Utah prisoners’ health care needs go unaddressed due to staff’s ‘culture of noncompliance,’ audit finds

Among other health care shortcomings, legislative auditors found nearly 40 inmate requests for medical care undocumented and shredded in a bin of papers.

(Leah Hogsten | The Salt Lake Tribune) The Dell High Side women's unit at the Utah State Correctional Facility, April 7, 2023.

When sent to prison, Utah inmates are also sentenced to navigate a health care system plagued by “systemic deficiencies,” legislative auditors reported in December 2021. Nearly a year and a half later, a follow-up audit found that many of the problems uncovered then have not been corrected.

All of that, legislative auditors say, can be attributed to “a culture of noncompliance and lack of accountability” among the Department of Corrections’ medical staff.

In the time since that initial audit was published, insulin and food distribution to diabetic patients has in some cases reportedly worsened; some inmates continue to be inappropriately billed for mental health services; staff haven’t kept adequate records of inmates’ requests for treatment or medications administered; and some personal health records and equipment are still improperly disposed of.

Of the 13 recommendations auditors reassessed from the 2021 report, the Department of Corrections told lawmakers last October that two were “in process” and all others had been “implemented.” However, according to the Legislature’s audit released Wednesday, auditors found that nine of the recommendations reported as “implemented” had not been.

“To me, that is something that’s really problematic — to make a report to the Legislature and then ... we have the auditors come and find out that report was not accurate,” House Majority Leader Mike Schultz, R-Hooper, said in response to the report at a committee meeting Wednesday. “That’s pretty concerning.”

Senate Minority Leader Luz Escamilla, D-Salt Lake City, had a similar reaction, saying, “This seems to be a full systemic, very problematic and concerning approach to accountability and transparency.”

A spokesperson for the Department of Health and Human Services — an agency recently tasked to take over the prison health care system — said as it works with the Department of Corrections, the agency will assume responsibility for implementing all recommendations, from both the most recent and the 2021 audits.

“We concur with all recommendations in this report and appreciate this follow-up audit as it will be key in helping us address and respond to ongoing issues within our system,” wrote Brian Nielson, the executive director of the Department of Corrections, in a letter responding to the latest audit.

He continued, “I recognize the ongoing concern with past recommendations, and the addition of new findings and recommendations, and as a result, I will ensure that UDC addresses all items in the follow-up report.”

Mishandling medication and records

Numerous types of medication administered, auditors found, were not properly recorded and in some cases were given to the wrong patient. The inmates reportedly corrected staff themselves on some occasions.

In one case, a seizure medication was documented as being distributed only twice over a 30-day period, despite the prescription directing that it be taken twice daily. Auditors also observed a four-week Hepatitis C treatment that was only documented as being given 16 out of 30 days in November, despite explicit instructions that the medication be administered daily.

Distribution of drugs regulated by the Utah Controlled Substances Act were not adequately documented, violating state law.

“A previous supervisor contributed to the culture of noncompliance by directing medical staff to ‘chart what you can,’” the report says.

The 2021 audit chastised the Department of Corrections for collecting medical co-pays for mental health services, despite the inmate handbook saying they should be available for free to “remove any real or perceived barrier to accessing mental health services.”

Since then, auditors found “at least six instances” in which inmates were again charged co-pays for mental health services.

When inmates asked for other forms of health care, medical staff in many instances weren’t documenting those requests. Failing to keep those medical records “threatens patient outcomes” and leaves no trail of when treatment was provided, auditors wrote.

One inmate who was suffering from major depressive disorder and had a history of self-harm asked to see a mental health provider, saying that he was in “crisis.” His request wasn’t documented and was reportedly disregarded by medical staff. Auditors found the form he filled out shredded and discarded in a secured bin.

After going through the contents of three shred bins in the medical room, auditors found 39 care requests that hadn’t been entered into the prison’s electronic health record system.

Another request left unrecorded came from a patient who was classified as “high-risk” and had recently visited the hospital. He asked to see a medical provider, saying he was experiencing breathing problems and dizzy spells, and had recently fallen.

“While we note that some (care requests) may have limited impact on an inmate’s health, the effect of not documenting (a care request) could be devastating,” auditors wrote.

Managers developed new procedures to ensure requests were being recorded in an effort to adhere to the department’s own policy and National Commission on Correctional Health Care standards. But during night visits to the prison, auditors found staff scrolling on social media and watching videos while they were two weeks behind on reviewing requests.

Auditors also found that staff were mishandling other types of records related to inmates’ health. Over a 12-week period, they found personal medical information discarded in dumpsters in three different locations at the Salt Lake City prison.

They also encountered unlocked biohazard bins with used medical equipment, such as syringes and scissors, that were in areas inmates have access to.

“Medical staff have failed to follow management directives suggesting that the root cause of persisting problems such as (personal health information), stems from a general disregard for rules and policies,” auditors wrote.

Treatment for diabetic patients

In many cases, care for incarcerated people with diabetes doesn’t meet the widely accepted standards from the American Diabetes Association, the latest audit found. The organization recommends insulin be administered 30 minutes before meals.

But inmates are waiting as long as nearly quadruple that time — 110 minutes — for a meal, auditors observed, which is an increase from the 92 minutes seen during the 2021 audit. As noted in the report, such deviations from the half-hour standard “could result in serious complications.”

In most instances, staff didn’t offer patients a snack while they waited, and inmates who are new or have behavioral problems often aren’t able to purchase food through the commissary.

Among new intakes who are diabetic, auditors observed more than 50 instances of blood sugar readings being “well above or below” what the ADA recognizes as a normal reading.

One of those inmates, auditors wrote, had a critically low blood sugar reading but was not approved for food beyond scheduled mealtimes and did not qualify for a special box of food for those with medical needs because of how recently he had arrived.

Inadequate treatment for diabetic patients is most prevalent at the Utah State Correctional Facility in Salt Lake City, whereas at the Central Utah Correctional Facility in Gunnison, staff have offered additional care to people with diabetes to resolve such issues, auditors reported.

Staff retention and satisfaction

In its efforts to implement legislative auditors’ past recommendations, the Department of Corrections has run into several recent snags.

When it attempted to transition to a new medical records system last August, it lost thousands of prescription records. The Department of Corrections continues to have problems with that system, and auditors wrote that the system limited the follow-up audit because it doesn’t track data in a way that meets National Commission on Correctional Health Care standards.

Over the last year, the department has also experienced significant turnover of its medical staff — from the top to bottom. The director of prison medical was fired last July, and the deputy director retired in October. Several other members of leadership also left.

In 2022, the turnover rate for EMTs was 97%, and 57% for nurses. An internal survey found that 47% of nursing staff were “dissatisfied” or “very dissatisfied” with their job.

“Medical personnel report challenges such as being understaffed, overworked, and underpaid as reasons for the lack of productivity and noncompliance,” the report read.

The Department of Health and Human Services began helping the Department of Corrections with some of its medical responsibilities last August, and Corrections Executive Director Nielson said he “quickly recognized through the resources that they brought to bear that they are truly experts and professionals in this field.”

The Legislature wrote in this year’s appropriations that it “intends that the Department of Corrections work with the Department of Health and Human Services over the 2023 interim to fully transfer provision of medical services at state correctional institutions to the Department of Health and Human Services by July 1, 2024,” and appropriated millions of dollars toward that effort.

As it works toward the transition, a spokesperson for the department said the audit shows where its biggest challenges will be, and that it’s prepared to resolve the uncovered issues.

“We’ve seen action and boots on the ground, so I think we’re very hopeful that things are moving in the right direction,” said Brian Dean, the Legislature’s deputy auditor general.