Key medical personnel were absent or sidelined by other Department of Corrections (DOC) administrators, according to the report by the Office of Corrections Ombuds.
Guards weren't forced to wear masks.
Symptomatic prisoners were allowed to mingle with others.
Urgent calls from a nearby hospital went unanswered.
The outbreak at Franklin County's Coyote Ridge Corrections Center sickened 277 prisoners and 73 staff and led to the death of two inmates. Missteps by administrators likely worsened the outbreak, according to the report by the ombuds office, an independent monitor. Findings of the investigation were released Monday.
"We know COVID-19 will enter the prisons; the question is how far it will spread and how damaging its impact [will be]," said Joanna Carns, director of the ombuds office. "The goal with this report is to bring transparency and closure to the incarcerated individuals and their families who lived through the outbreak, and to provide a roadmap of recommendations to DOC to help them fight the disease."
In response to the findings, a DOC spokesperson cited data showing that Washington's corrections system — unlike those of many other states, as well as prisons run by the federal government — has largely avoided outbreaks. Washington has one of the lowest rates of infections per 100,000 prisoners, according to data compiled by The Marshall Project.
" The Department of Corrections is continually enhancing its efforts to fight COVID and has implemented continuous quality improvement since the beginning of the pandemic," wrote spokesperson Susan Biller in an email.
The problems at Coyote Ridge started soon after the first inmate reported COVID-like symptoms, on a Friday night in May. Medical staff waited two days to test him, and his positive test result didn't arrive for another two days. Meanwhile, he was isolated, but his close contacts weren't tested or quarantined.
Other inmates said they reported symptoms to prison staff in May but weren't evaluated right away. One prisoner who felt ill, for instance, asked for a health check, but guards told him needed to sign up first. It wasn't until four days later, when he had a 102-degree temperature, that the prisoner was isolated and tested, according to the report.
Coyote Ridge is a minimum- and medium-security facility holding up to 2,468 men. About a fifth of the beds are for elderly inmates and those requiring assisted living — a population particularly vulnerable to COVID-19.
Prison staff prevented the virus from spreading into this high-risk ward by diligent mask-wearing and social distancing, among other measures — an accomplishment lauded by the ombuds report.
But in the main facility, the virus quickly spread.
Prison guards refused to wear face coverings, despite an April mandate from DOC headquarters. Coyote Ridge staff blamed state officials for "short-sighted management and bad leadership," according to the report, because they were "too slow with mandating that everyone wear" face coverings. Prison staffers, for instance, would carpool to work unmasked. Corrections officials believe staff likely introduced the coronavirus into the prison.
Once the virus had entered its walls, Coyote Ridge was slow to quarantine exposed inmates, investigators found. Administrators waited three days after the first patient's positive test result to quarantine a ward.
"By that point, the outbreak had already spread to multiple units," the report stated.
It was nearly another month before the prison placed all medium-security inmates on full lockdown, restricting their movements. Since then, the state has changed its protocols to require quarantine and isolation after symptoms are reported.
Where's the medical director?
When DOC realized it had a crisis on its hands, it staffed up an "incident command post" at Coyote Ridge, bringing administrators together with varied expertise, except for one key employee: the prison's medical director.
Instead, the emergency center was dominated by custody staff management — the side of the prison in charge of guards and operations. The core team included just one health care professional: Tim Taylor, the health services manager who was new to the role and had minimal medical training. He was unable to effectively advocate for more staffing, despite critical shortages, according to the report.
As the outbreak swelled, the facility medical director didn't enter the prison on 89% of workdays in June and 62% in July, investigators found. During that time, he was denied a seat in the command center, and instead sat in a small conference room nearby, apparently available for consultation.
But the administrators didn't lean on him for time-sensitive medical decisions.
DOC Chief Medical Officer Sara Kariko appeared on site at the command center for a few days at a time. But staff "felt micromanaged or, worse, some felt that the 'left hand didn't know what the right hand was doing,'" the report stated.
In one instance, Kariko "chastised" the medical director after he ordered coronavirus tests for three inmates with close contact to the original patient, staffers said — a move that was medically sound but apparently out of protocol at the time. Kariko told investigators she didn't chastise him but recalls "reiterating to the staff the current protocols."
Another health care staffer, the prison's infectious prevention nurse, was also missing during key moments. For about a month until May 7, when Coyote Ridge was preparing for a potential outbreak, he was "screened out" of work because he either had symptoms himself or was in close contact with someone who had symptoms or a positive test. But he was sent home without a laptop. When he returned "no one listened" to him, staffers said, and Taylor, the health services manager, "consistently dismissed the [nurse's] trained medical opinions."
In response to the report's findings about the incident command post and the infectious prevention nurse's opinions, Biller wrote that throughout the pandemic, DOC "has prioritized the advice of healthcare professionals and relied on science to mitigate the spread of COVID-19."
During the outbreak, corrections staffers also became frustrated that inmates apparently weren't reporting when they got virus symptoms.
"Instead of being able to rely on self-reporting, investigation and surveillance tactics like listening to phone conversations, monitoring video visits and JPay messaging, and reviewing incoming and outgoing mail became the main method of identifying sick people," according to the report. "Many staff said they were frustrated with the amount of outside family members suggesting that people hide their symptoms and try to 'ride it out in their cell.'"
Based on interviews, the ombuds report concluded "that rumors, both incorrect and correct, of conditions of confinement for people placed in medical isolation contributed to the minimal cases of self-reporting."
No consent for medical care
On June 13, a 72-year-old man reported he had an upset stomach and diarrhea. His heart rate was rapid and erratic, and his oxygen saturation was low. He was admitted to nearby Kadlec Regional Medical Center. The inmate later said he had symptoms in days prior but hadn't reported them.
Five days later, a nurse from the hospital called and emailed Coyote Ridge asking for permission to perform a medical procedure on the patient.
She tried four different prison health staff members, but nobody replied. As the need rose to an emergency, the hospital undertook the procedure without an official go-ahead. Finally, after an hour and 20 minutes passed, a prison nurse called back, but the procedure had already been done.
The inmate died four days later. The ombuds office has previously reported that the delay in obtaining consent did not contribute to his death.
The day the hospital called, Kariko, the DOC's chief medical officer, was deployed to Coyote Ridge. According to department policy, she could have given emergency consent for the procedure, but she later told investigators she was under the impression that department staff couldn't make such a decision.
The ombuds report offered a series of recommendations to better improve preparedness before an outbreak and to take more steps as one develops. Those include more quickly quarantining inmates and more rigorous testing and screening.
And the report suggests "on-site clinical leadership at all times at the start of the outbreak and for the duration that it lasts."
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