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-13- reporting led to retaliation, or their allegations were not taken seriously. A medical clinic incident notebook at Columbia documents the nursing staff’s treatment of youth’s injuries from alleged physical abuse by staff or pepper spray use. However, these abuse allegations appear never to have been investigated, even when an injury was noted by the nurse and could have possibly substantiated the youth’s claim.
(b) External ReviewWe found few external reviews of abuse allegations from outside agencies. The Division of Youth Services’ Division of Program Integrity conducted only 10 external reviews of abuse allegations between May 2000 and May 2002, most of them concerning staff at Columbia. We are aware of allegations of staff abuse at Columbia and Oakley that would have warranted more than 10 investigations from the Division of Program Integrity during that time period.
Moreover, during our tour of Columbia, children made various abuse allegations concerning specific staff. Several girls alleged that a recreation staff person forced girls to run and perform military exercises wearing tires. Many youth reported that the acting head nurse routinely denied medical care and access to appropriate health services. The girls in the advanced cottage alleged that a security guard engaged in inappropriate sexual behavior by standing in front of the uncovered windows of the girls’ cottage and observing them while they were undressing before going to bed.
We provided enough information for a thorough investigation to be conducted. We relayed the nature of the allegations, the approximate date and location of where the incidents occurred, and the names of the staff persons allegedly responsible for the incidents9 to the Mississippi State Attorney General’s Office (“Attorney General’s Office”).10 We were informed by the Public Integrity Division of the Attorney General’s Office that they
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9 We did not, however, provide the names of the allegedly involved youth in deference to the youths’ request for confidentiality, many of whom had relayed fears of retaliation.
10 The Mississippi Department of Human Services agreed to defer its investigation of the allegations to the Attorney General’s Office.
-14- would need the names of the youth making the allegations in order to conduct the investigation because approval of the youth court judge who adjudicated the youth delinquent was required.11
4. Severe Staff ShortagesColumbia and Oakley fail to keep the youth in their care safe due to severe staffing shortages. Oakley has a staff vacancy rate of 39 percent. Due to budgetary constraints, Oakley is under a hiring freeze and cannot hire new staff to fill the vacancies, according to administration officials. During our tours, we noted that the staff at Oakley, including the facility management, appeared to be under stress and overworked. The documentation we received indicated that the Division of Youth Services was notified as early as January 2002 that these shortages compromised the safety of both staff and youth on Oakley’s campus. Specifically, during an incident that resulted in the use of pepper spray, a staff person had to enlist the assistance of a youth to defuse a fight in one of the cottages. The facility investigator wrote to the administrators at the Division of Youth Services that “[t]here is a serious need for additional staff members which [sic] are adequately trained in juvenile justice and security requirements before a staff member or student is critically injured or killed.”
Staff and administration are typically required to work overtime. On the weekends, youth are sometimes distributed to other living units due to staffing shortages. In Units One and Two, one staff person supervises 30 or more juveniles on every shift. This ratio substantially departs from generally accepted professional practices. During our tour, staff and senior managers repeatedly told us that Oakley is a dangerous place to work. Staff repeatedly stated that they are unable to protect youth from harm. Some senior managers admitted that all critical incidents were not being reported because the facility cannot afford to fire abusive staff. Line staff accused other staff of assaulting youth and stated that nothing is done about the abuse.
Similarly, Columbia has staffing shortages and an inability to fill vacant positions. At the time of our on-site
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11 We were told that the Attorney General’s Office could not initiate its own inquiry without prior court approval or in conjunction with the Department of Human Services. See MS ST §§ 43-21-353; 43-21-261.
-15- investigation, Columbia had a hiring freeze and a vacancy rate of approximately 30 percent. The result of the shortage is particularly harmful for the girls. The girls’ cottage is severely overcrowded. Girls are made to sit in a confined lobby area or on the day room floor every evening for at least four hours in silence because staff shortages prevent them from staying in their rooms. Our expert noted a critical shortage of direct care workers. Like Oakley, Columbia’s staffing patterns substantially depart from generally accepted professional practices.
B. Mental Health CareThe Constitution requires that confined juveniles receive adequate medical treatment, including adequate mental health treatment and suicide prevention measures. Hott v. Hennepin County, 260 F.3d 901, 905 (8th Cir. 2001) (citing Williams v. Kelso, 201 F.3d 1060, 1065 (8th Cir. 2000)); Young v. City of Augusta, 59 F.3d 1160, 1169 (11th Cir. 1995); Horn v. Madison County Fiscal Court, 22 F.3d 653, 660 (6th Cir. 1994); Bowring v. Godwin, 551 F.2d 44, 47 (4th Cir. 1977).Oakley and Columbia house a large population of juveniles who suffer from mental disorders, substance abuse, and suicidal thoughts.12 A July 2001 study funded by the Mississippi Department of Public Safety Division of Public Safety Planning and the Department of Mental Health Division of Children and Youth Services found that between 66 and 85 percent of the incarcerated juvenile offenders in Mississippi “met DSM-IV diagnostic criteria for a mental disorder.”13 The study added that “multiple, co-occurring mental health and substance abuse diagnoses were evident . . . [and] 9% [of the juveniles] had suicidal thoughts and plans.” Oakley and Columbia do not provide adequate services for this vulnerable population. Lack of training, resources, program structure and staffing shortages
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12 However, as indicated previously, these youth should be committed to rehabilitation facilities operated by the Mississippi Department of Mental Health. See supra, p. 2.
13 Angela Robertson & Jonelle Husain, Prevalence of Mental Illness and Substance Abuse Disorders Among Incarcerated Juvenile Offenders (2001) (“the Mississippi State University Study”). Robertson and Husain are researchers at Mississippi State University.
-16- have severely affected Oakley and Columbia’s counseling programs and as a result youth with mental health concerns receive haphazard and cursory treatment.
1. Administration of Psychotropic MedicationsThe care of youth with severe mental illness requires assessment and management by a psychiatrist, and where medications are prescribed before confinement, the continuation of medications without interruption upon admission to the facilities. The management of youth with mental illness and the administration of psychotropic medications is seriously deficient at Oakley and Columbia.
Many youth on psychiatric medications are not allowed to continue to receive those medications when they are admitted to Oakley or Columbia. The physicians, not the psychiatrists, determine which youth with mental illness will continue to receive their psychotropic medicine while committed. For example, before his admission to Columbia, a youth was treated at a psychiatric hospital and discharged with a prescription for risperdal, which treats the symptoms of schizophrenia. His risperdal was continued in detention and his medicine was sent to Columbia when he was transferred. However, the facility physician discontinued the youth’s risperdal without referring him to the psychiatrist for follow-up treatment. In another case, a youth was hospitalized for mental health treatment and upon release was prescribed psychotropic medications. Upon admission to Columbia, the physician discontinued these medications and made no referral to the psychiatrist. After staff reported the youth’s unacceptable behavior, he was referred to the psychiatrist who, apparently either ignoring or being unaware of the youth’s prior history, prescribed a different medication altogether. The youth was still taking the facility-prescribed medication at the time of our visit, and staff continued to find the youth’s behavior unacceptable.
Physicians should not make decisions about whether a child will continue on most prescribed psychiatric medications. A psychiatrist should evaluate the youth’s medication needs based on a diagnostic interview, a review of records of prior care, and, if necessary, in consultation with the youth’s psychiatrist in the youth’s home community.
-17- Rarely are the contracted psychiatrists and staff psychologists informed when a child is admitted with or has a history of treatment with psychiatric medicine. Youth with mental illness often are untreated while in the facilities, even though they are admitted with a history of mental illness.
2. Managing Suicidal YouthOakley and Columbia fail to employ adequate suicide prevention measures. Activity, positive relationships between staff and youth, individual attention, school, exercise, reading, and counseling are necessary aspects of an adequate adolescent suicide prevention program. Instead, at Columbia, suicidal youth are isolated in SIUs in stripped cells, sometimes naked, are not allowed outdoor exercise, and receive very little schooling or counseling. As previously discussed, some suicidal girls at Columbia are placed in the “dark room.” Furthermore, in the isolation units or SIUs at both facilities, children’s mattresses are taken away during the day, leaving them with the option of lying or sitting on concrete or standing.
Boys at Oakley who are judged to be suicide risks are placed in an empty day room adjacent to the control room where they sit on the floor all day without access to books, school, or outdoor exercise. They also are not permitted to interact with other boys in the room. The counselor assigned to counsel suicidal youth attempts to see each youth once per day, but if she is unavailable, no one provides mental health counseling in her absence.
Suicidal youth are isolated in SIUs in stripped cells, sometimes naked, are not allowed outdoor exercise, and receive very little schooling or counseling... Children’s mattresses are taken away during the day, leaving them with the option of lying or sitting on concrete or standing.
C. Rehabilitative TreatmentThe Constitution requires that youth confined at Oakley and Columbia receive adequate rehabilitative treatment. Morgan v. Sproat, 432 F. Supp. 1130, 1135-36 (S.D. Miss. 1977); Pena v. New York State Division for Youth, 419 F. Supp. 203, 207 (S.D.N.Y. 1976). Oakley and Columbia youth, however, receive inadequate rehabilitative treatment. We found that counselors and psychologists are the staff responsible for rehabilitative treatment. Psychiatrists are contracted for only one day a month at both facilities. The majority of their time is spent conducting forensic evaluations for the court, rather than providing mental health or rehabilitative treatment to youth. Staff assigned to the housing units, such as juvenile correctional officers, function as security and play no role in
-18- the youths’ rehabilitative treatment. There is little or no interaction between the various disciplines regarding youths’ strengths and needs or rehabilitative treatment. The lack of communication between staff hampers their ability to provide a rehabilitative environment. Indeed, the programs’ current focus on discipline, control, and negative reinforcement fosters an atmosphere where staff demean, belittle, and abuse youth and is not conducive to rehabilitative treatment.
Oakley and Columbia counselors have masters degrees and the qualifications to provide effective rehabilitation, however, with the average caseload of between 20 and 30 youth, individual goals are impossible to achieve. For example, counselors routinely are unable to see youth individually or in group sessions. Moreover, therapy continuity is not maintained because counselors are reassigned when youth move from the basic to the advanced program. Furthermore, counselors are responsible for implementing youths’ individual treatment plans, but are not involved in the development of the plans. Counselors, typically, decide which goals they will work on with the youth and as a result youths receive canned group sessions, such as, “obey authority” or “value an education,” which have little rehabilitative value. A senior mental health employee at Oakley admitted that youth do not receive individualized rehabilitative treatment.
1. Individual Treatment PlansBoth facilities rely solely on individual treatment plans (“ITPs”) provided by the youth court, rather than developing an individualized plan once the youth arrives at the facility. Unfortunately, the courts’ ITPs are not comprehensive and fail to evaluate the youth’s mental health status. Youth are not involved in their own treatment planning, nor are the counselors or the youths’ parents. In addition, youths’ ITPs repeatedly contained the diagnosis of “conduct disorder, alcohol abuse, cannabis abuse, strong borderline and antisocial personality traits.” Given the time constraints, lack of information, and the absence of individual sessions with youth, it is not clear how the youth courts’ psychologists could make appropriate diagnoses. The fact that many diagnoses are remarkably similar heightens this concern.
2. Anti-Therapeutic Conditions
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Many of the conditions at Columbia do not promote rehabilitation or good mental health, but instead cause depression and mental deterioration. In the evenings, youth are required to sit in silence for large blocks of time while they sort their clothes, clean their boots, or for girls, braid each other’s hair. This time could be better spent productively engaged in activity and learning. The environment as it currently exists invites acting out by youth and the abusive institutional practices that too often follow. For example, youth are forced to perform physical exercise and threatened with SIU if they are caught talking to each other. In fact, youth expressed frustration at the wasted time and lack of rehabilitation services being offered in the evenings. Lack of activity, social interaction, and counseling assistance put youth at risk for depression.
Many of the conditions at Columbia do not promote rehabilitation or good mental health, but instead cause depression and mental deterioration. In the evenings, youth are required to sit in silence for large blocks of time... Youth are forced to perform physical exercise and threatened with SIU if they are caught talking to each other. Many of the conditions at Oakley and Ironwood, similarly, are harsh and do not promote rehabilitation. Oakley’s SIU is purportedly used to address the needs of the most vulnerable boys, but instead, functions like an adult prison. Instead of addressing the boys’ mental health or rehabilitative treatment needs, boys are either locked in isolated cells (where they are sometimes also shackled) or shackled and forced to perform work details around the campus in order to earn their way out of the SIU. They are not permitted to attend school or receive any educational instruction, and are provided limited access to counseling. Except for work details, the boys are permitted out of their cells only once a day to exercise in the hallway, but must eat their meals in their cells.
On the day of our arrival to Oakley, we observed a 13-yearold boy sitting in a restraint chair near the Ironwood control room. Reportedly, he was placed in the restraint chair to prevent self-mutilation. No staff approached him, and he was not allowed to attend school or receive programming, counseling, or medication. This boy had been severely sexually and physically abused by family members and had been in several psychiatric hospitals prior to being sent to Ironwood. Just before our arrival, he had been locked naked in his empty cell. His cell smelled of urine, and we observed torn pieces of toilet paper on the concrete floor that he had been using as a pillow.
He had been locked naked in his empty cell. His cell smelled of urine, and we observed torn pieces of toilet paper on the concrete floor that he had been using as a pillow.
3. The Military Program
-20- The use of paramilitary programs at youth training schools is not, in itself, unconstitutional. However, our experts noted, and it is generally accepted, that four segments of the youth population at Oakley and Columbia are particularly unsuitable for paramilitary programs: younger boys, girls, youth with developmental disabilities, and youth who are emotionally or physically fragile.
The disciplinary practices are particularly harmful to the younger boys at Columbia who are physically, emotionally, or psychologically unable to participate fully in the training program. Young boys at Columbia are not developmentally suited to benefit from the military approach. Many staff perceived that this particular population was noncompliant and anti-authority, when in reality, many of the boys are merely active third, fourth and fifth graders with short attention spans. The result is that the younger boys stay at Columbia longer because they are considered behavior problems. A Columbia counselor told us:
Additionally, the counselor stated that a suggestion had been made by other counselors to place at least the younger boys in a separate unit. However, they were told there was insufficient staff to run it. In our experts’ opinions, the military program is ineffective and harmful for younger boys.You can’t change developmental stages. They are not ready. They are playful . . . . The young kids usually stay longer, usually four to six months -- there is no tolerance for their silly behavior, so they have to start over. Many have ADHD [Attention Deficit Hyperactivity Disorder], and they have an especially hard time, partly because the doctor here usually takes them off medication -- they are not really defiant, but they can’t be judged the same as the older kids. I do a lot of counseling with young kids who cry and really miss their families. They get depressed.Columbia’s paramilitary program also is unsuitable for some of the troubled girls it serves. Our expert noted that girls may make some self-esteem gains in physically challenging programs but the girls at Columbia are deriving no benefits, physical or otherwise, from the program that is currently being administered. Harsh disciplinary practices are characterized as training. A June 2002 log book entry shows that a facility manager punished a girl by requiring her to sleep one hour and walk one hour for two
-21- successive nights. This same girl also had to eat every meal standing for one week thereafter. These punishments are largely unregulated and in some cases endorsed by supervisory personnel because they are considered military training. From a juvenile justice and mental health perspective, the military program is inappropriate for girls who have a history of being victimized and abused either physically or sexually.
A paramilitary program also is inappropriate for youth with learning or developmental disabilities. Youth are only permitted to move to the ‘advanced’ unit once they have met behavioral objectives and passed a written and oral test on military procedures. Youth with learning or developmental disabilities have difficulty passing the test and serve longer commitments because they cannot move beyond the basic phase of the program. One counselor stated that, “[a]t least ten percent are developmentally slow, and the staff don’t understand lowfunctioning kids. They can’t make it.” For example, staff made fun of a girl who had both physical and cognitive impairments. This girl was just learning to read and was unable to earn a grade higher than 70 on the military test the youth must pass in order to move from the basic to the advanced phase of the program. Her peers were concerned that she would never be able to pass the test. Youth with learning and developmental disabilities are particularly inappropriate for the programs offered at Oakley and Columbia.
Finally, youth who are physically or emotionally fragile are singled out and made to feel worse because of their fragility. Boys at Oakley reported staff routinely picked on boys who were small in size, emotionally sensitive, or had difficulty adjusting to the military program. Some, but not all, of these boys may be placed in Unit Two’s Magnolia Cottage for boys who for medical or psychological reasons are considered inappropriate for the physical training component of the military program. However, boys in Magnolia Cottage are verbally and physically abused by staff during non-physical components of the military program as often as the emotionally and physically vulnerable boys in other cottages. A 15-year-old former resident of Magnolia Cottage who was moved to the SIU told us that he tried to perform well in the non-physical aspects of the program but was sensitive to being teased by staff and had difficulty controlling his reactions, which precipitated his being sent to isolation in SIU. The Magnolia Cottage residents confirmed his account. Again, from a juvenile justice and a mental health perspective, the
-22- paramilitary training program, even when the physical aspects are eliminated, is not only ineffective, but harmful to such youth.
D. Medical and Dental CareYouth at Columbia and Oakley receive inadequate medical and dental care.
Staff shortages and a lack of medical leadership have greatly affected the ability of staff to provide necessary medical services to youth at Oakley and Columbia. No one is accountable for Oakley and Columbia’s medical program. Neither the facility director nor anyone in the Division of Youth Services or the Department of Human Services is directly responsible for primary care at either facility.1. Quality of CareColumbia has only two full-time Licensed Practical Nurses (LPNs) providing services for a 200 bed juvenile facility with an average of 13 new admissions every week. Oakley has five fulltime LPNs and a full-time contract RN servicing a population that can reach up to 400 with 15 to 25 new admissions every week. At Oakley and Columbia, LPNs are unsupervised and given responsibilities beyond their scope of practice. In short, the LPNs are practicing medicine without a license.
Oakley and Columbia do not have full-time physician assistants or nurse practitioners on staff and both have several vacant nursing positions. Oakley’s contract physician sees patients approximately four hours per week with half of his time performing clinical exams on new admissions; Columbia’s contract physician sees patients three hours per week. The physicians at Oakley and Columbia are contracted solely for clinical care and have no responsibility for the nursing staff or ensuring that policies and procedures are followed. The result is that access to adequate medical care is very limited. Also, responses to health issues such as chronic disease care and health education are virtually non-existent.
Columbia and Oakley routinely fail to continue youths’ preexisting medical regimens after they are committed to the training schools. At Columbia, medicines are often discontinued upon arrival. Even asthmatic youth do not receive follow-up care to ensure that their cases are being managed. For example, a
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girl was admitted to Columbia with a history of asthma. She was not asked about her medical history during her initial exam. She subsequently told the nurse about her inhaler and that it prevented asthma attacks if used prior to exercise. The youth never received an inhaler. While performing exercises, she began to have an asthma attack. She was not allowed to see the nurse and was told to continue to exercise or be punished for disobedience. In a highly restricted environment where access to medical services is limited, acutely asthmatic youth must have routine, scheduled follow-up care.
She subsequently told the nurse about her inhaler and that it prevented asthma attacks if used prior to exercise. The youth never received an inhaler. While performing exercises, she began to have an asthma attack. She was not allowed to see the nurse and was told to continue to exercise or be punished for disobedience. We found that nurses at Oakley do not routinely follow-up with youth after providing rescue inhalers. Poor care can cause severe illness in youth as the following example illustrates: A youth was admitted to Oakley in May 2002. He had a history of asthma and was hospitalized for acute asthma one month prior to his admission to Oakley. Several asthma medications were sent with him to Oakley including singulair and maxair. These and all other medications were discontinued upon his arrival. Moreover, medical staff made no attempt to find out his prior medical history. Two days after his admission, he developed acute asthma and suffered from shortness of breath, coughing, and wheezing for at least a week. The only treatment provided by the nurse was a rescue inhaler. The youth was finally examined by the physician who noted that his vital signs were significantly abnormal, but sent the youth back to his cottage without treatment. Another five days passed before the youth was permitted a consultation with an asthma specialist who subsequently prescribed singulair and maxair.
The facilities fail to maintain equipment or lack equipment to provide essential emergency services. Columbia’s medical clinic contained old, rusty, dirty, and sharp equipment stored in easily-accessible places such as unlocked drawers and trays on the counter in the examination room. Equipment that could be stolen easily and used as weapons such as scissors, razor blades and even a scalpel blade were left unattended and readily accessible to youth on a cart in the exam room rather than securely stored. The medical clinics at both facilities do not carry adequate emergency or medical equipment. For instance, the clinics do not carry oxygen or syringes which are necessary for emergencies, or basic medical equipment such as needles with engineered controls used to prevent injury to health staff.
-24- Staff fail to follow basic universal precautions which have led to dangerous health hazards for youth in the facilities. A nurse at Oakley was observed by our expert giving one resident a pre-filled syringe of the hepatitis B immunization. She accidentally inserted the same needle into the arm of the next resident before realizing her mistake. Moreover, a scalpel blade is repeatedly used by Columbia’s facility physician to shave warts, permitting the transmission of blood-borne pathogens from patient to patient. In violation of standard medical practice and at the risk of contamination, Oakley staff store food in the same refrigerator as pharmaceuticals such as immunizations and control solutions to analyze blood. Our expert noted that the Oakley physician conducted nine examinations in one day and never changed the roll of paper that lined the surface of the examination table.
2. Health Assessments
Columbia and Oakley’s health assessments are incomplete, and necessary intake services are not provided. Both facilities fail to give tuberculosis skin tests upon admission even though Mississippi is in the top quartile of states with annual incidence of the disease. Moreover, identified medical histories are not pursued. For example, a girl at Columbia had a history of thrombocytopenia.14 No platelet count was obtained upon admission to assess the status of disease activity or to determine risk of internal bleeding. This is of great concern because she is expected to be a full participant in the military program. Furthermore, abnormal medical findings are not pursued. For example, a youth at Columbia with a significantly low hematocrit15 did not receive further evaluation by the contract physician or a specialist, nor did the youth receive any treatment. A female patient, also at Columbia, with a green vaginal discharge noted during her admission physical examination was neither referred to the gynecologist nor provided treatment. At Oakley, a patient who had blood in his urine was not referred to the contract physician and received no evaluation or treatment. Another boy with a history of asthma was admitted to
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14 Thrombocytopenia is a disease of the blood in which there are too few platelets. It is a condition that interferes with clotting. 15 A low hematocrit means that there is a lower than normal level of red blood cells.