New York Times
>February 28, 2005
>In City's Jails, Missed Signals Open Way to Season of Suicides
>By PAUL von ZIELBAUER
>
>he warnings were right there in her medical file: a childhood of sexual
>abuse, a diagnosis of manic depression, a suicide attempt at age 13 - all
>noted when Carina Montes arrived at Rikers Island in September 2002.
>
>But none of them, state investigators said, were ever seen by the mental
>health specialist caring for her. He could never track down the file, which
>by December included another troubling fact: Ms. Montes had been placed on
>suicide watch by a jail social worker. Not that the suicide watch was
>terribly reliable; it depended in part on inmates paid 39 cents an hour to
>check on their suicidal peers.
>
>In her five months at Rikers, investigators later discovered, Ms. Montes
>never saw a psychiatrist.
>
>It did not, however, take a psychiatrist to pick up on the alarms she
>sounded near the end, when another inmate saw her tearing bedsheets and
>threatening to kill herself. But the guard who was called had no idea she
>was on suicide watch, did not notice the sheets and never reported the
>incident. Six hours later Ms. Montes was dead, hanging from a sheet tied to
>a ventilation grate.
>
>She was 29. Her offense: shoplifting 30 lipsticks.
>
>The death of Carina Montes was one in a spate of suicides in New York City
>jails in 2003 - six in just six months, more than in any similar stretch
>since 1985. None of these people had been convicted of the charges that put
>them in jail. But in Ms. Montes's death and four of the five others,
>government investigators reached a stinging judgment about one or both of
>the authorities responsible for their safety: Prison Health Services, the
>nation's largest for-profit provider of inmate medical care, and the city
>correction system.
>
>In their reports, investigators faulted a system in which patients' charts
>were missing, alerts about despondent inmates were lost or unheeded, and
>neither medical personnel nor correction officers were properly trained in
>preventing suicide, the leading cause of deaths in American jails.
>
>Prison Health came to Rikers in 2001 after signing a three-year, $254
>million contract and promising to deliver the health care that, compared
>with jails around the country, had helped make New York something of a
>model. And it spoke confidently about tackling the jails' biggest problem:
>how to handle their vast and volatile population of the mentally ill.
>
>The rash of suicides, and nine more during Prison Health's tenure, is one
>measure of the company's uneven and at times troubling record in meeting
>that challenge. But there are others.
>
>Ten psychiatrists with foreign medical degrees were allowed to practice
>without state certification for more than a year after they were supposed
>to have been fired for failing to pass the necessary test. When it finally
>dismissed them on the city's orders in 2003, Prison Health was left with
>about one-third of its full-time psychiatrist positions empty, according to
>city health department figures.
>
>The company has employed five doctors with criminal convictions, including
>one who had been jailed for selling human blood for phony tests to be
>billed to Medicaid. In all, at least 14 doctors who have worked for Prison
>Health have state or federal disciplinary records, among them a
>psychiatrist forbidden to practice in New Jersey after state officials
>blamed him for a patient's fatal drug overdose.
>
>The city's Board of Correction, an oversight agency that sets minimum
>standards for jails, has complained that the company shuffles doctors from
>jail to jail - regardless of where they are needed - to avoid city fines
>and create the illusion that each building is properly staffed.
>
>Many of the 30 current or former Prison Health employees interviewed for
>this article described an effort that, whatever its good intentions,
>frequently fails to adequately treat the mental illnesses that inmates take
>into jail and that follow them back out.
>
>Dr. Douglas Cooper, a psychiatrist who helped supervise mental health
>treatment at the nine Rikers jails until, he says, he quit in frustration
>in 2003, summed up the care as triage, buffeted by a sense of nonstop
>crisis. "The staff does the best they can," he said, "and what's left they
>sweep under the rug."
>
>Prison Health Services, a Nashville-area corporation that bills itself as
>the gold standard of jail health care, says it has done a solid job at
>Rikers and a 10th jail, in Lower Manhattan, caring for more than 100,000
>inmates a year as part of its largest contract among scores across the
>nation.
>
>The company says it has worked hard to find qualified mental health
>specialists, held increases in medical expenses below the national average,
>and saved the city hundreds of thousands of dollars.
>
>There is little dispute that New York City has long insisted on more
>generous jail care than most other places; the suicide rate, even under
>Prison Health, is about half the national average for jails.
>
>Then again, the rate was lower before Prison Health arrived. And in the
>four years since, the rate of suicides at Rikers has been higher than in
>the Los Angeles jail system, the largest and one of the most violent in the
>nation.
>
>Suicides - "hang-ups" in the cold vernacular of the cellblock - have always
>been a jailhouse reality. Because inmates can be resourceful when they set
>out to kill themselves, few people believe that hang-ups can be prevented
>entirely.
>
>Yet they can be a critical barometer of how well medical and correction
>workers are performing an essential task: protecting the vulnerable people
>in their care. In 2003, something broke in the city's jail system, and
>inmates slipped through a bewildering series of cracks.
>
>The first, Jose Cruz, a 48-year-old with H.I.V. and hepatitis, hanged
>himself with a torn bedsheet in January. Even though he had been put on
>suicide watch, correction officers placed him at the end of a cellblock
>where they could not see him from their post, said the State Commission of
>Correction, a panel appointed by the governor to investigate every death in
>jail. The medical staff, the commission noted, had inadequate training in
>preventing suicides.
>
>Thirteen days later, Joseph Hughes, a severely disturbed 24-year-old
>charged with murder, was found hanged four hours after a jail psychiatrist
>wrote that he was no danger to himself. The commission criticized the
>Prison Health staff, saying that Mr. Hughes's history of hallucinations and
>suicidal gestures required closer observation.
>
>Ten days after that, guards cut down Ms. Montes - whose increasing
>desperation had gone unnoticed because her medical file was missing, a
>failing the state commission had already criticized in three other deaths
>during Prison Health's time at Rikers.
>
>After two more suicides, an inmate found James Davis, 43, in his cell in
>June with a bootlace tied around his neck. A doctor, two nurses and two
>guards spent 15 minutes vainly administering C.P.R., unaware that oxygen
>tanks and cardiac medication were nearby, the commission said.
>
>No one thought to unknot the bootlace.
>
>Sixteen days later in a jail-clinic waiting room, a 19-year-old who had
>just returned from a psychiatric evaluation unit managed to hang himself
>from a metal stud in the ceiling, according to the city's Board of
>Correction. Another inmate rescued him while he was still semiconscious.
>
>The city's health department, which now oversees Prison Health's work at
>Rikers, did not contest many of the commission's findings, though it
>defended the work of the psychiatrist who evaluated Mr. Hughes as "not
>inappropriate." Company executives did not respond to the commission's
>reports, saying that they had never read them because city officials did
>not give them copies.Promising Vigilance
>
>The catalog of missteps and missed signals could not have come as a
>complete shock to city officials. Prison Health, after all, had attracted
>criticism around the country for faulty care. And by the time of the
>suicides, the state commission was busy investigating - and blaming -
>Prison Health for inmate deaths in county jails upstate.
>
>The city, though, has insisted that it has the tools to strictly monitor
>the company's performance. The state commission, too, concedes that city
>health officials are more vigilant than any county sheriff.
>
>In fact, soon after the city hired Prison Health in 2001 to salvage jail
>medical services after three tumultuous years under the direction of St.
>Barnabas Hospital, New York City officials battled the company over its
>failure to meet many of the city's most basic clinical standards, and
>threatened to cancel the contract. Now, after a series of changes the city
>ordered - including suicide prevention and oversight measures prompted by
>the 2003 deaths - the health department says care has improved. On Jan. 1,
>it granted the company a $300 million contract for another three years.
>
>"They were the most qualified bidder and they were the most cost
>effective," said Dr. Thomas R. Frieden, the health commissioner, who
>described Prison Health as willing to make improvements when asked. "I
>don't think they're angels."
>
>Others are more skeptical. The city comptroller's office, prompted by
>Prison Health's record and questions raised by The New York Times, asked
>the health department to delay signing the new contract until the
>department addressed concerns, including the Board of Correction's
>complaints of staff shortages at Rikers. Dr. Frieden replied that he saw no
>reason to wait.
>
>But the new contract, according to two state officials, appears to violate
>a state law intended to keep business interests from influencing medical
>care. For example, it fails to ensure that doctors are the ultimate
>overseers of all medical treatment, policy and records. And the contract
>makes the doctors who are actually doing the work at Rikers subcontractors
>to Prison Health, the reverse of what the law requires.
>
>The health department and the company say the contract is legal.
>
>For those who work in the jails, though, the larger issue is the quality of
>the care. Figures provided by the city and St. Barnabas show that the
>clinical staff at Rikers has shrunk by 20 percent since the hospital was in
>charge, despite only a modest decline in the jail population. And several
>doctors and other employees said that mental health care is worse than
>before.
>
>Forever unable to find enough psychiatrists, the company plugs the gap by
>hiring part-timers, as well as psychiatrists from temporary agencies, some
>of whom may never have treated inmates. More than one-third of the mental
>health staff is part time.
>
>Doctors rely on medical charts that have often been out of date or simply
>unavailable because of a shortage of clerks, according to the Board of
>Correction. Psychiatric evaluations and medications have been delayed for
>days or weeks, while inmates sometimes turn violent or suicidal, say the
>board and Prison Health employees.
>
>Of course, the demands on Prison Health and the correction system are
>tremendous. The mentally ill have flooded New York's jails ever since the
>city cracked down a decade ago on lesser crimes like vagrancy. As many as
>one in four of the 14,000 prisoners in city jails on an average day have
>psychological ills, which need close supervision and expensive medicines.
>Often they fake symptoms or attempt suicide as a way of getting special
>treatment. In those ways, a mentally ill inmate jailed on a minor charge
>usually requires closer attention than a career criminal.
>
>"If you asked every jail administrator in the country what kind of criminal
>they want in their jails, everyone would say murderers," said Michael P.
>Jacobson, who was city correction commissioner from 1995 to 1997. " 'Give
>me a nice murderer.' "
>
>Just what society owes these troubled inmates is open to debate. But the
>guilt or innocence of most of them have not been settled. Many are in jail
>on minor charges or because they are unable to make bail. And though most
>leave within a week, many remain for months, and jail is the only place
>where they are likely to get any treatment or medication. The city, in
>fact, is required to create treatment plans for the most seriously
>disturbed upon their release.
>
>Since The Times began last year to request information on the suicides,
>examining jail records and details of the Prison Health contract, city and
>company officials have made changes to prevent more deaths. The rate of
>suicides has slowed; in the 20 months since the spate of six suicides,
>there have been four.
>
>Still, there are lapses. One of those four, David Pennington, 27, killed
>himself in July. Over three days in which he became increasingly
>irrational, correction officers went to the mental health staff for help
>three times, and a doctor even sent him to a psychiatrist, yet Mr.
>Pennington was never examined, state records say.
>
>In a letter, a health department official disputed that finding and
>defended the care Mr. Pennington received. The official said the inmate was
>seen by a psychiatrist the day he died and was not clearly suicidal. The
>psychiatrist was fired three months later, Prison Health said, for reasons
>unrelated to the death.
>
>In the end, though, Prison Health is just the latest partner of a
>bureaucracy with its own blemished history: the correction system, which
>was unable to deal decisively with suicides for decades, as recommendations
>from state and local authorities were ignored, and fitful attempts at
>change failed.
>
>A Moment of Opportunity
>
>The company's arrival at Rikers in January 2001 was a milestone for New
>York. The contract, negotiated with the administration of Mayor Rudolph W.
>Giuliani, was a linchpin in the city's effort to privatize government
>programs, and made New York's jail system the largest in the nation to
>entrust its health care to a commercial enterprise.
>
>The deal was driven in great part by a determination to save money, and
>dovetailed with efforts to get the city out of the business of everything
>from job training to welfare enforcement. For years the city had used
>public hospitals to provide care in its jails, only to face skyrocketing
>costs and plenty of embarrassments. Prison Health, with its already shaky
>reputation, marked a calculated gamble.
>
>The contract, though, was an even bigger deal for Prison Health. It raised
>the company's $382 million yearly revenue by 21 percent, and pushed Prison
>Health to the forefront of a booming correctional health care industry. It
>also made the company responsible for treating more mentally ill people
>than anyone else in the nation except the Los Angeles County Jail.
>
>Yet Prison Health had not told its new employer the whole nature of its
>operations, records and officials in the city comptroller's office suggest.
>In 1999, the company bought EMSA Correctional Care, which had been working
>for the city's Department of Juvenile Justice for three years. Prison
>Health, according to documents and interviews with city officials,
>subsequently became responsible for providing care to the 5,000 youngsters
>in the juvenile system every year.
>
>That care, during 2000, would come under fire by a half-dozen Family Court
>judges in the city, who found that children were often receiving inadequate
>treatment.
>
>But when negotiating the Rikers contract later that year, Prison Health
>filed papers with the city saying the company had "no N.Y.C. presence." The
>comptroller's office, which was not obligated to review the Rikers contract
>at the time, now says that Prison Health's filings were incomplete and
>misleading.
>
>The company rejects that claim, and says the papers were accurate and
>honest, and had properly listed EMSA as an affiliate doing the work at
>juvenile justice. City health officials say they have no problems with
>Prison Health's representations.
>
>Prison Health not only won the Rikers contract, but also benefited from an
>added bonus: an easy act to follow. St. Barnabas Hospital in the Bronx had
>just been fired after a striking number of jail deaths - 34 in its final
>year, including 2 suicides - prompted a criminal investigation. Though no
>charges resulted, the Board of Correction, an eight-member watchdog panel,
>complained about the cost-cutting it saw as a root cause.
>
>But under Prison Health, the rates of inmate deaths and suicides have risen
>slightly. In a foreshadowing of the spurt of suicides to come, six inmates
>killed themselves from May 2001 to January 2002.
>
>In a string of memos to city health officials, the Board of Correction told
>of missing medical records, delayed psychiatric medications and minimal,
>inexperienced staffs. Correction officers, it said, sometimes had to pitch
>in, referring inmates for mental evaluations.
>
>It was not supposed to be that way. Stung by the St. Barnabas experience,
>city health officials had set up elaborate ways of measuring Prison
>Health's performance, including a beefed-up quarterly report card with 35
>standards. But during its first year, the company met those standards only
>39 percent of the time. Its overseer at the time, the city's Health and
>Hospitals Corporation, threatened in July 2001 to scuttle the contract, and
>fined the company $568,000.
>
>Company executives say that the transition from St. Barnabas was rocky, but
>that their performance has improved, and they have managed some significant
>achievements: speeding distribution of medicine, creating a program to
>monitor inmates with hypertension and installing a computer system for
>appointment scheduling.
>
>Yet the company has not made good on several requirements in its contract.
>For example, it frequently sends inmates to hospitals without performing
>tests or providing information on their medical history and treatment,
>according to reports by the State Commission of Correction. And Prison
>Health never came up with the rigorous suicide-prevention plan it promised
>the city in 2000.
>
>"I had no training as to what we do when a patient becomes depressed and
>becomes suicidal," said Michele Garden, a psychologist who was treating Mr.
>Cruz, the first to kill himself in 2003. She quit later that year.
>
>The correction system had its own problems, having failed to tackle the
>issue of suicides despite a series of detailed studies that began in the
>late 1960's.
>
>The city hired a suicide-prevention coordinator in 1980, but gave him only
>a paltry budget. John Rakis, who got the job, recalls having doubts about
>the assignment while interviewing his first patient in the only spot
>available in the Bronx House of Detention: the barbershop.
>
>"He was hallucinating, and at some point got up and started screaming and
>threw over the barber chair," said Mr. Rakis, who now advises the state and
>city on jail health care. "I went upstairs and thought, 'I don't think this
>is going to work.' "
>
>He was right. When he quit in 1984, the Correction Department eliminated
>the job. A rash of suicides followed in 1985 - 11 for the year, with 3 in
>one week.
>
>In the early 1980's, the city created a Prison Death Review Board,
>including members from the mayor's office and the Health and Hospitals
>Corporation, to investigate and prevent deaths. But fearing that the
>board's inquiries could fuel lawsuits, Health and Hospitals representatives
>began refusing to discuss the deaths, said Board of Correction officials.
>The review board has not met since 1997.
>
>When Prison Health arrived in 2001, the entire machinery for monitoring
>suicidal inmates remained lethally porous. The system depended, as it still
>does, on "suicide prevention aides," inmates paid pennies an hour to make
>checks every 10 minutes. In an investigation last year, the state
>commission found that one of these aides was responsible for watching
>troubled or newly admitted inmates in 34 separate cells.
>
>Guards were supposed to help, too, looking in on suicidal inmates every 15
>minutes. But that often became a half-hour, said the correction
>commissioner, Martin F. Horn.
>
>"You could pick and choose which rules you wanted to follow," said Mr.
>Horn, who arrived in January 2003.
>
>Inmates continued to kill themselves, and in its reports on the deaths, the
>state commission insisted repeatedly that those on suicide watch be
>observed at all times. In late 1999, it sent all jails and prisons a
>directive to make that the rule. City correction officials ignored it.
>
>Not until four years later, after the spate of six suicides, did the city
>follow the directive. Two weeks after the sixth suicide, in July 2003, the
>health department replaced the Health and Hospitals Corporation as Prison
>Health's direct overseer, and took action to tighten suicide watches.
>
>The Correction Department ordered a flurry of other changes to ensure
>closer monitoring, and hired Lindsay M. Hayes, a nationally known expert on
>jail suicides, to recommend improvements. But it gave The Times only an
>edited version of his report, stripped of his analysis and recommendations,
>and would not allow Mr. Hayes to discuss his findings publicly. The health
>department also refused to disclose its own investigations of the 2003
>suicides.
>
>Yet Mr. Horn, who became correction commissioner the month the six suicides
>began, said they were a jarring sign that something was dangerously wrong.
>
>"I found it personally distressing," he said. "I was shellshocked."'
>
>A Scramble for Help
>
>On any given day, a psychiatrist walking the halls at Rikers could be a
>doctor from a temp agency who had never practiced there before. He could be
>a doctor who had never treated prisoners at all.
>
>Or he could be someone like Dr. Edward M. Berkelhammer, whose work the New
>Jersey Board of Medical Examiners called "a danger to the public" in 1986.
>It suspended his medical license for two years, fined him and ordered him
>to see a psychiatrist himself after a patient died in his care.
>
>Dr. Berkelhammer was putting a 26-year-old woman through drug
>detoxification when his mistake in administering drugs resulted in her
>overdose, the board ruled. He was working with an expired license, and he
>continued to compound his troubles. In 1989, New York suspended him for two
>months for lying about his record in applications for a license. And in
>1990, New Jersey revoked his license for failing to obey its orders.
>
>In an interview, Dr. Berkelhammer said that the girl's death was a single
>incident long ago, and that he was "very well thought of" at Kings County
>Hospital in Brooklyn, where he worked for several years afterward, treating
>psychotic inmates. "Of all the people at Rikers, I'm the last person anyone
>has to worry about," he said.
>
>Indeed, there are doctors at Rikers with checkered pasts, including
>criminal convictions.
>
>Dr. Ammaji Manyam, for instance, was sentenced to a year in jail in 1990 on
>charges of conspiracy and attempted grand larceny, for selling blood in a
>scheme to charge the state for bogus tests. Her medical license was revoked
>in New York, New Jersey and California, but restored in New York in 1997,
>after she said she wanted to work in a jail clinic because she knew from
>experience how poor the medical services were. Dr. Manyam did not return
>calls seeking comment for this article.
>
>Others have had their medical credentials called into question. New York
>officials revoked the license of a Prison Health psychiatrist, Joseph S.
>Kleinplatz, in 2003 after Illinois officials concluded that his diploma
>from a Mexican medical school had been forged. The company then fired him.
>His lawyer, Karen S. Burstein, said he was a good doctor with a real
>diploma; a state appellate court has ordered that his case be reconsidered.
>
>The health department is now reviewing Prison Health's system for checking
>doctors' credentials.
>
>Becky Pinney, the vice president in charge of Prison Health operations in
>New York City, said the company had done its best to weed out doctors with
>disciplinary records. Most of them, she said, had first been hired by St.
>Barnabas Hospital - though Prison Health rehired them, as it did most of
>the hospital's staff at Rikers. She said the company was thorough in
>investigating job candidates, running names through state and federal
>databanks, and rechecking credentials every two years.
>
>Finding qualified doctors, particularly psychiatrists, is a fundamental
>challenge for any jail medical operation. While Prison Health says it pays
>competitive salaries, doctors who have left for other jobs said they made
>much more working fewer hours.
>
>"You have so many people vying for psychiatrists in a city this size, it
>makes it even more difficult," Ms. Pinney said. The company has responded
>aggressively, she said, recruiting at Columbia University's medical school
>and mailing solicitations to every psychiatrist in the city and North
>Jersey.
>
>The company, then, often takes what it can get - witness the 10 unlicensed
>psychiatrists who Prison Health was supposed to fire by the end of 2001
>because they had failed to pass state medical tests. The city allowed the
>company to keep them on for another 16 months, but when the doctors failed
>even then to obtain certification, it had them dismissed.
>
>Prison Health soon rehired three of the psychiatrists, at reduced salaries,
>as social workers and mental health specialists.
>
>"There's a reason these people have failed to demonstrate to the board that
>they are qualified," said Dr. Robert L. Cohen, who was medical director at
>Rikers from 1982 to 1986, when Montefiore Medical Center ran health care.
>
>But if hiring doctors is hard, keeping them is tougher, say many who have
>worked at Rikers. "They cannot get psychiatrists to stay there," said
>Roberta Posner, a psychologist who headed a mental health unit when she was
>fired in 2001 after 12 years at Rikers. The company would not say why it
>dismissed her; Ms. Posner said it was for complaining. "The staff is so
>stressed and so spread out that they can barely manage," she said.
>
>There are only 10 full-time psychiatrists working with inmates at Rikers,
>the company said. It employs 30 part-timers, and 8 others from two
>temporary agencies, including one in Atlanta called Psychiatrists Only.
>
>Some current and former workers at Rikers said the reliance on such help
>disrupts treatment. A deputy health commissioner, James L. Capoziello,
>conceded, "It's not the optimal way of doing things."
>
>When doctors cannot be found, the company has filled in with less skilled
>workers, say city officials and Prison Health employees. Since 2002, the
>city has allowed more than one-third of the psychiatrist positions to be
>filled by nurse practitioners or physician assistants, who are licensed to
>diagnose medical problems and prescribe medications. The health department
>says that the company is now using only seven of those workers to
>substitute for psychiatrists, and that it plans to end the practice.
>
>Cathy Potler, deputy director of the Board of Correction, said that some of
>those nurses and physician assistants had little or no background in
>psychiatry.
>
>"The result," she told city officials in a May 2003 letter, "is that the
>least experienced mental health staff are assigned to the facility with
>patients who are in need of the highest level of care."
>
>'Juggling Hand Grenades'
>
>As soon as Dr. Douglas Cooper arrived at work in the summer of 2003, the
>phone would ring and, he said, his heart would sink. He was facing another
>day of too few employees, too many psychotic inmates and a corporate boss
>that he says was more interested in paperwork than patients.
>
>As the assistant supervising psychiatrist for all nine Rikers jails, he
>would have to figure out how to handle more than 300 patients at the
>island's largest mental health unit, in the largest jail at Rikers, where
>he worked. On the line was Prison Health's Rikers office, ordering him to
>send one or two of his four or five psychiatrists - each of whom might
>already have 30 patients to see - to jails that could not meet their
>city-mandated staffing quotas that day.
>
>Rikers had a lyrical name for the practice: floating. But Dr. Cooper
>likened it to a bumpy ride on a unicycle with three punctures and only one
>patch. "They move the patch around to whichever hole is leaking air the
>fastest," he said.
>
>Mental health care, he said, was merely damage control, and the inmates
>treated first were the many who knew they could get attention by
>threatening violence to themselves or others. Meanwhile, the staff tried to
>keep tabs on the patients who were quieter but often in more peril.
>
>"You were juggling hand grenades, and one of them was going to go off,
>hopefully not in your hands," said Dr. Cooper, 52, who quit that August
>after nine years at Rikers.
>
>His experience goes to the heart of what many employees say is the reality
>of daily medicine at Rikers. In interviews, more than two dozen current and
>former Prison Health doctors, physician assistants, psychologists and
>social workers said they were spread so thin that most mental health care
>was minimal. Most spoke on the condition that their names not be printed,
>saying they feared losing their jobs.
>
>The numbers do not lie, they say. In 2000, the last year under St.
>Barnabas, the jails had about 830 full-time clinical employees, according
>to the hospital. Today, Prison Health has a clinical staff of about 670,
>the health department said.
>
>That figure, set by the city, is inadequate, Dr. Cooper said - "designed to
>ration health care to cut costs as close to the bone as possible, and to
>provide a semblance of health care when one doesn't really exist." Prison
>Health, or P.H.S. as it is commonly known, goes along, more concerned with
>pleasing the city than with serving patients, he said.
>
>The company's approach, he said, is essentially this: "Put your best face
>forward, hide as many problems as you can and hang on to the contract for
>as long as you can."
>
>As a case in point, he and others cited the way the company regards
>different kinds of paperwork. Medical records, on one hand, are often
>outdated or unavailable, they said. Senior clinicians said they commonly
>had to sign off on treatment without seeing a medical history, a practice
>they said could jeopardize their licenses, and inmates' health.
>
>But at the same time, employees said, Prison Health uses doctors and other
>highly trained specialists to produce and double-check another set of
>papers: the blizzard of documents that city bureaucrats use to gauge the
>company's performance. The paper chase actually appears to have grown out
>of an effort by the city to prevent a reprise of the St. Barnabas years. In
>its first contract with Prison Health, the city listed the numbers of
>doctors, nurses, clerks and other staff required at each jail. Failure to
>document compliance with that list, known as the staffing matrix, for a
>single day, or even a shift, could result in a $5,000 fine.
>
>But Prison Health has turned the matrix into a meaningless yardstick,
>several doctors and physician assistants said. Some mental health
>clinicians said that a number of their most experienced colleagues - the
>clinical supervisors helping run the medical programs in each jail - work
>full time reviewing reports for the city, making sure boxes are marked and
>evaluations signed. Even those working with inmates said they were
>overwhelmed.
>
>"It became impossible to have a therapeutic conversation with a patient -
>it was just checking off boxes," said Dr. Daniel Selling, a clinical
>psychologist who quit in March after about eight months at Rikers. "The
>P.H.S. administration could care less what I do with a patient."
>
>In the practice known as floating, the company has often sent a doctor or
>nurse with a backlog of patients at one jail to another where there are
>fewer inmates to treat, simply to avoid fines, the Board of Correction
>said. The city has repeatedly fined Prison Health for incomplete filings,
>but never for treatment that resulted in injury or death.
>
>"The constant shuffling of mental health providers from one facility to the
>next keeps them from being able to see his/her patient caseload," Ms.
>Potler, the board's deputy director, complained to city officials in her
>May 2003 memo. The company says it has greatly reduced that problem.
>
>Floating, in turn, led to fudging, said several current and former
>employees. To sidestep a fine, they said, Prison Health has had employees
>sign in at one jail but then work at another. When there have been too few
>doctors to float, medical administrators have signed in - but without
>seeing any patients, said three senior clinicians. One added, "The practice
>is clearly fraudulent."
>
>Health department officials said they were not aware of any deception by
>Prison Health. But they said the staffing matrix had been changed in the
>new contract to ensure that a core group of mental health workers at each
>jail cannot be floated. The fines have been eliminated, officials said, and
>the company will be graded more on treatment than on paperwork.
>
>Company officials denied that any employees had been forced to sign in at
>jails falsely. Ms. Pinney said that she tried to avoid moving employees
>between jails, but that it was sometimes necessary to meet patients' needs.
>The complaints about short-staffing, she said, were untrue, if expected.
>
>"We've set a very high standard of performance for our employees," she
>said. "Some people like that and some people don't like that."
>
>Several doctors said that an overextended and discouraged medical staff
>would not pick up on suicidal behavior.
>
>"People lose touch, because the pressure is on," one mental health
>supervisor said in exasperation. "And if patients are not the priority," he
>added, "the consequence is those six suicides."
>
>Alone at the End
>
>From the first days she spent at Rikers Island, charged with shoplifting 30
>tubes of Revlon lipstick from a Rite-Aid in the Bronx, it was obvious that
>Carina Montes was carrying around something a lot weightier than stolen
>merchandise.
>
>A 29-year-old former gang member with a gunshot scar on her stomach and a
>teardrop tattooed under her right eye, Ms. Montes was sexually abused as a
>child. She was 8 when she began seeing a psychiatrist for depression,
>medical records show. She tried to kill herself three times, at ages 13, 18
>and 25, and arrived at Rikers severely depressed.
>
>She told some of this in her intake exam, to a physician who diagnosed
>manic depression and prescribed antipsychotic medication, state
>investigators said. But little of the information would follow Ms. Montes,
>they said, as Prison Health passed her from one staff member to another,
>losing track of her records and even seeming for months to lose track of
>the young woman herself.
>
>Over the five months she had left, she would never be seen by a doctor
>again, the State Commission of Correction found. At the end, she would have
>no one to help her but other inmates and a rookie jail guard.
>
>Isolation was nothing new for Ms. Montes. Born in Puerto Rico, she dropped
>out after the ninth grade into a different sort of education, selling crack
>on the Grand Concourse, then paying for it in city jails and upstate
>prisons. Paroled from a drug sentence in March 2002, she had no family to
>turn to - just Ana Torres, a lover who took her in from a women's shelter.
>
>That Sept. 13, the day after Ms. Montes landed at Rikers, the doctor
>recommended an immediate mental health examination. But nearly three months
>passed before Prison Health performed the exam, which took place only
>because a guard had noticed Ms. Montes acting strangely, records show.
>
>The social worker who finally examined her on Dec. 7 was a "floater" who
>rarely worked in the women's jail. Learning of Ms. Montes's three attempts
>to kill herself, he placed her on suicide watch.
>
>It took another 23 days before Ms. Montes was seen by a mental health
>specialist, Brett Bergman. But he did not know his patient was on suicide
>watch, he later told investigators, because he could not find her medical
>file. "Patient appears to be doing well and was stable," Mr. Bergman wrote.
>Although he saw her twice more in the next month, he still could not locate
>the file.
>
>No other clinician had a chance to help her; on Dec. 2, after she fought
>with another inmate, the correction staff placed her in a
>protective-custody cellblock that had no regular mental health services.
>
>On Feb. 6, her isolation proved deadly. Although she was on suicide watch,
>Ms. Montes had not been seen by any mental health worker for nine days,
>records show. No one noticed that Ms. Montes, a diabetic, had refused her
>insulin injections for two days.
>
>But another inmate, Linda Vega, saw her weeping in her cell that morning,
>distraught over a quarrel with a new lover four cells away. "Everything I
>love don't love me," she lamented, according to Ms. Vega, and said she
>would hang herself. "I then noticed sheets torn apart between her legs,"
>Ms. Vega told city investigators.
>
>At 11 a.m., alerted by inmates, a newly hired guard, Kje Demas, stood
>outside Ms. Montes's open cell door and asked if she was all right. "I'm
>O.K., I'm just going through something," she said, the guard told
>investigators. Officer Demas said he had never been told she was on suicide
>watch. He did not see the bedsheets or any cause for alarm.
>
>Shortly before 5 p.m., another guard heard inmates screaming and found Ms.
>Montes hanging from an air vent.
>
>The Correction Department fired Officer Demas for failing to notify a
>superior. The health department said it "counseled" Mr. Bergman and his
>supervisor for not reviewing the medical charts they could not find, and
>imposed a rule that inmates on suicide watch be interviewed every two days.
>
>There was no penalty for Prison Health.
>
>Ms. Montes's body was shipped a few miles northeast of Rikers - to Hart
>Island, where the city buries its unclaimed dead.
>
>
>Joseph Plambeck contributed reporting for this article.
>
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