Covid-19 Review Series Fact Sheet, Part 3

Roy W. Wesley OFFICE of the Inspector General OIG INSPECTOR GENERAL Bryan B. Beyer Chief Deputy Inspector General Fact Sheet Independent February 1, 2021 Prison Oversight The COVID-19 Review Series: A Special Three-Part Review Prepared by the Of f ice of the Inspector General at the Request of the California State Assembly Part Three: California Correctional Health Care Services and the Cumulative Cases of COVID-19 Among Both the Incarcerated Population and Departmental Staff at San Quentin State Prison From May 31, 2020, California Department of Corrections and Rehabilitation Caused Through August 31, 2020 a Public Health Disaster at San Quentin State Prison When They Transferred Medically Vulnerable Incarcerated Persons From the California Institution for Men Without Taking Proper Safeguards In April 2020, the Speaker of the Assembly requested the Office of the Inspector General (the OIG) assess the policies, guidance, and directives the California Department of Corrections and Rehabilitation (the department) had implemented since February 1, 2020, in response to the novel coronavirus disease (COVID-19). Specifically, the Speaker requested we focus on three concerns: 1) the department’s screening process for all individuals entering a prison or facility in which incarcerated persons are housed or are present, 2) its distribution of personal protective equipment to departmental staff and incarcerated persons, and 3) how it treats incarcerated persons who are suspected to have either contracted or been exposed to COVID-19. This Fact Sheet presents highlights from the third report in this series, which we published in February 2021. Note: Confirmed Date is the earliest collection date of a positive or detected COVID-19 test. Source: Unaudited data provided by the California Department of Corrections and Introduction Rehabilitation to support its population and staff COVID-19 trackers. The California Institution for Men was one of the department’s first prisons to experience a COVID-19 outbreak. As of May 27, 2020, the department morbidity and mortality from COVID-19 disease. Between May 28 and reported 654 confirmed cases among the prison’s incarcerated population and May 30, 2020, in an effort to protect those individuals from the virus, California 55 cases among its staff. Among the prison’s population were many incarcerated Correctional Health Care Services (CCHCS) and departmental management persons with various medical conditions, which made them vulnerable to severe transferred 189 incarcerated persons to Corcoran and San Quentin. Findings Pressured by CCHCS executives, the California Institution for Men inadequately screened 189 incarcerated persons before transferring them. • Emails we reviewed showed that CCHCS executives and departmental management pressured the California Institution for Men to rush the transfers of incarcerated persons. • Despite knowing COVID-19 test results were outdated, CCHCS executives pressured the California Institution for Men to transfer medically vulnerable incarcerated persons. ○ The prison had not tested 172 of the 189 transferred incarcerated persons for COVID-19 for at least two weeks prior to the transfers. Time Line of COVID-19 Testing of Incarcerated Persons Transferred From the California Institution for Men on May 28, 29, and 30, 2020 80 7766 S C Q O R = = 48 28 70 N = 189 60 Incarcerated Persons 50 40 S C Q O R = = 20 173377 30 S C Q O R = = 15 122277 2299S C Q O R = = 25 4 20 SQ = 111144 TThhrreeee AArrrriivvaall COR = 3 DDaatteess 10 33 S C Q O R = = 2 1 S C Q O 11 R = = 0 1 S C Q O R = 11 = 1 0 11 S C Q O R = = 0 1 CC DD CC RR 0 1 6 12 131415 19 22 23 28 29 30 May 2020 Test Collection Dates at the California Institution for Men 10111 Old Placerville Road, Suite 110, Sacramento, California 95827 5 Telephone: (916) 255-1102 5 www.oig.ca.gov htlaeh cinortcele ’secivreS eraC htlaeH lanoitcerroC ainrofilaC ehT :ecruoS s’noitatilibaheR dna snoitcerroC fo tnemtrapeD ainrofilaC eht dna metsys drocer .sgol noitatropsnart 2,500 n = 2,237 2,000 N = 2,514 Incarcerated Confirmed Persons Cumulative Cases 1,500 1,000 n = 277 500 Departmental Staff 0 31 4 8 12 16 20 24 28 3 7 11 15 19 23 27 31 4 8 12 16 20 24 31 May June July August 2020 California Institution for Men Medical Executive California Institution for Men Supervising Nurse California Institution for Men Physician and Nurse Executive California Institution for Men Medical Executive [Official Title] California Institution for Men Supervising Nurse Medical Executive Physician Departmental Headquarters Manager Corcoran Manager Corcoran Manager Departmental Headquarters Manager Roy W. Wesley OIG OFFICE of the Inspector General INSPECTOR GENERAL Bryan B. Beyer Chief Deputy Inspector General Fact Sheet Independent February 1, 2021 Prison Oversight Findings (continued) • Lacking guidance, the California Institution for Men likely screened incarcerated persons for symptoms of COVID-19 too soon before their transfers to properly identify symptomatic individuals. ○ The prison screened 55 of the incarcerated persons who were to be transferred to San Quentin at least six hours before they boarded the transportation buses. The department transferred incarcerated persons on buses without allowing for the proper amount of physical distance between incarcerated persons. • CCHCS executives approved increasing the number of passengers on a bus from 19 persons to 25. Test Results for Incarcerated Persons Housed in San TTiieerr 55 Quentin’s South Block Facility’s Badger Housing Unit on May 31, 2020, Who Tested Positive for COVID-19 TTiieerr 44 Between May 31, 2020, and August 6, 2020 Transferred Tran N sf o e t r red TTiieerr 33 P N P N Tier 5 5533 17 0 0 TTiieerr 22 Tier 4 3388 9 0 0 Tier 3 0 0 3300 40 Tier 2 0 0 2277 43 TTiieerr 11 Tier 1 0 2 2299 33 Note: Of the incarcerated persons who transferred from the California Institution for Men to San Quentin, 119 were housed on tiers 1, 4, and 5 in the prison facility’s Badger housing unit along with 202 incarcerated persons who were already housed in the unit. Source: Unaudited data provided by the California Department of Corrections and Rehabilitation to support its COVID-19 population tracker and housing data from the Strategic Offender Management System. 10111 Old Placerville Road, Suite 110, Sacramento, California 95827 5 Telephone: (916) 255-1102 5 www.oig.ca.gov .lareneG rotcepsnI eht fo ecfifO eht yb hpargotohP Duration of Time Between When California Institution for Men Health Care Staff Screened Transferring Incarcerated Persons for COVID-19 Signs and Symptoms and When the Incarcerated Persons Departed the Prison More Than 12 hours * 3 N = 189 Incarcerated Persons 10 to 12 Hours 15 Transferred to: California State Prison, Corcoran 8 to 10 Hours 11 San Quentin State Prison 6 to 8 Hours 26 CCHCS Medical Executive 4 to 6 Hours 20 CCHCS Director 2 to 4 Hours 13 37 0 to 2 Hours 16 Initial After Departure † 34 13 CCHCS Director No Record on File 1 CCHCS Medical Executive 0 10 20 30 40 50 * One entry was 25 hours before departure. First Name † Screening time recorded in the department’s electronic health record system was after the bus departure time recorded on the transportation logs. Sources: The California Correctional Health Care Services’ electronic health record system and the California Department of Corrections and Rehabilitation’s transportation logs. San Quentin was not equipped to properly quarantine or isolate incarcerated persons with suspected and confirmed cases of COVID-19, and the prison failed to take actions that could have mitigated the resulting widespread outbreak. • One hundred and nineteen incarcerated persons who transferred into San Quentin were housed in the prison’s Badger Housing Unit, which contains open bar cells where air could move and circulate. After confirming cases of COVID-19, “ • Within the first few weeks, 15 incarcerated persons who transferred from the both San Quentin and Corcoran “By all accounts, the failed to properly conduct contact- California Institution for Men tested positive for COVID-19. COVID-19 outbreak at tracing investigations, risking the • Of the 321 incarcerated persons housed in San Quentin’s Badger Housing further spread of COVID-19. San Quentin has been the Unit on May 31, 2020, 177 tested positive for COVID-19 from May 31 through • San Quentin did not conduct worst epidemiological August 6, 2020. contact tracing for the transferred disaster in California • The prison allowed staff to work and move throughout the prison, likely incarcerated persons who tested correctional history.” transmitting the virus from location to location. positive; the prison stated there were too many positive cases over ○ By the end of August 2020, 2,237 incarcerated persons and 277 staff members a short period of time to conduct Source: California First District at San Quentin had contracted COVID-19. contact tracing. Court of Appeals ruling on October 20, 2020. In re Von • Corcoran conducted contact Staich (2020) 56 Cal.App.5th 53, tracing; however, it did not make 57, review granted and cause a strong effort to identify all transferred sub nom. Staich on close contacts, and recorded only H.C. (Cal., Dec. 23, 2020, No. incarcerated persons in the cell / S265173) 2020 WL 76479”21. bunks near the infected person. N = 321 P = Positive N = Not Positive Notable Results Our review found the department’s efforts to prepare for and execute the transfers of 67 medically vulnerable incarcerated persons to California State Prison, Corcoran, and 122 to San Quentin State Prison were deeply flawed, and risked the health and lives of the medically vulnerable incarcerated persons whom the department was attempting to protect, as well as the staff transferring the incarcerated persons and those who worked at both prisons.