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what happened on that phone call. It could have potentially led to the incident [Epstein's death], but we don't, we will never know."
V. Failure to Conduct SHU Inmate Counts and Staff Rounds on August 9--10
A. SHU Inmate Counts
As detailed in the BOP policies section of Chapter 2, the BOP requires COs assigned to guard inmates to conduct institution-wide counts of inmates at regularly scheduled intervals each day to ensure that all inmates are present and accounted for at the appropriate location within the facility. Performing an institutional count is one of the basic and essential aspects of a CO's job, and the count was one of the basic and essential components of the daily operation of MCC New York. The Captain told the OIG that counts are a core responsibility of COs and ensure accountability of the inmates. The Evening Watch Operations Lieutenant said that it is very important that the institutional count is accurate because that is how staff members know if all inmates are present and if anyone has escaped.
On weekdays, MCC New York conducted institutional counts at 12 a.m., 3 a.m., 5 a.m., 4 p.m., and 10 p.m. The 10 p.m. count was a stand-up count, which meant that inmates were required to stand when they were counted. Pursuant to BOP policy and MCC New York SHU Post Orders, two COs were required to perform the institutional count for each housing unit, including the SHU. To perform the institutional count in the SHU, BOP policy and MCC New York SHU Post Orders required two officers to walk from tier to tier to observe and count each individual inmate. During each count, one CO would count the inmates while the other officer observed the inmates. The two officers would then switch roles and compare the count numbers. If the totals did not match, then the officers had to conduct another count in the same manner. COs had to document their performance of inmate counts on an official MCC New York form often referred to as a count slip.35
On the count slip, COs were required to fill in the date and time the count had been performed, write the total number of inmates physically present in the unit counted, and then both COs printed their name and signed the count slip. Once the COs had completed and signed the count slip, the count slips were then collected and delivered to the Control Center. Officers assigned to the Control Center were responsible for comparing the count slips from each housing unit to the institution's inmate roster to ensure that each inmate was accounted for. Only after all the count slips had been collected from each housing unit, and the numbers on the slips had been matched to the institution's inmate roster, could the institutional count be deemed "cleared" or completed. If a housing unit's count slip was incomplete or did not match the number of inmates that were supposed to be in the unit, then the count had to be redone in that housing unit via a more intensive version of the institutional count, called a bed-book count, which is when inmates are counted using their picture cards. Records of each institutional count, including the count slips, were provided to a supervising official and retained by MCC New York.
The OIG's investigation found that none of the required SHU inmate counts were conducted from 4 p.m. on August 9, 2019, until Epstein was discovered hanged in his cell at approximately 6:30 a.m. on August 10, 2019. Further, the OIG determined that SHU staff did not conduct any 30-minute rounds after approximately 10:40 p.m. on August 9, and that the count slips and round sheets had been falsified. As a
35 This BOP form is officially entitled "Metropolitan Correctional Center; New York, New York; Official Count Slip."
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