TDCJ Serious Incident Review

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Institutional Division Serious Incident Review

TO: Gary Johnson DATE: February 27, 2001 Institutional Division Director

THRU: Janie Cockrell

Deputy Director for Security

FROM- Les Woods SUBJECT.- Serious Incident Review

Regional Director Smith Unit/University Medical Center, Lubbock

January 3, 2001 Incident

BACKGROUND

On January 3, 2001, at approximately 2240 hours, an offender, while being treated at the University Medical Center (UMC), manipulated his restraints, produced what appeared to be a gun, and took two hospital employees hostage. The two hospital employees were sexually assaulted by the offender during the time they were held hostage. An incident review team was formed at the request of Gary Johnson, TDCJ-ID Director. The team was comprised of the following members:

Les Woods, Regional Director, Region 11

Joe Fernald, Senior Warden, Gurney Unit

Linda Moten, Senior Warden, Gatesville Unit Teresa Moya, Assistant Warden, Murray Unit

Neel Barnaby, Regional Supervisor, Internal Affairs

Pradan Nathan, Associate Division Director, Health Services Pafty Garcia, Technical Writer 11, Executive Services

The review team made an on-site visit to the UMC in Lubbock on January 9, 2001. Additional

follow-up interviews have been conducted with numerous staff members since January 9, 2001 to produce this report.

SCOPE AND OBJECTIVES

The scope of the review team was to examine unit staffing, security procedures, emergency response, Internal Affairs procedures, physical design (UMC), medical procedures, classification, and post trauma procedures. The objectives of the team were to identify procedures that may prevent similar incidents in the future as well as to offer suggestions and corrective actions for the Smith Unit Warden. The team utilized interviews with staff, visual inspections of the area where the incident occurred, and a review of all applicable documents and procedures pertinent to the incident.

Serious Incident Review - Smith Unit/UMC Lubbock February 27, 2001

INCIDENT REVIEW

Participant Summary Offender

Nelson, Dekenya, TDCJ # 687262, BIM/25/MH, Administrative Segregation

Category A, Level 1, LC3

Serving a cumulative sentence of 140 years for aggravated assault of a public servant; aggravated sexual assault; burglary of a habitation (2); unauthorized use of a motor vehicle and forgery from Smith and Bowie Counties.

Employees:

Boyd, Gary, W/M/28, Lieutenant of Correctional Officers

Jones, Johnny, W/M/23, Sergeant of Correctional Officers Bueno, Manuel, H/M/41, Correctional Officer III Gonzales, Elida, H/F/54, Correctional Officer III

Chronology of Events

On January 3, 2001, at approximately 1515 hours, Smith Unit Correctional Officers Manuel Bueno (CO 111) and Debra Pacheco (CO 111) were instructed by Sgt. Johnny Jones to go to cell F-227 and escort offender Dekenya Nelson, TDCJ # 687262, to the unit medical department. Offender Nelson was complaining of internal bleeding. Offender Nelson claimed he swallowed a can opener at the Robertson Unit about three weeks prior and it had not been removed from his body. Officer Bueno stood in front of Nelson's assigned cell and ordered offender Nelson to submit to a strip-search. Once offender Nelson was completely stripped and had passed his clothes to Officer Bueno, Officer Pacheco went to the triage room and called MCCI control to open the cell door. Officer Bueno remained directly in front of offender Nelson's cell and then passed offender Nelson his clothes through the food slot. When offender Nelson was fully dressed, he threw up blood into the toilet. Offender Nelson, while bent down, picked up a rag to clean his cell and Officer Bueno instructed offender Nelson that the clean-up could wait.

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Authority/Assistant Director of Nurses, who then coordinated medical transportation with Dawson County EMS and notified the University Medical Center (UMC), Emergency Room nurse, of offender Nelson's status.

Sgt. Jones advised Lt. Gary Boyd that RN Horton made a decision to transport offender Nelson to the UMC in Lubbock for treatment. Sgt. Jones advised Lt. Boyd that the offender was going to be transported by ambulance and security staff was already assigned for the transport. Lt. Boyd advised Sgt. Jones to make a copy of offender Nelson's travel card. At this time, Lt. Boyd informed Sgt. Jones that offender Nelson was an escape risk and was highly assaultive and the offender should not leave the unit without proper documentation.

In preparing the documentation for travel, Sgt. Jones advised Lt. Boyd that the complete file was not yet at the'Smith Unit and the information received on offender Nelson only included a copy of his travel card. (Offender Nelson arrived on the Smith Unit on December 22, 2000 from the Robertson Unit.) Lt. Boyd advised Sgt. Jones to make a copy of the copy (of the travel card) and the offender's hall card so that proper documentation would accompany the offender.

Unit medical staff had placed offender Nelson on a gurney and Officer Bueno was providing security of the offender. During this time, offender documentation was being copied and prepared for the transport (i.e., travel card, security precaution designation form, and hall card). Sgt. Jones informed Officer Bueno that he and Officer Elida Gonzales (CO 111), who was assigned to Utility for this shift, were going to transport offender Nelson to the UMC, but he did not have copies of all documentation yet to accompany offender Nelson on this transport. Officer Gonzales was instructed to go get the van for transport.

RN Horton was advised by Sgt. Jones of the need to produce copies of documentation before the transport to the LJMC. Offender Nelson was placed inside the ambulance at this time. Sgt. Jones then retrieved a copy of the travel card. Sgt. Jones called the Back Gate Officer and advised him to hold the ambulance in place until the remaining proper documentation (hall card) could be delivered to the escorting officers (Bueno and Gonzales). Officer Bueno entered the ambulance at the sally port area of the High Security facility. At approximately 1750 hours, the ambulance exited the Back Gate.

Officer Gonzales was assigned as the weapon officer for this transport. She retrieved the weapon from the #2 Picket, which is adjacent to the gate entrance to the High Security facility. Officer Gonzales asked the Picket Officer to call the supervisor and ask if it was okay for her and Officer Bueno to switch duties since she did not have her glasses and did not feel comfortable ddving a State vehicle. The Picket Officer called a supervisor and received the approval from the supervisor for Officer Gonzales and Officer Bueno to switch duties. The Picket Officer then relayed this information to Officer Gonzales.

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The offender documentation was delivered to the Radio Picket Officer and then given to Officers Bueno and Gonzales. Officer Gonzales and Officer Bueno switched duties at the Radio Picket, which is the #1 Picket at the front gate entrance of the Smith Unit. Officer Gonzales then assumed the position in the ambulance and Officer Bueno took charge of the weapon (.357 revolver) and assumed a position in the chase vehicle.

At approximately 1800 hours, the ambulance and chase vehicle left the Smith Unit. Once en route, the ambulance made a stop in Lamesa so ambulance staff could change out staff. A new nurse and driver entered the ambulance. The ambulance then proceeded to the UMC in Lubbock. While in the ambulance, offender Nelson was only secured with hand restraints.

The ambulance arrived at the UMC, Emergency Room entrance, at approximately 1913 hours. Offender Nelson was removed from the ambulance and was accompanied into the hospital, at approximately 1914 hours, by Officer Gonzales, the driver and nurse of the ambulance. Approximately one-half minute later, Officer Bueno (who was parking the van/chase vehicle) entered the Emergency Room with restraints in hand. At 1915 hours Offender Nelson was wheeled into a treatment room of the Emergency Room. Officer Bueno assumed the post of outside security officer (weapon officer) and remained outside the treatment room. Officer Gonzales assumed the post of inside security officer to provide security of the offender while in the treatment room.

Offender Nelson was moved to Emergency Room 5 - 8 at approximately 1924 hours and was assigned to bed 8. This particular room maintains four beds (beds 5 - 8), separated by curtains. Leg irons and belly chain were applied to offender Nelson. Medical staff needed to draw blood from Offender Nelson. Officer Gonzales removed the hand restraints from offender Nelson. Once the blood was drawn the hand restraints were re- applied on offender Nelson. Offender Nelson was then taken to the radiology room for x- rays. Medical staff advised that the hand restraints needed to be removed prior to taking any x-rays. Officer Gonzales removed the hand restraints, the x-rays were taken, and then the hand restraints were re-applied by Officer Gonzales. Offender Nelson was then taken back to his room - bed S.

During this time, Officer Bueno, armed with a weapon, maintained his distance. He remained outside of Emergency Room 5 - 8. He called the Smith Unit to advise they had arrived and then he called Sgt. Ragsdale (Montford Unit employee), who was located on the 4th floor of the UMC. Sgt. Ragsdale and another Montford Unit Correctional Officer came down to the Emergency Room. Officers Bueno and Gonzales were relieved so they could take a break. Offender Nelson remained in bed 8 of Emergency Room 5 - 8.

Officers Bueno and Gonzales took a 15 to 20 minute break then returned to the Emergency Room. Offender Nelson was still in bed 8 of the Emergency Room at this time. Officers Bueno and Gonzales were waiting to see if the medical staff was going to admit offender Nelson, or if he was going to be returned to the Smith Unit.

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At approximately 2210 hours, medical staff decided to admit offender Nelson. Two Correctional Officers (Monfford Unit employees) came down to relieve Officers Bueno and Gonzales. At this time, all restraints on offender Nelson were exchanged, The Montford Unit officers applied their restraints on offender Nelson, and Officer Gonzales removed her restraints from offender Nelson.

While reviewing the offender's information, Sgt. Ragsdale noticed that all documentation was not with offender Nelson. At approximately 2221 hours, Officer Bueno went out to the van to get the offender documentation he did not bring into the hospital.

At approximately 2225 hours, the Emergency Room nurse came in and informed security officers that offender Nelson would not be admitted. The Monfford Unit officers removed their restraints from offender Nelson and Officer Gonzales re-applied her restraints (hands/legs restraints and belly chain) on offender Nelson.

The nurse brought in a wheel chair for offender Nelson. Offender Nelson stated he felt dizzy and asked to stay in the bed until all discharge papers were completed and signed. A few minutes later offender Nelson said he was cold and asked Officer Gonzales for a blanket. She picked up a blanket from the floor and covered offender Nelson. (A nurse had previously removed the blanket from offender Nelson's bed and placed it on the floor.)

At approximately 2240 hours offender Nelson informed C)fficer Gonzales that he needed to urinate. The nurse gave the offender a container in which to urinate. Offender Nelson placed the container under the blanket. According to Officer Gonzales, offender Nelson seemed to have a difficult time; he was squirming and moving.

Officer Gonzales felt uneasy with offender Nelson's movements under the blanket and turned to call for Officer Bueno, who was standing guard outside of the room. At this time, offender Nelson got out of the bed, unrestrained, and was then behind Officer Gonzales. Officer Gonzales yelled for Officer Bueno, and she drew her baton. As offende@Nelson ran across the room to the treatment bed (bed 5) across from his bed, he pulled what appeared to be a gun out of his pants.

The elderly couple that was in this area immediately left when offender Nelson ran in to the bed 5 area. Offender Nelson was then in the treatment area (bed 5), behind the curtain, with two nurses.

Officer Bueno, now standing at the doorway of the room with his weapon drawn, noticed offender Nelson waving what appeared to be a gun. Officer Gonzales, still in the treatment room, saw offender Nelson's legs under the curtain and she went to swing at him under the curtain with her riot baton, but at that time she heard someone yell that he (offender Nelson) has a gun. Officer Gonzales looked up, before she could strike offender Nelson with her baton, and saw what appeared to be a gun, held by offender Nelson, pointing directly at her. Offender Nelson informed Officer Gonzales he would shoot her if she struck him and Officer Bueno, standing immediately outside the room, was yelling for

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Officer Gonzales to get out of there. According to Officer Bueno, offender Nelson had one of the nurses by her neck.

Officer Bueno advised hospital staff and other persons in the area to step out of the area. Offender Nelson advised Officer Bueno to get back or he would shoot the nurses that were still in the room. Offender Nelson then closed and barricaded the door to Emergency Room 5 - 8. The two female nurses were held hostage at this time by offender Nelson. Officer Bueno maintained a position in the Emergency Room hallway with his weapon drawn.

The hospital security officer (an off-duty DPS officer) arrived in the Emergency Room at this time, with his weapon drawn and advised the staff at the nurses station to call 91 1. He remained directly outside the Emergency Room treatment room 5 - 8 until additional law enforcement arrived.

By 2246 hours, Lubbock Police Department officials arrived in the Emergency Room. By 2300 hours, more Lubbock Police Department officers had arrived with their SWAT Team and hostage negotiators. The Emergency Room area was evacuated and the Lubbock Police Department assumed control of the situation. Mr. Bill Bates of the Lubbock Police Department established contact with offender Nelson via telephone.

Sgt. Ragsdale, who was back on the 4th floor of the UMC, was notified of the incident down in the Emergency Room and responded to the incident, along with several other Montford Unit officers. At approximately 2315 hours, Smith Unit Warden Anderson was notified of the incident by Warden W. Stephens of the Montford Unit. Warden Anderson immediately called staff in to set up a command post at the Smith Unit with Assistant Warden Davila in charge. Warden Anderson then proceeded to Lubbock.

Warden Stephens, security supervisors, emergency response team, and hostage negotiation team of the Montford Unit all responded to the incident at the UMC.

The Lubbock Police Department initiated and controlled the negotiation process. Through the negotiation process, offender Nelson's initial and only demand was to be transferred to a facility close to Tyler, Texas.

At approximately 0006 hours on January 4, 2001, offender Nelson surrendered to the Lubbock Police Department. During this incident, offender Nelson sexually assaulted the two nurses he held hostage. Once offender Nelson was restrained, the hostages were immediately provided care and treatment and were taken to the Rape Crisis Center.

Offender Nelson had disassembled the fabricated gun and search of his person or the room did not produce a handcuff key.

Offender Nelson was handcuffed and escorted to a Lubbock Police patrol vehicle.

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At approximately 0430 hours, Capt. M. Chumley of the Montford Unit obtained custody of offender Nelson from the Lubbock County Jail and transported him to the Montford Unit.

An x-ray was taken of offender Nelson's abdominal/rectal area at approximately 0500 hours and a handcuff key appeared in his rectal area. This is assumed to be the handcuff key used to escape from his restraints in the hospital.

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Serious Incident Review - Smith Unit/UMC Lubbock February 27, 2001

UNIT STAFFING

The Smith Unit is staffed according to the Texas Department of Criminal Justice (TDCJ or Agency) Security Administrative and Security Staffing Plan dated October 1, 1999. The Smith Unit High Security facility operates according to the Staffing Plan dated May 3, 2000. Security staff work eight-hour shifts.

Findings

• The unit is allofted 422 full-time Correctional Officer positions and 10 part-time Correctional Officer positions. On the day of the incident, there were 370 full-time Correctional Officer positions filled and 5 part-time Correctional Officer positions filled.

• According to card schedules, there are 66 full-time officers and 2 part-time officers assigned to 2 d shift High Security. On the day of the incident, there were 35 officers present to fill 19 duty posts. Some of the 19 duty posts (i.e., 4-A Housing Rover) are staffed by more than one Correctional Officer. The remaining 33 officers were off work due to regular day off, sick leave or other scheduled time off (8 officers off on holiday/compensatory time, 3 officers off on sick time, 3 officers off on administrative leave, and 19 officers off on regular days off).

• Staffing was adequate for 2nd shift High Security on the date of the incident and all critical duty posts were appropriately staffed.

• The escort staffing requirement for the transport of the offender did comply with Agency policies and procedures. However, in addition to Agency policies and to ensure the custody of High Secubty offenders, the Smith Unit had a written policy, extending the Agency procedures, which stated that a Sergeant and two Correctional Officers will transport a High Security offender to off-unit (free world) medical facilities. Security supervisors did not follow written unit policy.

For 2rd shift, High Security, the average length of service for Correctional Officers is 18.3 months. The average length of service for security supervisors is 84.8 months of service.

At the time of the incident, Officers Bueno and Gonzales each had II months of TDCJ service as Correctional Officers; Sgt. Jones had 53 months of TDCJ service; and Lt. Boyd had 100 months of TDCJ service.

Recommendations

For those offenders considered to be highly assaultive or high escape risks, unit administration should utilize, as much as possible, more seasoned Correctional Officers when transporting offenders.

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Unit administration should ensure that all established procedures are properly followed when transporting offenders.

Agency policies concerning the staffing requirement when transporting administrative segregation offenders should be reviewed by Agency administration.

SECURITY PROCEDURES AND EMERGENCY RESPONSE

The committee reviewed unit security procedures and emergency response pertinent to the incident. A surveillance camera located in the UMC Emergency Room produced a video which guided a portion of this report's timeline and findings.

Findings

• Security procedures/Post Orders were in place at the time of the incident.

• Offender Nelson arrived at the Smith Unit on December 22, 2000, from the

Robertson Unit.

• Offender Nelson's last cell search was documented on December 28, 2000. According to unit procedures, cell searches for High Security offenders will occur one time per week. There were 6 days between his last cell search and the date of the incident.

• Staff interviewed were familiar with requirements of duty posts. Officers Bueno and Gonzales completed the Pre-Service Training Academy in January 2000. Additionally, Officers Bueno and Gonzales attended the training session on Escort and Transport Training in July 2000.

• Copies of offender Nelson's travel card, hall card, and security precaution designation form accompanied Officers Bueno and Gonzales for this transport. The security precaution designation form indicates that security precautions have been issued on an offender (as per Security Memorandum (SM)-01.09, "Security Precaution Designations"). For offender Nelson, the following security precautions were marked: escape designator and staff assault designator. Additionally, the Segregation Confinement Record (1-201), which shows offender Nelson as "level 1, security detention segregation status," was also available to security staff on the Smith Unit High Security housing area.

• Offender Nelson was strip-searched prior to going to the unit medical department, but he was not searched again after that. IHe was not pat or stdp-searched prior to entering the ambulance or leaving the unit.1 According to Post Order 07.070, "Transfer Officer," the Transfer Officers shall pat-search offenders prior to boarding the transfer vehicle.

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Security supervisors did not properly verbally alert transporting officers of offender Nelson's escapelassault risk. I Security supervisors did not review offender Nelson's travel card or other documentation, as indicated in written Smith Unit procedures for transport of High Secudty offenders. However, Officers Bueno and Gonzales were given offender documentation to indicate his status (travel card, security precaution designation form). The necessary time was not taken to thoroughly prepare this offender for transport (i.e., security supervisors did not brief officers on the content of the offender documentation prepared for the transport; officers did not review offender documentation provided; offender was not properly searched).

Offender Nelson was not properly secured when he left the Smith Unit on January 3, 2001. He was restrained with only hand restraints while in the ambulance and upon entering the hospital. This is not typical unit practice or procedure. According to the UMC Emergency Room Manager, the practice had been that offenders arrive in full restraints, unless the offender's condition was so critical that the full restraints could not be applied. Post Order 07.070, "Transfer Officer," states that a combination of restraints (i.e.,Ihandcuffs, leg irons, leg chain or restraining belt$viii be applied to any offender before leaving the unit. I in addition, specific unit procedures indicate that prior to a High Security offender leaving the unit, the offender will be placed in full restraints - handcuffs, leg irons with bellychain. Officers Gonzales and Bueno did not properly restrain the offender. As per the TDCJ Pre-Service Training Curriculum, "Transporting Offenders," all offenders who are transported shall be secured in handcuffs, belly chains, and leg irons, unless otherwise instructed by their supervisory officer.

• Written Smith Unit procedures indicate that a Sergeant and two Correctional Officers will transport a High Security offender. The Sergeant will ride in the front seat of the ambulance and a Correctional Officer will ride in the back with the offender. The second Correctional Officer will follow the ambulance in a separate vehicle. Offender Nelson was transported to the hospital secured by only two Correctional Officers.

• Through interviews with security supervisors at the Smith Unit High Security Facility, it was common practice to send a supervisor on a transport only if the offender's behavior warranted precaution. For example, if the offender was displaying assaultive or belligerent behavior at the time of transport, a supervisor would accompany the Correctional Officers on the transport. If the offender had not recently displayed any assaultive or belligerent behavior, a supervisor would not participate in the transport. The procedures varied from one supervisor to another and from one offender to another.

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Post Order 07.073, "Public Medical Facility Escort OfficeC' states that the offender will wear leg irons at all times while in a public medical facility, unless prohibited by medical condition or physicians orders. Officers Gonzales and Bueno applied the leg irons while Offender Nelson was in the second treatment room of the UMO Emergency Room.

Post Order 07.074, "Ambulance Security Officer," states that restraints to include handcuffs, leg irons, and belly chains, will be utilized at all times (unless contradicted for medical reasons) when transporting offenders by ambulance. Offender Nelson was only secured by hand restraints while in the ambulance.

Offender Nelson was not under constant security supervision while in the hospital room. At approximately 1920 hours, Officer Gonzales left the first treatment room and went out to the hallway, for approximately 2 !/2minutes, where Officer Bueno was standing guard. At this point, offender Nelson remained in the treatment room with two medical staff personnel and without a security officer present. Officers did not keep constant sight of offender Nelson while he was in restraints. He was also covered for a period of time with a blanket. The offender must be kept under constant supervision, as stressed in the Pre-Service Training Academy, Training Curriculum "Restraint Tactics".

• The weapon used by offender Nelson was fabricated from a hairbrush, binder from a book, a deodorant bottle, deodorant/soap, and pages from a Bible which had been colored black. These items were put together in a way to resemble a handgun. The brush was used as the gun handle. The deodorant bottle with the book binder inside of it was used as a gun barrel. The soap was used as a mold. The deodorant was used to glue the black paper to the item. The weapon was destroyed by offender Nelson prior to surrendering to law enforcement authorities.

• Offender Nelson used a handcuff key to escape from his restraints. It is unknown at this point how offender Nelson acquired the handcuff key. However, the review team believes the offender left the Smith Unit with the key on his person. An x-ray taken the day after the incident, on 01104/01 at approximately 0500 hours, shows a handcuff key in offender Nelson's rectal area. (See Attachment F)

• Additional security staff were properly notified and responded in a timely manner to the incident. Warden Stephens, security supervisors, emergency response team, and hostage negotiation team of the Montford Unit all responded immediately to the incident. Security staff assigned to the 4th floor of the UMC also responded to the incident. Warden Anderson, once notified, established a command post at the Smith Unit.

• Lubbock Police Department officials responded within minutes of the onset of the incident.

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According to offender Nelson's statement, he indicates that this incident was an escape attempt. This claim is under investigation.

Recommendations

Unit administration should enforce Agency policies and procedures through unit training or shift briefings. Correctional Officers and security supervisors need to be very familiar with Agency policies (i.e., strip-search procedures, transport procedures) as well as unit procedures. Correctional Officers and security supervisors should be familiar with the applicable Post Orders prior to assuming a duty.

• The Smith Unit medical transport policy for High Security offenders should be reviewed by the Agency administration.

• Communication between shift supervisors and shift officers needs to be improved so that critical information is effectively exchanged. Transporting officers should be familiar with the offender documentation they are carrying (i.e., travel card, security precaution designations) prior to the transport.

Supervisors should prioritize more effectively the security responses needed during their shift.

0 Unit administration should implement additional training on offender search and restraint procedures.

4 Security supervisors should check the secure status of an offender upon transport off unit grounds.

0 Unit administration should review employee actions.

0 The use of handcuff restraint boxes shall be reviewed by the Agency. (See Attachment G)

Unit administration should review their key control procedures.

Agency administration should review cell-search policies for administrative segregation areas.

Procedures have been implemented for the transporting unit to notify the Western Regional Medical Facility (WRMF) shift supervisor when an offender is being transported to the University Medical Center in Lubbock. The WRMF supervisor will then contact the Montford Unit security supervisor, located on the 4 th floor of the University Medical Center, of an incoming offender and estimated time of arrival (See Attachment H).

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INTERNAL AFFAIRS (IAD)

Internal Affairs is currently reviewing information to determine factors in the crime. Findings

• The Lubbock Police Department has criminal jurisdiction over this case.

• The TDCJ-IAD is conducting an on-going investigation of the incident to determine if

offender Nelson received any outside help in this incident.

0 Evidence has not confirmed offender Nelson's claim of an escape attempt and some evidence has refuted it.

Recommendations 0 None

PHYSICAL PLANT DESIGN

A visual inspection of the University Medical Center was conducted by the review team. Findings

• The Emergency Room to which offender Nelson was assigned, the radiology room

and nurses station are all within close proximity. (See Attachment E)

• On the date of the incident, the hospital already had an established holding area for offenders.

0 Montford Unit correctional staff are assigned to the 4th floor of the UMC for security of those patient offenders that have been admitted to the hospital.

• The doors to Emergency Room 5 - 8 did not have any windows. (See Attachment E)

Recommendations

The review team recommends placement of holding cages in a designated area of the hospital to enhance the security of offenders. The current hospital holding area does not have holding cages in place.

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Serious Incident Review - Smith Unit/UMC Lubbock February 27, 2001 MEDICAL PROCEDURES

A review of security issues related to the medical evaluation process at the University Medical Center was conducted by team members.

Findings

• Once x-rays are taken on patient offenders, they are forwarded electronically to New Mexico for official reading. When the UMC radiology staff member reviewed the x-rays, the hairbrush was pointed out to other radiology staff, however, security staff was not alerted.

• The weapon used by offender Nelson appeared on the x-ray taken at UMC. This x- ray was taken at approximately 2020 hours on January 3, 2001. (See Attachment F)

0 Offender Nelson laid in Emergency Room 5 - 8 (bed 8) for a long period of time (over two hours) before it was determined he would not be admitted.

Recommendations

• Once an offender is seen by medical staff and while a determination to admit him is being made, the offender should be taken back to the hospital holding area unless otherwise indicated by a physician.

• Greater emphasis should be placed on maintaining effective communication between Agency security staff and hospital staff.

CLASSIFICATION

A review of the offender's classification file was conducted by review team members. Findings

• Offenders Nelson was appropriately assigned to Administrative Segregation,

Category A, Level 1, LC3.

• A copy of offender Nelson's travel card and hall card accompanied the officers for the transport. The travel card has offender information, such as name, TDCJ number, all units of assignment and dates of assignment, work history, conduct, criminal history, security precaution designators (i.e., assault designator, escape risk designator), and other information. The hall card indicates the offender's name, TDCJ number, living assignment, and work assignment.

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• Offender Nelson was received by the TDCJ on October 21, 1994. During his incarceration, he has incurred many disciplinaries for such cases as refusing to work, refusing to groom, threatening an officer, and other cases.

• Since his incarceration, and as of the date of this incident, offender Nelson has been transported to a free world hospital 50 times. Offender Nelson has an extensive medical and behavioral history.

• Offender Nelson has a prior sexual assault on a female Food Service Manager. This incident occurred in 1996 at the Telford Unit. He has since been charged for the offense and his current sentence includes time to be served for this offense.

Recommendations 0 None

POSTTRAUMA

Post Trauma procedures were reviewed by the review team. Findings

• Procedures were in place and working well. Unit staff support officers responded

and offered assistance to Officers Gonzales and Bueno.

• The UMC nurses were taken to a Rape Crisis Center for care and evaluation. Recommendations

None

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CONCLUSION

The serious incident review team reviewed all applicable evidence and conducted staff interviews in relation to this incident, Un@ staffing was in accordance with Agency policy and procedures, Post Orders and other unit procedures were in Place at the time of the

incident,

Through investigation it appears that policy violations did occur on January 3, 2001. Search and restraint procedures were not fully and effectively implemented. Security supervisors did not follow written unit policy regarding the transport of High Security offenders.

Lt. Boyd, the 2 Id shift supervisor on duty, was aware of offender Nelson's history. When he and Sgt. Jones were finalizing procedures for transporting offender Nelson to the University Medical Center (UMC), he did inform Sgt. Jones that offender Nelson was an assaultlescape risk, However, these secuoty supervisors did not follow established unit

procedures in the transporting of offender Nelson.

Officer Sueno' did attempt a proper stdp-search of offender Nelson before escorting offender Nelson to the unit medical department. However, the offender was not searched again as the day and incidents progressed. Prior to exiting the back Rate and when Officers Gonzales and Buena switched duties (weapon officer and chase vehicle officer) a search on offender Nelson should have occurred. Officers Buena and Gonzales, who each had I I months of service at the time of the incident, indicate they have never been on an ambulance run, but they have performed other transports.

Restraint procedures were not fully implemented. The offender was not properly (fully) restrained prior to leaving the Smith Unit. Restraints were not visible to the security staff at all times. While in the hospital bed, covered with a blanket, offender Nelson's restraints were not visible to the Correctional Officers. t

Also, the offender should have been accompanied at all times by an officer. Offender Nelson was not under constant security supervision while he was at the UMO. At one point, offender Nelson was left unsupervised in a treatment room along with two medical staff personnel.

The Internal Affairs Division is continuing with an on-going criminal investigation of the incident to determine if offender Nelson received any outside help in this incident.

Since the incident, the Smith Unit implemented new procedures when transporting offenders to the UMC. When a transport occurs, the unit will contact the shift supervisor at the Western Regional Medical Facility (WRMF). The WRMF supervisor will then contact the Montford Unit security supervisor, located on the 40' floor of the UMC, of an incoming offender, estimated time of arrival, offender custody level, and any other security information (i.e., assaultive nature, security threat group information). The Montford Unit

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security supervisor will meet the incoming transport and assist in coordinating TDCJ and UMC security procedures.

As a result of this incident, and to prevent any future incidents, TDCJ security staff will heighten security precautions when transporting offenders to hospitals for treatment.

CORRECTIVE ACDON:

Corrective action has been implemented since the incident occurred on January 3, 2001. The Smith Unit Warden has imposed disciplinary actions on the security staff involved in the incident: Lieutenant - probation, suspension without pay, demotion; Sergeant - recommended for dismissal (final approval given by Division Director); two Correctional Officers - recommended for dismissal (final approval given by Division Director).

Administrative Segregation cell-search policies are currently in revision to reflect that cell- searches shall occur every three days. Additionally, the Security Operations Department has ordered handcuffs with restraint boxes. The use of a restraint box, in addition to hand restraints, makes it more difficult to manipulate the restraints.

Attachment A - Executive Summary Attachment B - Smith Unit Profile

Attachment C - 2nd Shift Duty Roster for 01/03/2001 Attachment D - Unit Staffing Plan

Attachment E - Pictures of Emergency Room

Attachment F - Pictures of x-rays taken 01103/01 and 01/04/01 Attachment G - Pictures of restraint box

Attachment H - Memo on revised procedures for transport notification

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Serious Incident Review - Smith Unit/UMC Lubbock February 27, 2001

EXECUTIVE SUMMARY

Officer Bueno placed handcuffs behind offender Nelson's back through his cell food slot and then he and Officer Pacheco escorted offender Nelson to the unit medical department. While in the medical department, offender Nelson threw up blood again and Officer Bueno then had to place the handcuffs in front due to an IV that had to be placed into offender Nelson's arm. Offender Nelson was observed by Jim Horton, RN, Assistant Unit Health Authority/Assistant Director of Nurses, who then coordinated medical transportation with Dawson County EMS and notified the University Medical Center (UMC), Emergency Room nurse, of offender Nelson's status.

In preparing the documentation for travel, Sgt. Jones advised Lt. Boyd that the complete file was not yet at the Smith Unit and the information received on offender Nelson only included a copy of his travel card, (Offender Nelson arrived on the Smith Unit on December 22, 2000 from the Robertson Unit.) Lt. Boyd advised Sgt. Jones to make a copy of the copy (of the travel card) and the offender's hall card so that proper documentation would accompany the offender.

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Serious Incident Review - Smith Unit/UMC Lubbock February 27, 2001

accompany offender Nelson on this transport. Officer Gonzales was instructed to go get the van for transport.

RN Horton was advised by Sgt. Jones of the need to produce copies of documentation before the transport to the UMC. Offender Nelson was placed inside the ambulance at this time. Sgt. Jones then ret6eved a copy of the travel card. Sgt. Jones called the Back Gate Officer and advised him to hold the ambulance in place until the remaining proper documentation (hall card) could be delivered to the escorting officers (Buena and Gonzales). Officer Buena entered the ambulance at the sally part area of the High Security facility. At approximately 1750 hours, the ambulance exited the Back Gate.

Officer Gonzales was assigned as the weapon officer for this transport. She retrieved the weapon from the #2 Picket, which is adjacent to the gate entrance to the High Security facility. Officer Gonzales asked the Picket Officer to call the supervisor and ask if it was okay for her and Officer Buena to switch duties since she did not have her glasses and did not feel comfortable driving a State vehicle. The Picket Officer called a supervisor and received the approval from the supervisor for Officer Gonzales and Officer Buena to switch duties. The Picket Officer then relayed this information to Officer Gonzales.

The offender documentation was delivered to the Radio Picket Officer and then given to Officers Buena and Gonzales. Officer Gonzales and Officer Buena switched duties at the Radio Picket, which is the #1 Picket at the front gate entrance of the Smith Unit. Officer Gonzales then assumed the position in the ambulance and Officer Buena took charge of the weapon (.357 revolver) and assumed a position in the chase vehicle.

At approximately I 800 hours, the ambulance and chase vehicle left the Smith Unit. Once en route, the ambulance made a stop in Lamesa so ambulance staff could change out staff. A new nurse and driver entered the ambulance. The ambulance then proceeded to the UMC in Lubbock. While in the ambulance, offender Nelson was only secured with hand restraints.

The ambulance arrived at the UMC, Emergency Room entrance, at approximately 1913 hours. Offender Nelson was removed from the ambulance and was accompanied into the hospital, at approximately 1914 hours, by Officer Gonzales, the driver and nurse of the ambulance. Approximately one-half minute later, Officer Buena (who was parking the van/chase vehicle) entered the Emergency Room with restraints in hand. At 1915 hours Offender Nelson was wheeled into a treatment room of the Emergency Room. Officer Buena assumed the post of outside security officer (weapon officer) and remained outside the treatment room. Officer Gonzales assumed the post of inside security officer to provide security of the offender while in the treatment room.

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Serious Incident Review - Smith Unit/UMC Lubbock February 27, 2001

applied on offender Nelson. Offender Nelson was then taken to the radiology room for x- rays. Medical staff advised that the hand restraints needed to be removed prior to taking any x-rays. Officer Gonzales removed the hand restraints, the x-rays were taken, and then the hand restraints were re-applied by Officer Gonzales. Offender Nelson was then taken back to his room - bed S.

During this time, Officer Bueno, armed with a weapon, maintained his distance. He remained outside of Emergency Room 5 - 8. He called the Smith Unit to advise they had arrived and then he called Sgt. Ragsdale (Montford Unit employee), who was located on the 4 th floor of the UMC. Sgt. Ragsdale and another Montford Unit Correctional Officer came down to the Emergency Room. Officers Bueno and Gonzales were relieved so they could take a break, Offender Nelson remained in bed 8 of Emergency Room 5 - S.

At approximately 2210 hours, medical staff decided to admit offender Nelson. Two Correctional Officers (Montford Unit employees) came down to relieve Officers Bueno and Gonzales. At this time, all restraints on offender Nelson were exchanged. The Montford Unit officers applied their restraints on offender Nelson, and Officer Gonzales removed her restraints from offender Nelson.

At approximately 2225 hours, the Emergency Room nurse came in and informed security officers that offender Nelson would not be admitted. The Montford Unit officers removed their restraints from offender Nelson and Officer Gonzales re-applied her restraints (hands/legs restraints and belly chain) on offender Nelson.

At approximately 2240 hours offender Nelson informed Officer Gonzales that he needed to urinate. The nurse gave the offender a container in which to urinate. Offender Nelson placed the container under the blanket. According to Officer Gonzales, offender Nelson seemed to have a difficult time; he was squirming and moving.

Officer Gonzales felt uneasy with offender Nelson's movements under the blanket and turned to call for Officer Bueno, who was standing guard outside of the room. At this time,

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Serious Incident Review - Smith Unit/UMC Lubbock February 27, 2001

offender Nelson got out of the bed, unrestrained, and was then behind Officer Gonzales. Officer Gonzales yelled for Officer Bueno, and she drew her baton. As offender Nelson ran across the room to the treatment bed (bed 5) across from his bed, he pulled what appeared to be a gun out of his pants.

The elderly couple that was in this area immediately left when offender Nelson ran in to the bed 5 area. Offender Nelson was then in the treatment area (bed 5), behind the curtain, with two nurses.

Officer Bueno advised hospital staff and other persons in the area to step out of the area. Offender Nelson advised Officer Bueno to get back or he would shoot the nurses that were still in the room. Offender Nelson then closed and barricaded the door to Emergency Room 5 - S. The two female nurses were held hostage at this time by offender Nelson. Officer Bueno maintained a position in the Emergency Room hallway with his weapon drawn.

Sgt. Ragsdale, who was back on the 4 th floor of the UMC, was notified of the incident down in the Emergency Room and responded to the incident, along with several other Montford Unit officers. At approximately 2315 hours, Smith Unit Warden Anderson was notified of the incident by Warden W. Stephens of the Montford Unit. Warden Anderson immediately called staff in to set up a command post at the Smith Unit with Assistant Warden Davila in charge. Warden Anderson then proceeded to Lubbock.

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Ssriou-S Incident Review - Smith Unit/UMC Lubbock February 27,2001

Warden Stephens, security Supervisors, emergency response team, and hostage negotiation tearn of the Montford Unit all responded to the incident at the Li M C.

The Lubbock Police Department initiated and controlled the negotiation process. Through

the negotiation process, offender Nelson's initial and only demand was to be transferred to a facility close to Tyler, Texas.

At approximately 0006 hours on January 4, 20C)i @ offender Nelson surrendered to the Lubbock police Department. During this incident, offender Nelson sexually assaulted the two nurses he held hostage. - Once offender Nelson was restrained, the hostages were immediately provided care and treatment and were taken to the Rape Crisis Center.

Offender Nelson had disassembled the fabricated gun and search of his person or the room did not produce a handcuff key.

Offender Nelson was handcuffed and escorted to a Lubbock Police patrol vehicle.

At approximately 0430 hours, Capt. M. Chumley of the Montford Unit obtained custody of offender Nelson from the Lubbock County Jail and transported him to the Montford Unit,

An x-ray was taken of offender Nelson's abdominavrectal area at approximately 0600

hours and a handcuff key appeared in his rectal area. This is assumed to be the handcuff key used to escape from his restraints in the hospital.

The serious incident review team reviewed all applicable evidence and conducted staff interviews in relation to this incident. Unit staffing was in accordance with Agency policy and procedures. Post Orders and other unit procedures were in place at the time of the

incident.

Lt. Boyd, the 2nd shift supervisor on duty, was aware of offender Nelson's history. When he and Sgt. Jones were finalizing procedures for transporting offender Nelson to the University Medical Center (UMC), he did inform Sgt. Jones that offender Nelson was an assaultlescape risk. However, these security supervisors did not follow established unit

procedures in the transporting of offender Nelson.

OlTicer Sueno did attempt a proper strip-search of offender Nelson before escorting offender Nelson to the unit medical department. However, the offender was not Se2rched again as the day and incidents progressed. Prior to exiting the back gate and when officers Gonzales and Bueno switched duties (weapon officer and chase vehicle officer) a

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Serious Incident Review - Smith Unit/UMC Lubbock February 27, 2001

search on offender Nelson should have occurred. Officers Bueno and Gonzales, who each had I 1 months of service at the time of the incident, indicate they have never been on an ambulance run, but they have performed other transports.

Also, the offender should have been accompanied at all times by an officer. Offender Nelson was not under constant security supervision while he was at the UMC. At one point, offender Nelson was left unsupervised in a treatment room along with two medical staff personnel.

The Internal Affairs Division is continuing with an on-going criminal investigation of the incident to determine if offender Nelson received any outside help in this incident.

Since the incident, the Smith Unit implemented new procedures when transporting offenders to the UMC. When a transport occurs, the unit will contact the shift supervisor at the Western Regional Medical Facility (WRMF). The WRMF supervisor will then contact the Monfford Unit security supervisor, located on the 4th floor of the UMC, of an incoming offender, estimated time of arrival, offender custody level, and any other security information (i.e., assaultive nature, security threat group information). The Monfford Unit security supervisor will meet the incoming transport and assist in coordinating TDCJ and UMC security procedures.

As a result of this incident, and to prevent any future incidents, TDCJ security staff will heighten security precautions when transporting offenders to hospitals for treatment.

CORRECTIVE ACTION:

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TDCJ Serious Incident Review

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