“I discovered several examples of medical diagnosis that were either unacknowledged or untreated. One detainee was found to be human immunodeficiency virus (HIV) positive but was not told about the diagnosis. Other examples include detainees who were found to be hypothyroid or diabetic who did not receive care or received inadequate care. One female detainee was documented to have persistent hematuria [blood in urine] since January 2018 without a proper investigation into the etiology of her condition. She was still at [Aurora ICE Processing Center] at the time of our visit. Any of these findings alone can be considered an ‘Immediate Jeopardy’ according to the Center[s] for Medicare & Medicaid Services (CMS) and can lead to the closure of large health systems.”
“Our team identified a detainee who had arrived in the facility having recently had a peri-rectal abscess drainage. This is a surgical procedure and it resulted in a wound that had post-surgical drains in place. The surgical history, and presence of an open wound were noted properly at intake screening, but the detainee never received even the most basic care for his wound. 1) He was not kept in the infirmary and was sent into general population with an open wound and surgical drains in place. 2) No wound care was provided. 3) No bandages or dressings were provided. 4) There was no timely referral to surgical follow up, apparently because there was an unnecessary delay in providing basic care while awaiting outside records 5) a telephone interview with the Medical Director confirmed he was totally unaware of the case over a week after the detainee arrived in the facility.”
“Case #3 alleged that a pregnant detainee did not receive adequate medical attention after she slipped and fell in the shower, causing vaginal bleeding. … [A]s a best practice, a pregnant female with abdominal pain must have an ultrasound to rule out an ectopic pregnancy (pregnancy outside of the uterus) as this is a life threatening condition. In this case, this pregnant female with abdominal pain was administered Tylenol without a determination of the location of the pregnancy. ... I cannot emphasize enough that although this patient's complaint of vaginal bleeding was not supported by the documentation, the medical care did not meet the standard of care of a pain in pregnancy.”
“Mental health services for ICE detainees at St. Clair is woefully inadequate and virtually non-existent. While detainees who arrive at St. Clair with a history of receiving psychotropic medication are kept on this regimen and referred for mental health services, they are not being treated by mental health staff unless their condition is ‘homicidal or suicidal.’ Accordingly, medical staff continue to refill psychotropic medication without the detainee receiving mental health counseling to determine appropriateness and/or effectiveness of dosage. This is extremely problematic and dangerous for ICE detainees.”
“The reviews identified many [seriously mentally ill] detainees who, by default, were living in the [special housing unit] or isolated in general population. The acutely distressed detainees also have difficulty living in any stressful environment because they are easily overwhelmed by changes in routine and by relatively minor stressors. Their coping strategies/defense mechanisms are usually maladaptive, making bad situations worse, resulting in transient psychotic episodes and/or self-injurious behavior. The reviews identified at least half a dozen detainees whose distress either did not come to the mental health staffs' attention or was minimized by mental health staff. Regardless of the reasons why they were ‘falling through the cracks,’ their distress was being exacerbated, increasing their risk of suicidal behavior.”
“When I met with and reviewed the charts of detainees with mental disorders, I observed several cases where diagnoses and treatment plans were inaccurate and this could have been avoided by obtaining a collateral history. Overall, the pervasive lack of collateral information resulted in persons with serious mental disorders receiving incorrect diagnoses, suboptimal care and, in particular, they were not receiving the appropriate psychotropic (and specifically, antipsychotic) medications. … Mental health leadership and oversight is absent at Adelanto.”
“CRCL received two complaint referrals from the Office of the Inspector General (OIG) filed by detainee #1 alleging [Orange County Jail] officials physically assaulted, threatened, and tampered with his medical equipment while he was hospitalized. ... [T]he struggle between the officer and the detainee had occurred over the television remote control. Detainee #1 wanted to turn the volume down so he could rest, and Officer #1 wanted to control the loudness so he could watch television. Detainee #1 was trying to call the nurse via the remote control call button, and the IV was pulled loose during the struggle for the remote. ... [M]y investigation substantiates that unnecessary and excessive force was used by Officer #1 that resulted in the detainee's medical IV being pulled loose.”
“The officer deployed the taser during the incident at the top of the staircase which resulted in the detainee sustaining a serious head injury when the detainee fell, knocking him unconscious. The officer yelled at the unconscious detainee to move. The detainee could not comply as he was unconscious and the use of the taser also temporarily immobilized him. The officer then threatened to taser the unconscious detainee again and subsequently moved the detainee who was still unconscious. The movement could have led to the detainee sustaining permanent physical injury of the neck and or spine.”
“A total of 29 incidents of use of force (pepper spray or restraint chair) between 2018 and 2019 were reviewed. Of the 29 incidents, eighteen or 62% involved detainees experiencing acute mental health distress (head banging, strangulation, threats to harm self and behaviors interpreted by staff as potential for self-harm). ... Documentation of efforts to resolve the situation via consultation with and assessment and intervention by mental health were warranted but were lacking in all cases reviewed. Further, identification of signs of acute distress and therefore early intervention by staff (thus reasonable effort to resolve the situation) was lacking since it is unusual for these behaviors to occur without warning. Typically, detainee needs/requests have been unmet or signs indicative of emotional distress (threats, pacing, yelling, etc.) are not responded to appropriately.”
“The medical clinic at Stewart [was among] the dirtiest medical spaces I have ever seen in a U.S. detention facility. ... There were paint chips on the floor that appear to have collected over time; a crumbling shower had debris on the shower floor. Corners were dusty. In the rest of the medical unit, trash cans were full and multiple staff members reported that trash was not emptied on a daily basis. A mattress in the treatment room was so old and cracked that it would have been impossible to sanitize it in between uses. We found pills on the floor in the hallways. Counter surfaces were old and deteriorating making them impossible to clean properly.”
“The medical unit was observed to be dirty and in a general state of disrepair. ... The medical devices used to look into the ears and eyes (Otoscope and Ophthalmoscope) were dusty and grimy. The countertop in an exam room was cluttered, which provides harborage for vermin, and a dead roach was also found on the counter. ... An infestation of ants was found on the floor under the storage racks in the dry storage room, along with food debris, and leaking syrup was running down the wall. Numerous flies were observed throughout the kitchen including in the pantry, dishwashing room, and they were landing on food, equipment, and kitchen supplies, while the workers were preparing the food and trays for the dinner meal.”
“There is a lack of general cleaning with dirty floors and drain covers. Flies and ants were observed in the common food service areas providing evidence of deficient pest control. Efforts to control flies and ants was not observed. Food was found in the cold and freezer storage areas that was uncovered and/or undated. The freezer had condensation on the ceiling. There was very old food items in the freezer (as old as 2017). Storage shelving and containers was pushed against the wall that prevents proper cleaning. Food is not being stored and thawed properly.”
“The female detainees also reported being yelled at and subjected to rude and hostile treatment by some of the custody staff. ... The female detainees provided the names of several officers whom they alleged treat them disrespectfully. One officer had been nicknamed by the detainees as ‘Officer Ferocious.’ The detainees' allegations of staff misconduct allegations included verbal disrespect and harassment by custody staff, discrimination of detainees by facility staff based on race, and retaliation by facility staff following submission of detainee grievances. I was concerned about the significant number of detainee staff complaints, so I interviewed the investigator for the facility. There were no formal investigations of staff related to detainee mistreatment complaints.”
“During interviews, detainees described extremely disrespectful, offensive and profane language that [Orange County Jail] staff use when addressing them. ... Examples of mistreatment include a Sergeant entering the female unit and greeting the female detainees by yelling, ‘Hello a**holes and bitches.’ Staff also reportedly refer to female detainees as ‘ICE fish, tuna, or mackerel,’ an apparent reference to their immigration status. Both male and female detainees reported that staff yell at them as a normal course of business and make racist comments. One staff even sings ‘ICE, ICE Baby’ when working in the unit. Multiple staff make comments such as, if detainees do not like the treatment, they should not have come to our country. A [correctional officer] working in a male unit confronted a group of detainees stating, ‘Who's the f***ing p**** who made the complaint against me?’ The [correctional officer] was upset that a detainee filed a complaint against him.”
“Detainee #1 was subsequently involved in an incident that resulted in him being placed in a restraint chair. ... One male officer began to cut the detainee’s clothes off with a pair of scissors which was described by interviewed staff as standard practice. Shortly after the officer began cutting the fabric of the leg of the pants that the detainee was wearing, the male officer handed the scissors over to the female officer who then proceeded to cut the male detainees clothes off. ... A female staff should never conduct an unclothed search of a detainee unless exigent circumstances exist, and no other male officers are present or available. ... There is no justifiable correctional reason that required the detainee who had a mental health condition to have his clothes cut off by a female officer while he was compliant in a restraint chair. This is a barbaric practice and clearly violates 2008 PBNDS, Searches of Detainees Standard, 2.11 SAAPI Standard, 2008 PBNDS Searches of Detainees and Use of Force and Restraints, and basic principles of humanity.”