By Eva Ruth Moravec
San Antonio Express-News
June 4, 2010
A Bexar County Jail employee is being disciplined after failing to properly complete a single-page medical screening form during an inmate’s intake, causing the facility to fall into noncompliance with state standards once again.
Meanwhile, an independent review of practices at the jail released under the Freedom of Information Act reveals that Detention Health Care Services staff did not complete psychiatric screenings on two inmates who committed suicide in 2009. Other issues were also noted in the independent review, and both errors in screenings have caused the sheriff’s office and the medical staff to review their policies.
Adan Munoz Jr., executive director of Texas Commission on Jail Standards, said his agency issued the notice of noncompliance May 24, two days after Theresa Olden, 46, died of natural causes at the jail annex’s infirmary. Although the Bexar County medical examiner’s office ruled the death was caused by a pulmonary embolism, the TCJS examined the circumstances of her death, as it does with all inmate deaths.
“Information we’ve received reveals Bexar County isn’t completing all of the screening form; parts of the document weren’t filled in,” Munoz said. “It’s just a paperwork situation — it doesn’t mean that led to the death.”
Deputy Chief Roger Dovalina with the Bexar County Sheriff’s Office said several questions — listed on a form completed upon intake, asking inmates about their mental health — weren’t asked, and one employee has been disciplined.
“We’re retraining our staff who do the interviews, and making sure they know the importance of filling out the forms,” he said.
The jail has 30days from when the noncompliance notice was issued to come into compliance with state law, but the incident marks the second demerit the jail has received for failing to complete screenings.
The first came in the form of an independent review, conducted by national inmate suicide expert Lindsay Hayes of the National Center on Institutions and Alternatives at no cost to Bexar County taxpayers.
Among other problems, Hayes found that two Bexar County Jail inmates who committed suicide last year were not psychiatrically screened by DHCS staff, employed by University Health System. He recommended that staff should be randomly audited and reminded to fill out the forms, the report states, and University Health System leadership agrees.
Theresa Scepanski, the system’s vice president of organizational development, said the screening form is mandatory, but some employees had stopped the screening after inmates said they weren’t suicidal.
“Staff is required to complete the entire screening tool,” she said in an e-mail, “and we have already started a random record audit to ensure that the tool is being completed.”
Hayes’ February jail visit came at the request of Sheriff Amadeo Ortiz, who wanted an independent third party to evaluate practices after Bexar County had more than three times the national average of inmate suicides last year. Five inmates hanged themselves at the 200 N. Comal St. facility last year.
This year, two inmates have hanged themselves in the Bexar County Jail. Joe Anthony Lopez, 26, was found in a routine inspection just before Hayes’ February visit; Nicholas Tucker, 22, was found during a routine check May 28.
Dovalina said Tucker, who’d been in jail for three days on an assault charge, did not show any signs of being suicidal and was housed in a general-population cell.
Tucker’s family declined to comment.
State jail regulators determined, preliminarily, that the jail didn’t do anything wrong.
“The cell checks, the forms used to document when an inmate’s booked — everything appears to be there,” Munoz said. “What we’re seeing on paper is that there’s no need to go down there and investigate.”
“If an inmate wants to commit suicide, it’s almost impossible to keep him from doing it,” Ortiz said, “but even one is too many. Mr. Hayes provided us with some very good recommendations that we will definitely implement.”
Also mentioned in Hayes’ report was a “high tolerance for potentially suicidal behavior,” a crowded booking area that doesn’t give inmates much privacy during medical screening, a lack of suicide-prevention training, housing suicidal inmates in cells not equipped for them and several falsified reports.
In light of the evaluation, Ortiz said 30 detention officers will receive crisis-intervention training this year and other training to help them notice changes in inmates’ behavior that could pre-empt a suicide. Scepanski said DHCS is implementing a new mandatory suicide-prevention training class, and a mandatory pre-service suicide-prevention curriculum.
Jail staff will talk more about potentially suicidal inmates with the aim of eliminating Hayes’ “high tolerance” observation, and so far this year, overcrowding issues experienced last year — which caused potentially suicidal inmates to be placed in cells where they could hang themselves — have not been repeated, officials said.
Capacity at the jail is 3,670 inmates, officials said, and 805 inmates can be held in the annex.
The booking-area issues will be addressed in a facility to be built, Ortiz said, and two guards were disciplined for falsifying details on two suicides.
Overall, Hayes said the issues he found with Bexar County Jail are typical of jails that experience an unusually high number of suicides, and he’s confident the problems will be fixed. He conducts about a dozen evaluations nationwide annually, he said.
“There were a large number of suicides in a small period of time, which is concerning to everyone,” he said in a telephone interview after his report was made public. “But I have every indication that they will make the internal changes.”