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16 instances were missing.
Institution Response: 4. Documentation Accuracy:
The Reconstruction team indicates it is critical that all descriptions of the incident accurately reflect objective evidence, and references
In reference to typographical errors noted in PDS/BEMR notes, the Chief Psychologist has spoken to all psychology staff members concerning proof reading all documents entered to reduce typos and to improve information accuracy. Additionally, there is a second Staff Psychologist in the department which helps reduce the workload on current psychologists, allowing more time for documentation review.
Regarding the Reconstruction team's concerns in reference to Mr. Epstein's expunged incident report, staff shall continue to follow Program Statement 5270.09, Inmate Discipline Program in writing incident reports as appropriate. As more complex matters (including attempted suicide) warrant, Special Investigative Services staff will conduct appropriate investigations and make a determination as to whether an incident report is warranted. Psychology Services staff will also be consulted where their expertise is required.
The Reconstruction team stated medical staff conducted Mr. Epstein's Intake Screening late. SENTRY records reflect Mr. Epstein arrived in MCC New York's Receiving and Discharge (R&D) area on July 6, 2019, at approximately 9:24 p.m. His medical Intake Screening was conducted at approximately 9:38 p.m., by Physician Assistant (PA) on the same night and approximately 14 minutes after his arrival in R&D. On July 9, 2019, he was placed on Psychological Observation and at approximately 12:38 p.m., he was escorted from Psychological Observation to Health Services for a Medical Assessment and a History and Physical, which was performed by PA within three (3) days of his arrival. According to Program Statement 6031.04, Patient Care, a provider must perform a History and Physical within 14 days of the inmate arriving at BOP facility. The History and Physical and Intake Screening were conducted timely and in accordance to policy.
Regarding use of the incorrect Suicide Watch Log and the re-creation thereof, the Chief Psychologist and Drug Abuse Coordinator counseled the Drug Treatment Specialist (DTS) concerning her documentation in the suicide watch log book. There was no ill-intent on the part of the DTS as all log books were maintained; the original log book written by the officer and the one documented by the DTS. The DTS indicated a desire to assist the officer as he had written in the wrong log book. Specifically, he wrote in the inmate companion log book rather than the staff log book. However, she was informed that this is not her role and she is not to document in a log book for anyone else observing an inmate on suicide watch. In the future, only the staff member watching the inmate on suicide watch and Operations Lieutenants document in the suicide watch log book. Log books are now being closely monitored on a daily basis by the Chief Psychologist.
Incomplete entries were noted in the BP-292s. SHU training is conducted quarterly, in which emphasis will be placed on the importance of proper 292 documentation. In addition, the SHU Lieutenant will review 292s on a daily basis and provide the Captain with an assurance memorandum. 292s will be printed for the previous week every Sunday, and the SHU Lieutenant will acquire any needed signatures from the respective OICs in a handwritten manner.
The Reconstruction team findings noted discrepancies in the procedures approved for Psychological Observation.
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DOJ-OGR-00025118