Shortage of medical staff plagues Milwaukee jails
At one point this spring, a court-appointed watchdog found that 30% of all medical jobs at the county's two jails weren't filled
By Jacob Carpenter
Milwaukee Journal Sentinel
MILWAUKEE — The private contractor responsible for medical care at Milwaukee County's jails has failed to meet basic standards of care and staffing mandates, putting inmates' health at risk, newly obtained documents and interviews with former employees show.
At one point this spring, a court-appointed watchdog found that 30% of all medical jobs at the county's two jails weren't filled, a rate he called "inconsistent with adequate quality of service."
Inadequate staffing by Armor Correctional Health Services and poor record-keeping by employees have led to a failure to deliver timely medical treatment, according to the records and former employees.
The problems mirror some found recently at two jails staffed by Armor in New York, where the company has been temporarily banned from bidding on contracts as part of a legal settlement.
Armor's issues come as investigators look into four deaths since April at the Milwaukee County Jail, including one reported on Friday. It's not clear whether Armor's performance contributed to any of the deaths, but one inmate died of dehydration and a woman gave birth to a stillborn child without jail or medical staff noticing.
Armor's failures are documented in a May report by Ronald Shansky, who monitors overcrowding and medical services at the Milwaukee County Jail and House of Correction. Shansky, a medical doctor, inspects the jail twice a year under terms of a 2001 legal settlement between the county and inmates.
Armor serves both the downtown Milwaukee County Jail and the House of Correction in Franklin. The Milwaukee County Jail, which is run by Sheriff David A. Clarke Jr., mostly houses pretrial detainees. The House of Correction, which is operated by the county, holds convicts serving short sentences and overflow from the Milwaukee County Jail.
Shansky's findings focus largely on staffing vacancies. He singled out Armor's lack of permanent, full-time nurses, who make up the majority of the jails' medical staff. Half of all registered nurse and nurse practitioner positions were vacant in May, he found.
Shansky also criticized Armor for employing just one psychiatrist who worked three days per week. He called the lack of psychiatry services "the main problem with mental health" at the jails.
Two former nursing supervisors who recently worked at the House of Correction echoed Shansky's findings.
In separate interviews with the Milwaukee Journal Sentinel, the former staffers said they saw inmates who didn't get necessary medications and went weeks without being seen by a nurse or doctor. Sandra Baumgartner, a former nursing supervisor at the House of Correction, said she was stretched so thin that she feared being unable to respond to a major medical emergency — which could put her nursing license at risk.
"It's not run very well, they don't have staffing and inmates aren't getting the things they need," Baumgartner said. She started working at the jail for Armor in May and said she quit in August out of frustration with Armor.
In a written response to questions from the Journal Sentinel, Armor said it "absolutely" has provided adequate staffing levels. It disputed Shansky's statements about staff vacancies, arguing that its subcontractors help fill medical shifts at the jails.
"Armor's Milwaukee-based team of caregivers has made many improvements in the delivery of quality patient care since contract inception," the company said in the statement. "Our Milwaukee team works diligently to ensure consistent delivery of quality patient care."
But Armor's monthly staff-level reports, obtained by the Journal Sentinel, suggest Armor hasn't fixed its employment issues since Shansky's visit in May.
In September, the company had so few nurse practitioners that it could fill only half of the contractually required staff hours. Its registered nurses worked 80% of the required hours. Armor covered some of the nursing shortage by adding more licensed practical nurses, who have fewer credentials and make lower wages because they are qualified to provide only basic medical care.
The jail did employ three psychiatrists in September, but they combined to work just 117 hours that month, barely half of the required 208 hours.
Armor did not respond to questions about the discrepancies between the staffing reports and its stance that it sufficiently staffed the jails.
Clarke, who pushed to hire Armor in 2013, refused an interview request about Armor's performance at the Milwaukee County Jail. Through a spokeswoman, Clarke said the Journal Sentinel's coverage has been "biased, unfair and written more as editorials with an agenda, rather than informative news."
One of Clarke's top deputies, Inspector Edward Bailey, said at a public hearing in June that "everybody is happy" with the quality of medical services provided but Armor has "a staffing and retention issue that needs to be addressed."
House of Correction Superintendent Michael Hafemann also refused an interview request.
In an email, Hafemann said House of Correction staff ensures all Armor contract provisions are being met and properly credentialed medical personnel are hired. He also said the staffing reports obtained by the Journal Sentinel "can be misleading" but refused to clarify or provide reports that he believes portray a more accurate picture of staffing levels.
A need for help
The quality of inmate medical care has been an issue at the county's jails for two decades.
In 1996, a group of inmates sued the county, alleging overcrowding and inadequate medical treatment. The lawsuit resulted in a settlement in 2001, when the county agreed to specific standards of care. To ensure compliance, Shansky was appointed to monitor and report on whether improvements were made. Based in Chicago, Shansky is a physician who provides outside consulting and monitoring of medical care in prisons and jails.
In the 15 years since the settlement, the Milwaukee County Jail and House of Correction still haven't reached full compliance.
"This has been going on way too long," Milwaukee County Supervisor Peggy West said at a June committee meeting. "This was supposed to take two years."
The county was responsible for inmate health care until 2013, when the county turned to Armor amid challenges with hiring medical staff. Clarke argued the private company would save the county money and provide better service.
At the time, Armor worked in about 20 county jails and state prisons, primarily in Florida. The Miami-based company brought in about $150 million in revenue from inmate care contracts in 2013, posting an $18 million profit, according to confidential financial records obtained by the Journal Sentinel.
Armor won the Milwaukee County contract, and in the first couple years, it received mostly positive reviews.
"Overall, I believe we have continued to see some progress and the program has moved closer to substantial compliance" with the court settlement, Shansky wrote after a visit in November 2015.
Then Shansky came back in May.
Short staff, bad results
In the winter of 2016, Armor's health services administrator, director of nursing and assistant director of nursing all left Milwaukee's county jails. At the same time, Armor didn't have enough psychiatrists, nurses and physician assistants to meet its contract obligations.
In his May report, Shansky noted that 17 of the 31 required, full-time registered nurse positions were vacant, as were seven of the 14 nurse practitioner jobs. Armor used third-party contractors and overtime to patch some gaps, but Shansky worried that wasn't enough.
"Providing reasonable quality services in a timely fashion is extremely problematic when such a high vacancy rate exists," he wrote in his report.
Armor's staffing reports, obtained by the Journal Sentinel through a public records request, show the company has consistently failed to meet its requirements — even with other contractors providing medical employees.
For example, the company is supposed to provide the equivalent of 31 full-time registered nurse positions per month. But from January to September, the company averaged about 21.5 positions filled.
The company is also required to fill the equivalent of 10 full-time advanced registered nurse practitioner jobs. So far this year, it has averaged 6.4 positions filled.
Overall, the company has fallen 14% short on its staffing requirements this year. As a result, the county has withheld about $875,000 from the company, which has a $15.8-million base contract.
Armor officials said they've used outside, third-party medical staffing agencies to "meet our obligation and commitment to deliver quality patient care." The company, they said, is not immune to the nationwide nursing shortage.
But the former nursing supervisors interviewed by the Journal Sentinel said Armor's inability to cope with that shortage has affected inmate care.
Baumgartner, the nurse who feared losing her license, said there's "no validity at all" to Armor's claims of providing adequate treatment. She said many inmates who turned in written requests to see a doctor or nurse would go weeks before being seen.
"Every day, the pile of sick call slips was probably six inches thick," Baumgartner said. "If, by chance, there was somebody to do sick calls, you'd take a couple off the bottom, and then there'd be more the next day."
Former House of Correction supervisor Gloria Beal, a 20-year employee at the facility, said she saw a multitude of problems: inmates suffering from hypertension didn't get regular blood pressure monitoring, anti-seizure prescriptions weren't given at proper intervals, patients went through drug withdrawal without any medication.
Beal said the issues started in early 2016, when Armor lost three top administrators in Milwaukee and several nurses left the company.
"I have seen something that was very good decline into something not so good," said Beal, who was fired in May for bringing a cellphone into the jail.
Shansky was unable to gauge the full impact of staff shortages on patients because Armor's records systems didn't work properly.
For example, he couldn't determine how long inmates had to wait after asking to see a doctor or nurse — a basic metric in corrections health care. Shansky manually checked some files, with varying results.
"In the records we reviewed, we did identify a few which had significant delays, more than a week, and also an inconsistency between the written request and what was described on the physical findings," Shansky wrote.
Shansky also found "critical documents" were missing from the files of patients who were hospitalized outside of the jail or treated by outside doctors.
A pattern of trouble?
Nationally, Armor has had a mixed record of performance.
Armor's clients have been generally complimentary of the company. In a bid proposal last year, Armor included letters of recommendation from nearly all of its clients, which lauded Armor for its commitment to patient care and the local communities they serve.
But Armor endured a rash of deaths and reports of patient mistreatment at two jails it served in New York: the Nassau County Correctional Center on Long Island and the Niagara County jail in the Buffalo area.
From 2011 to 2015, at least seven inmates died following major lapses in medical care at the jail, according to the New York Commission of Correction's Medical Review Board. In 2014, the board wrote that Armor "has engaged in a pattern of inadequate and neglectful medical care" in New York, leading it to question whether Armor should care for inmates.
The New York attorney general sued Armor in July for fraud, breach of contract and making false claims. In its lawsuit, the attorney general's office levied some of the same allegations as those voiced by Shansky and former employees: inadequate staffing, incomplete record-keeping and failure to timely treat patients.
The two sides settled this month, with Armor agreeing that it would pay $350,000 in penalties and reimbursements and refrain from bidding on any contracts in New York for three years. Armor's contracts with Nassau and Niagara counties have ended, so the company is no longer in the jails there.
In the settlement, Armor did not admit any wrongdoing. Armor has called the New York Medical Review Board's investigations "incomplete," "biased" against private contractors and "consistently inaccurate with respect to the facts and applicable medicine."
It remains to be seen whether Armor bears any responsibility for the four deaths in the Milwaukee County Jail this year.
The medical examiner's office confirmed one inmate, Terrill Thomas, 38, died of dehydration while in solitary confinement in April. The office hasn't released information about the July death of the stillborn child. And the cause and manner of death remains unknown in the case of 38-year-old Kristina Fiebrink, who was found deceased in her cell in August, and 29-year-old Michael Madden, who died last week.
The Milwaukee Police Department and Milwaukee County Sheriff's Office have not released any investigative findings in the deaths. The Wisconsin Department of Corrections' Office of Detention Facilities, which investigates in-custody deaths after local police finish their reviews, aren't reviewing any of the cases yet.
Armor representatives declined to comment about the deaths.
Shansky did not address Thomas' case and Armor's role in his May report because the company did not provide him with documents about it. He wrote that he was "more than a little chagrined" about Armor's failure to provide the records.
Shansky is scheduled to inspect the jails again on Monday, with a report issued in the following weeks.
©2016 the Milwaukee Journal Sentinel