NEW YORK STATE COMMISSION OF CORRECTION In the Matter of the Death of Maria Viera, an inmate of the Monroe County Jail TO: Sheriff Patrick O'Flynn Monroe County Sheriff's Office 130 Plymouth Avenue South Rochester, NY 14614 FINAL REPORT OF THE NEW YORK STATE COMMISSION OF CORRECTION FINAL REPORT OF MARIA VIERA PAGE 2 GREETINGS: WHEREAS, the Medical Review Board has reported to the NYS Commission of Correction pursuant to Correction Law, section 47 (1) (d), regarding the death of Maria Viera who died on September 2, 2010 while an inmate in the custody of the Monroe County Sheriff at the Monroe County Jail, the Commission has determined that the following final report be issued. FINDINGS: 1. 2. 3. 4. Maria Viera was a 53 year old white female who died on 9/2/10 'at 6:17 a'.m. from Myocarditis whil_e in the custody of the Monroe County Office of the Sheriff. Viera was receiving fifteen minute supervision when a correction officer and a FINAL REPORT OF MARIA VIERA .5. PAGE.3 On 8/31/10, Viera was remanded to the Monroe County Jail and at 5:28p.m. booked by Deputy R.S. The deputy completing the Booking Officer's Visual Opinion noted an affirmative answer to the question of "Does the resident appear to be under the influence of alcohol? If yes, are any of the following observed?:" 1. 2. 3. 4. 5. 6. 7. Headache, auditory or visual hallucinations Tremors or shakes Nausea or vomiting Sweating Nervous, fidgety and/or pacing Confusion/disorientation with time, place and/or people Itchy; crawling, burning skin or numbness Deputy R.S. stated that she gave an affirmative answer to the question as Viera self-reported she was under the influence.of drugs. Deputy R. S. stated she did not observe any of the listed symptoms. 6. Prevention Screening Form, giving Viera a score of two. Viera denied any history of counseling or mental health evaluation/treatment. The questions that were affirmatively "Detainee has a his of drug or al_cohol abuse;" and "Detainee is apparen or drugs." .Deputy R.S. stated she answered this question with a positive answer as Viera self~reported she was under the influence of drugs. 7. On 8/31/10 at approximately 8:30p.m., Cpl. T. escorted Viera, who was unarraigned at this time, to the medical office where she was s?creened by a registered . nurse employed by FINAL REPORT OF MARIA VIERA PAGE 4 Correctional Medical Care (CMC). CMC is the contracted health care provider and is a general business corporation that holds itself out as both a medical and psychiatric services provider to County Jail inmates. RN T .A. signed the Booking Officer's Visual Opinion form completed by Deputy R.S. that indicated she reviewed it. On the Booking ?Officer's Visual R.S. indicated violation of CMC Procedure or Other Drug Problems which states: Inmates who admit to daily or drug consumption will be placed on a DETOX flow sheet and monitored, This decision speaks to RN T.A. 's inexperience. RN T.A. stated at the time of the Commission's interview, she had been a registered nurse for about one year and her only nursing employment was her one year at the Monroe County Jail. Assignment of a registered professional nurse one year out of nursing school and without medical-surgical experience to an intake medical/mental health/substance abuse assessment post without experienced supervision represents inadequate and inappropriate credentialing on the part of CMC, Inc. B. RN T.A. stated she "assumed" she called the Rite Aid pharmacy, as it was her practice to document the medication's name, dosages, administration times on the form, if the medications are verified. RN T.A. stated she leaves FINAL REPORT OF MARIA VIERA the PAGE 5 on the medical screen blank if she is T.A. 's reasoning specious rationalization and for that reason invalid. In its mortality review of this case, CMC, Inc. management asserted that RN T.A. most certainly contacted? the pharmacy. This is not consistent with RN T.A.'s statements to Commission staff or with the record. 9. Deputy R.S. stated upon Viera's return from the medical unit, she was not given paperwork completed by the medical department notifying security to place the inmate on detoxification status. 10. On 9/1/10 at 8:30 a.m., Viera refused to attend her court appearance for arraignment. Deputy D.C. and Transport Officer S.I. attempted to change her mind about her decision. Viera cited that she already knew that she would be held in jail and would not consider attending her arraignment. The judge who heard Viera's case arraigned her in absentia. Deputy D.C. stated she. was the booking officer who receives the postarraignment paper work and lists the inmates who need to see the medical staff for a second screening with the medical staff. On 9/1/10 at approximately 10:00 a.m., Deputy D.C. contacted the City Court to verify that Viera had been committed and was informed that Viera had been committed. The securing order for commitment was signed by City Court Judge T.M. with an adjourned court date of 9/2/10 at 11:00 a.m. 11. As part of Monroe County Jail procedures, Deputy D.C. had Viera change into a jail jumpsuit. Deputy D.C. stated she observed Viera' s hygiene as poor. Viera reported she had been abusing heroin on a daily basis and been in a "crack house" for several days prior to her arrest. Deputy D.C. stated she locked Viera back into booking cell S-17. The usual practice is when female inmates attend their arraignments, their paperwork is returned to the booking officer including the booking check list that reports whether they are to be placed on the medical call-out sheet. The inmates are then referred to the medical unit for a second screening. Deputy D. S. never received any paperwork for Viera as she did not attend court. Instead her paperwork werit to jail records staff. On 9/1/10 at 11:19 a.m., Deputy D,C. changed Viera's status in the computer system to a detoxification status because of her knowledge of Viera during past Monroe County Jail FINAL REPORT OF MARIA VIERA PAGE 6 incarcerations and the fact she reported to the deputy that she was using heroin daily. 12. On 9/1/10 at approximately 2:45 p.m., Deputy D.C. removed Viera from detoxification on the status board in the computer since no formal paper work was provided by the facility' s medical department. 13. On 9/1/10 at approximately 5:30 p.m., Deputy R.S., who was assigned as the evening officer in booking, stated Viera ate her dinner. Deputy R.S, stated that at 6:.45 p.m. another inmate requested to see the nurse. called the medical unit and notified them of such. Deputy R.S. stated as t of the housing area to the Central Booking desk, she observed Viera bending over the toilet. Deputy R.S. asked Viera if she was alright and she nodded in response, laying back on her mat. Although Viera did not ask to see the nurse, Deputy R.S. stated tha.t RN M. did not perform a physical assessment of Viera, even though Viera was observed to be exhibiting clinical signs warranting a nursing assessment. RN M. was unavailable to interview as she had retired. 14. All three shifts of security staff in the reception unit compared the computerized detoxification lists. If an inmate is removed from the detoxification list, the reception security staff will check the computerized notes verifying that the inmates has been released from detoxification. On 9/1/10 at 10:00 p.m., Deputy D. from Monroe County Jail's Reception Unit placed Viera back on the computerized status board as an inmate needing detoxification. However, at the time of Viera's incident, the medical department and security were maintaining separate lists. The nursing staff could not the computer system but could ask the 15. On 9/2/10 at approximately 12:40 a.m., Deputy C.M. opened cell door BKG #17 to let inmate F.G. into Viera's cell. Deputy C.S. stated she observed Viera awake lying on her side facing the wall. She observed Viera's head was moving and did look at the door as inmate F.G. was placed in the cell. Deputy C.M. stated Viera did not appear in any distress at that time. Deputy B.B. who assisted escorting inmate F.G. to the cell in FINAL REPORT OF MARIA VIERA PAGE 7 booking reported that Viera was lying on her left side facing the wall but turned her head as inmate F.G. entered the cell. On 9/2/10 at 2:10a.m., Sgt. M.L., who was the operations sergeant, made a round in booking and stated he observed nothing unusual. 16. Both Deputies C.M. and B.B. conducted 15 ?minute rounds in booking from 12:40 a.m. until the registered nurse arrived in the booking area at approximately 5:00 a.m. Deputy? C .M. stated that Viera continued to lie on her left side for the remainder of the night until the nurse entered t.he cell at 5:15 a.m. Deputy C.M. stated she did not open the cell after placing inmate F.G. into Viera's cell and assumed Viera was sleeping. Officer B.B. stated she did not enter Viera's cell until she accompanied the nurse on the detoxification round. Officer B.B. stated that she observed Viera lying on her left side facing the wall and assumed she was sleeping. 17. On 9/2/10 at 5:15a.m., RN R.W. was completing The clinical evidence at the scene indicates that Viera was dead for an extended period prior to discovery. 18. a.m., the Rochester City Fire Department received call and arrived at the scene at 5:39 a.m. FINAL REPORT OF MARIA VIERA 19. PAGE 8 The Monroe County Office of the Sheriff's investigation into Viera' s_ death was conducted by Lt. J.K. He determined that due to Viera's refusal to attend her arraignment, her postarraignment paperwork was not delivered to the booking officer, but rather was delivered back to Monroe County Sheriff's jail records unit. As a result, Viera was not placed on the list for the medical staff to evaluate. As a result, Lt. J. K. made ? recommendations for improving the process of booking inmates. The Monroe County staff interviewed reported satisfaction with the procedures. The recommendations are: All staff should be reminded to notify the medical staff if they place an inmate on detoxification status and also report to their supervisors if an inmate refuses to attend their arraignment. All staff should be reminded to separate paperwork to give to the booking officer or a supervisor after arraignment. The medical staff should place inmates on detoxification status when they first see them, not leave sticky notes. A medical deputy is now assigned to the booking area to control movement to and from the medical area and collect the notifications from the medical staff to place inmates on detoxification status for the purpose of giving them to the reception security staff. Medical staff has access to? security's ?list of inmates on detoxification status and constant supervision. Detoxification medical rounds should be conducted as close as possible to the same time daily. The Booking and Reception security staff is making joint rounds at shift change with the registered nurses working in the booking area to confirm they have the same inmates on detoxifica.tion status. Also CMC, Inc. updated its detoxification policy and their nurses reported to Commission staff that they now complete joint rounds with security staff at shift change in Booking and Reception which has improved communication with the security staff. FINAL REPORT OF MARIA VIERA PAGE 9 RECOMMENDATIONS: TO THE SHERIFF OF MONROE COUNTY: That a review be conducted into the performance of Deputies. C.M. and B.B. who were assigned the supervision of Viera from 9/1/10 to 9/2/10 from 11:00 p.m. to 5:15a.m., given that Viera was deceased for an extended period prior to discovery. TO THE PRESIDENT OF CORRECTIONAL MEDICAL CARE, INC. (CMC): 1. CMC, Inc. shall provide the Medical Review Board with a written explanation as to why RN T.A. was not properly credentialed by experience, orientation, training, supervision and demonstrated competence to manage the intake medical/mental health/substance abuse assessment and referral operations of a large urban jail, and what remedial measures will be taken in that respect. 2. CMC, Inc. shall monitor the registered nurse, T.A., for her? practice of professional nursing in the areas of assessment and documentation of inmates' admission encounters for evaluation, monitoring and referral of medical, mental health, and drug/alcohol use and detoxification procedures for a period of not less than nine (9) months. The Board requires that CMC, Inc. advise the Medical Review Board within one year as to the outcome of such review and action (s) taken for continuing enhanced supervision of this registered nurse's practice. 3. CMC, Inc. shall deliver an in-service education colloquium to the professional nursing staff at the Monroe County jail regarding the physical assessment, treatment, and documentation of inmates' abuse of alcohol/drugs and associated detoxification procedures. Special emphasis should be given to the quality of nursing rounds and to indicators for physical assessment based upon clinical observations without regard to whether the detoxing inmate requests to be seen. Written evidence that such colloquium was delivered shall be provided to the.Medical Review Board on or before January 31, 2012. 4. That a review be conducted into the performance of R.N. M. who was assigned medical/nursing supervision of Viera from 9/1/10 to 9/2/10 from 11:00 p.m. to 5:15a.m., given that Viera was deceased for an extended period prior to discovery. FINAL REPORT OF MARIA VIERA PAGE 10 PLEASE TAKE NOTICE that your evaluation and response to the above-entitled recommendations should be made in writing directly to this office within thirty (30) days. WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner, NYS Commission of Correction, 80 Wolf Road, 4th Floor, in the City of Albany, New York 12205 this 20ili day of December, 2011. Commissioner PHR:mj 10-M-124 9/11 cc: Emre Umar, President, Correctional Medical Care, Inc.