and inappropriate approach to the patient. : Po Po Pp | a As noted elsewhere herein, this represents a reckless and cavalier diagnostic approach to this patient.FINAL REPORT OF JESSE RAMIREZ PAGE 5 a7 18. 19. 20. 2a On’ 8/5/09, Correction Officer 6.C. was assigned the A post on Quad Upper 13/15 for the 11:00 p.m. to 7:00 a.m. tour. At approximately 5:00 a.m., Officer G.C. observed Ramirez pacing back and forth in the tier. Officer G.C. called Ramirez over and asked him what was going on. Ramirez stated that he was upset due to family problems, was not sleeping well, and was being seen by mental. health for depression. Ramirez began crying and said that his girlfriend didn’t want to be with him anymore. Officer G.C. talked with Ramirez and assured him that she would get him sent down to the mental health clinic as'soon as sho could. Officer G.C, filed a Roferral of Inmates to Mental Health Services form on Ramirez noting “unable to sleep,” “being depressed” and documenting “innate is crying profusely and is continuously stating he needs to speak to a psych.” Officer G.C. was relieved by Officer L.R. at 7:00 a.m. Officer G.C. debriefed Officer L.R. and informed her of the need to have Ramirez sent to the mental health clinic. Officer L.R. made notification to area Captain A. who took responsibility for proceseing the referral.FINAL REPORT OF’ JESSE RAMIREZ PAGE 6 22. 23. 24. 25. 26. 27. 28 29. Ramirez was observed by Officer L.R. to follow his usual housing unit routine for the zest of the morning. After the count, Ramirez went to the dayroon to use the phone. At approximately 9:30 a.m., he went cut to the recreation yard. This represents flagrantly inadequate mental health evaluation and treatment by PHS, Inc. staff. Officer K.P. was assigned supervision of the B post on 8/5/09 for the 3:00 p.m. to 11:00 p.m. tour. Officer L.R, remained the A post officer for overtine. Officer K.P. conducted the count at approximately 3:20 p.m. and had all inmates accounted for. Officer K.P. then conducted a supervisory tour at 3:45 p.m. with all appearing secure. Officer K:P. proceeded to hand out soap supplies to the inmates and began on the 15 side of the unit. At approximately 4:10 p.m., he approached Ramirez’ cell (#3) and observed that a sheet was covering the bars on the cell door. Officer K.P. pulled the sheet away and observed Ramirez on the floor with 2 ligature around his neck and affixed to the cell door Officer K.P. called to Officer L.R. and ordered cell #3 opened. Officer K.P. had difficulty opening the cell door as the sheet was janmed in the door mechanism. Officer K.P. ordered Officer L.R. to release a nearby inmate to assist him. Officer K.P. and an innate finally forced the door open and were able to enter the cell. Ramirez was found seated on the cell floor with hie back against the cell door. Officer K.P. utilized his cut doxn tool to remove the ligature from Ramirez’ neck. Ramizez was checked for a pulse and breathing, found none, and started CPR.FINAL REPORT OF JESSE RAMIREZ PAGE 7 RECOMMENDATIONS TO THE DEPUTY COMMISSIONER, DIVISTON OF WEALTH CARE ACCESS AND, IMPROVEMENT, NYC DEPARTMENT OF HEALTH AND MENTAL HYGIENE: 1, The Division shall requize PHS, Inc. to conduct a comprehensive quality improvement review of the psychiatric care provided to Ramirez: by PHS, Inc. while in the custody of the NYC Department of Correction. Specizically, the review shall focus on: 2, ‘The Division shall require PHS, Inc. to conduct a comprehensive quality improvement review of the mental health care provided to Ramirez by the mental health clinicians while in the custody of the NYC Department of Correction. Specifically, the review shall focus on: a. Verification of continuity for patients who are recommended for Group therapy as part of their treatment plan have been afforded the opportunity to attend such programs; v 3. ‘The Division shall require PHS, Inc. to conduct training for all clinical staff on suicide risk assessment, as approved by the State Commission of Correction 4. "The Deputy Commissioner, in consultation with the Health Commissioner, should ask the NYC Corporation Counsel's Office to inquire into the status of PHS, Inc. to lawfully hold itself out as a medical care provider in Now York State.FINAL REPORT OF JESSE RAMIREZ PAGE 8 WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner, NYS Conmission of Correction, 80 Wolf Road, 4% Floor, in the City of Albany, New York 12205 this 24" day of December, 2010. Commissioner PHRIm} o9-m-114 8/10 ec: Eric Berliner, Executive Director of Health Services Lewis Finkelman, General Counsel Archana Jayaram, Chief of Staff Louise Cohen, Deputy Commissioner Correctional Health Services, NYC Department of Health & Mental Hygiene Robert Berding, Deputy Executive Director Policy and Planning, NYC Department of Health & Mental Hygione George Axelrod, Deputy Executive Director, NYC Department of Health & Mental Hygione‘STATE OF NEWYORK * EXECUTIVE DEPARTMENT ‘STATE COMMISSION OF CORRECTION CHAIRMAN ta : Alfred E. Smith State Office Building Thomas A. Balen , 80 S. Swan Street, 12th Floor Albany, New York 12210-8001 Cowmissioners shee? (618) 485-2346 Phys Harrson-Ross, M.D FAX (618) 485-2467 Tomas J Loughren September 17, 2013 Commissioner Dora schriro NYC Department of Correction 75-20 Astoria Blvd. Ste 100 East Elmhurst NY 11370 Andy Henriquez 349-10-10161 4/7/13 13-M-54 Natural, opce Dear Commissioner Schriro: The above referenced case has been approved by the Medical Review Board and NYS Commission of Correction for closure without further comment. Should you have any questions or comments, please do not hesitate to contact my office. erely, phy{fis Harrison-Ross, Comifissioner & Chairwoman Medical Review Board sii cc: Chief Sara Taylor Eric Berliner, Associate Commissioner, Health Services Unit Thomas Bergdall, General Counsel ‘An Equal Oppertunity/Atfimative Action EmployerSTATE OF NEW YORK * EXECUTIVE DEPARTMENT STATE COMMISSION OF CORRECTION 80 WOLF ROAD, 4TH FLOOR ‘ALBANY, NY 12205-2670 (618) 485-2346 COMMISSIONER FAX (518) 485-2467 Phyfis Harison-Ross, MD. CHAIRMAN Thomas A: Bellein June 21, 2011 Commissioner Brian Fischer NYS Department of Corrections ‘and Community Supervision Building #2 - State Campus Albany, New York 12226 RE: Jose Martinez 09-R-2958 pop: 6/26/10 MRBH: — 10-M-94 cop: Natural FAC: Mohawk CF/Walsh MC Dear Commissioner Fischer: The above referenced case has been approved by the Medical Review Board and NYS Commission of Correction for closure without further comment. Should you have any questions or comments, please do not hesitate to contact my office. Sincerely, tt. hes fate NA) Phyllis Harrison-Ross, M.D. Commissioner and Chairwoman Medical Review Board cc: Superintendent, Mohawk CF Elizabeth Ritter, Assistant Commissioner For Health Services ‘An Eque! Opportunty/Afiomative Action Employer