More than six months after the death of inmate Mario Martinez at Santa Rita Jail, 2 Investigates is now hearing from nurses who say Alameda County’s jails are plagued by supply shortages, broken equipment, and a staffing crisis.
And a newly-released investigative report from the Sheriff’s Department shows that a malfunctioning oxygen tank was unable to be used on Martinez just before his death from an asthma attack.
New details on delays
2 Investigates has been looking into the county’s jail medical provider, Corizon Healthcare, since Martinez’s death in July, and has uncovered a series of controversial medical decisions, warnings about poor oversight, and more than a hundred thousand dollars in legal campaign contributions to public officials who simultaneously oversee the company’s contract.
Martinez collapsed in Santa Rita Jail’s common area on July 15, 2015, while suffering an asthma attack. Medical records show that for months he was dealing with nasal polyps that obstructed his breathing and can be an especially dangerous condition in combination with asthma. Despite two court orders requiring treatment and referrals from jail doctors that Martinez undergo surgery, the problem was never fixed.
Now, an investigative report recently released by the Sheriff’s Department shows that a malfunctioning oxygen tank in the jail’s medical facility was involved in the treatment just before Martinez’s death.
The report states that after Martinez collapsed to his hands and knees during the asthma attack, a nurse “went to grab the oxygen tank from the sick call room but noticed the crank to turn it on was missing.” That nurse immediately ran to another housing unit in the jail to retrieve a different oxygen tank, according to the witness narrative.
“About two to three minutes later, [the nurse] returned with an oxygen tank and applied an oxygen mask on Martinez,” the report goes on, stating that one minute later, Martinez was not breathing.
Corizon admits there was a problem with the first oxygen tank that caused a “very slight delay,” but says a second tank was quickly available.
In a statement to 2 Investigates, company spokesperson Martha Harbin said the crank or “key” was missing from the first oxygen tank because it had fallen off while a nurse was carrying it.
“The most important point remains the same: Faulty equipment was not a factor in the patient’s death and oxygen was available when medically required. I also can add that the oxygen tanks are checked and signed off on daily,” the statement concludes.
Harbin also pointed out that the cause of death on the Coroner’s report was not listed as “lack of oxygen delivery.” She said instead that Martinez “died because he had mucous plugs in his lungs that blocked the oxygen from getting to the lung tissue.”
Martinez’s cause of death is listed as “acute asthmatic respiratory insufficiency” in the autopsy report. The autopsy findings state that Martinez also had mucus plugs present in his lungs, as well as “an extensive history of asthma and polyps in his nasal cavity.”
Short supplies, broken equipment?
Six months ago, when 2 Investigates first asked Corizon about Martinez’s death and treatment, the company stated that he was “provided medically appropriate and necessary care.”
But two nurses employed at the county’s two jail facilities – Santa Rita and Glenn Dyer – tell 2 Investigates that broken equipment and supply shortages are chronic issues, and inmate lives are in danger because of the conditions.
One nurse who is still employed by Corizon was too afraid to show her face out of fear of retribution. She said there are times that the nurses on staff are struggling to do their jobs because of malfunctioning equipment, and because basic supplies like gauze, rubber gloves, and other medical necessities have run out.
“Sometimes your computers don't work, she said. “Sometimes we don't have some of the simplest supplies.”
Blaire Behrens, a former nurse at Glenn Dyer, told 2 Investigates about an instance when an oxygen tank was empty when a nurse went to use it, but she says since then procedures have changed so that staff is checking them regularly. But she says other supply and equipment problems are common.
“Let's say you need an ACE bandage, it's not there. Or you need an ice pack, a heat pack or something of that nature, or some Steri-Strips. Those types of things are not stocked in there,” said Behrens. “You're trying to take care of these inmates; you need to have the supplies to do it.”
Behrens says when she and her fellow nurses learned about Martinez’s death, they were “shocked and saddened.”
“Something went very wrong in his line of care and at the end of the day the buck stops with Corizon,” Behrens said. “We are trying to hold everything together, but they [Corizon] are making it harder and harder for us to do that.”
Dennis Dugan, a representative from the National Union of Healthcare Workers (NUHW), also tells 2 Investigates that during site visits he has witnessed nurses carrying their own medical equipment brought from home because items at the jail clinics, such as blood pressure cuffs, are unreliable or broken.
When asked about the allegations of broken equipment and inadequate supplies, Corizon denied there was any truth to the claims. In an email, Harbin said, “Statements regarding chronic broken equipment at the site are inaccurate and designed to cast our company’s reputation in a false light at a time when our contract for services is up for rebid.”
The company spokesperson went on to say that equipment is checked daily and the company expects medical workers to report any problems to Corizon’s administrators. Harbin also said that the company has a toll-free phone number where employees may anonymously report “any aspect of our operations, including equipment repair and availability.” But she says in the last two years the hotline has received no phone calls regarding equipment issues.
But Behrens says, in her eyes, the responsibility ultimately falls on Corizon, and on the Sheriff and Board of Supervisors to oversee them.
“What I would like the public to know is that it could be your brother, your sister, your mother your father son daughter that goes to jail, and is going to be in a dangerous situation being there,” she said. “It could happen to anybody.”
A new crisis
Complaints about equipment aren’t the only issues impacting inmate healthcare, according to nurses who spoke to 2 Investigates. They say they’ve been facing a staffing crisis since the beginning of this year when Corizon laid off 49 Licensed Vocational Nurses (LVNs) as part of a staff restructuring effort required by a legal settlement in the wake of the death of inmate Martin Harrison in 2010.
A nurse who spoke to 2 Investigates on the condition of anonymity says in the wake of the January layoffs Corizon did not have any replacement RNs hired and ready to pick up the slack. She described her workday as “pandemonium.”
"Devastating, mass confusion, there was no plan. How do we get the work done?" she said.
The nurse said days after the layoffs took effect, the remaining RNs and LVNs were required to work mandatory overtime, 16-hour double shifts, and to take on double or triple workloads to fill the gap.
“If you're doing the same amount of work with half the staff,” the nurse said, “they're not getting the same amount of care.”
Behrens says her name was not on the list of LVNs scheduled to be laid off in January so she took a voluntary layoff in order to save someone else’s job. When asked how she would respond to possibly being viewed as a disgruntled former employee she told 2 Investigates, “I take my job very seriously.”
“While I was there, I cared about what I did, and any of the people that I took care of there could tell you that,” she continued. “I'm doing this [interview] because I care, not because I've been laid off. I actually volunteered for that. So it's a bigger picture. I care about what happens there.”
Shortly after the layoffs in January, Corizon issued a statement saying that the company has been trying to “minimize the impact on existing staff” while still complying with the settlement order.
“Many of the nurses who work in the jail have been with us for a number of years and are highly trained and experienced in the correctional healthcare setting,” the statement continued. “They are valuable employees and we regret there is no continued role for them under the settlement agreement.”
But the attorneys who brought the Harrison case and negotiated the $8.3 million settlement terms tell 2 Investigates that their intention was never for Corizon to execute mass-layoffs. The settlement does not explicitly call for LVNs to be terminated, but did require Corizon to remove LVNs from any jobs that perform diagnostic assessments by a deadline of December 31, 2015.
According to the settlement, “Licensed California Registered Nurses or a higher level care provider (physician, physician’s assistant, or nurse practitioner) will conduct all Receiving Screenings and patient assessments on all inmates in Alameda County Jails…”
Corizon said that late last year, “after exhausting all avenues, it became clear there was no way within the constraints of the contract to add the required Registered Nurses and maintain the same level of LVN staffing” and they notified and began working with the nurses’ union.
But union representatives claim that Corizon had ten months to make the staffing changes required by the Harrison settlement and instead waited until the eleventh hour, creating an unnecessary staffing crisis. In a statement to 2 Investigates, NUHW said staffing shortages have since caused “deteriorating conditions” in the jail facilities.
“Inmates are waiting hours for medications that are supposed to be dispensed first thing in the morning. Schedules show nearly half the work shifts unfilled, caregivers are forced to rush through their duties, and medical supplies have run short. Staff are having to bring in basic supplies like bandages and thermometers from home to ensure inmates are getting basic care,” the statement reads.
Corizon tells 2 Investigates that seven newly-hired RNs began orientation in mid-January and have since started picking up shifts at the jails. NUHW reps say they are unaware of any newly-hired staff members, and haven’t seen additional RNs added to the schedules.
According to the company, the remaining 18 LVNs who are still working at the jail facilities will be laid off on February 26 and will be replaced by more highly-qualified RNs. A date of hire for those replacement staff members is unclear.
Another inmate comes forward
Corizon is now facing more legal troubles in Alameda County and new allegations from a former inmate that he suffered under the company’s medical mistakes.
Darrell Buckins, 38, says his kidney stones were misdiagnosed by a doctor at Glenn Dyer jail last year, and went untreated for six months, leading to a chronic urinary tract infection. He says he first complained about abdominal pain in December 2014, and was suffering from dehydration and frequent urination.
“I never had any problems like this where I urinated constantly or abdominal section pain,” he said. “I definitely knew something was wrong. I was definitely sure something was wrong.”
Buckins says Corizon medical staff ordered blood tests and a urinalysis, and he was told the tests came back negative. However, Buckins says his symptoms got progressively worse over the following months.
In an inmate grievance form submitted to the Sheriff’s Office, Buckins wrote, “I am now urinating blood and experience pain in my penis, my abdominal section is burning all over.”
He went on to describe symptoms that, according to medical records, he had been complaining about for months, including frequent urination, dehydration, and headaches. “Blood is forming at the tip of my penis, even when I am not using the bathroom,” Buckins wrote. “I am experiencing excruciating pain, help me.”
“The way that the jail is it's like you're trapped in a cell,” he said. “And there's nothing that nobody can do and you just have to bear with it and for months and months I was forced to bear with it.”
Buckins said he eventually passed kidney stones and, in all, endured six months of pain before he was finally examined by an urologist, prescribed antibiotics, and properly treated.
“Six months later down the line I started passing the stones and they kinda took my situation serious like what I was saying was truthful,” he said. “If the doc would have caught it – I never had kidney problems – I don't believe I would have passed kidney stones. I don't believe I would have suffered for this long.”
Now Buckins has an attorney and has filed a $550,000 claim against the county and the City of Oakland. The Office of the Alameda County Counsel has confirmed that the county has denied Buckins’ claim, which serves as a precursor to a lawsuit, and forwarded it to Corizon because “it exclusively alleges healthcare services concerns.”
Corizon’s spokesperson told 2 Investigates that “it is not at all uncommon” for clients like Alameda County to forward any claims related to medical care to the company, “because we indemnify our clients form legal claims resulting for our care.”
Regarding Buckins’ allegations of medical mistakes in his case, Harbin replied, “I can’t provide you with a comment regarding the actual claim as we received it just recently and have not yet completed our review of the records from the jail. In all likelihood there will be little I can tell you due to patient privacy.”
Still waiting for answers
Tanti Martinez has also filed a wrongful death claim against the county and Corizon, and says she plans to move forward with filing a lawsuit because it may be the only way she gets the justice she’s seeking in the wake of her son’s death.
The Sheriff’s Department has closed its investigation and handed its report over the Alameda County District Attorney’s Office. Although they did not open their own investigation, the DA’s Office says they reviewed the Sheriff’s report and also determined “there is no basis for a criminal charge.”
Last year, the Alameda County Board of Supervisors created a Public Safety Community Relations Ad Hoc Committee that addressed questions surrounding Martinez’s case and Corizon’s contract. Board Supervisor Nate Miley, who 2 Investigates previously reported had accepted $15,000 in campaign donations from Corizon, serves as the chair.
The committee held two meetings since November and was scheduled to hold a third meeting last month, but it was canceled. And Tanti Martinez says she did not push for it to be rescheduled.
“I did feel like we got the runaround. And that's why I said, you know what, no more disrespect. Time to put that to an end, and move on to the next phase,” said Tanti Martinez.
Instead, she showed up to the regularly scheduled Board of Supervisors meeting on February 2 to have her say about Corizon during the public comments section.
Miley said the board is still in the process of scheduling the next ad hoc committee meeting. He also assured the public that the Board of Supervisors is working to “track and monitor” the situation and promised transparency for the public.
In the meantime, the county has opened the bidding process for its jail healthcare services and is now accepting bids for the upcoming contract. Corizon’s current contract, which has been extended three times since 2008 without a public bid, is set to expire at end of June. The winning vendor will be expected to take over services at the jail facilities in July. Corizon has told 2 Investigates that it plans to compete for the new contract.
The General Services Agency, which handles bidding and procurement for county contracts, declined to say how many companies have submitted paperwork to begin the process so far, but bidders have until March 31.
Tanti Martinez says she plans to be there every step of the way, attending public forums and doing her own research into the companies vying to land the county’s biggest contract.
“We are not going to let another provider be in place that is going to totally ignore a human being,” said Martinez. “I want you to know that we are not going away. As we walk out, guaranteed, we will be back. We are not going away. Trust that.”