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Extreme overtime puts California’s prison health overhaul at risk

Inmate Rayshawn Taylor, 30, of south Sacramento says he told a physician at Deuel Vocational Institution in Tracy that he was suicidal in order to get moved into suicide watch and out of a cell with a white inmate who had racist tattoos.

First of two parts.

California's prison health care employees work hard – or so it would seem by their schedules. Many average 12 hours a day; others routinely log 16- to 18-hour shifts for months on end, creating a costly overtime free-for-all in this budget-strapped state.

An abundance of forced and voluntary overtime has driven some nurses beyond human endurance. In the process, the long hours have opened the door for deadly lapses in a health care system just beginning to recover from decades of neglect.

"People who are pushing it to that level, working a ridiculous number of hours, usually crash," said Yolanda Esparza, a certified nursing assistant who works evenings and some nights at the California Institution for Women in Corona.

"I myself have witnessed people sleeping at their posts – heavily, snoring, full sleep. They don't even notice people walking by. It's pretty common," Esparza said.

Asked what happens when nurses are found sleeping on the job – a gross violation of prison rules – one prison nursing director said simply, "We would wake them up." Often, she said, the nurse is then sent back to work.

A Bee investigation found that lax recruitment, worsened by the state budget crisis, and programs such as one for the suicidal that's exploited by savvy inmates, have contributed to extreme staff work schedules. Correctional officials have tolerated the practice despite criticism about the price of prison health care, which cost more than $2.1 billion in the year ending in June 2008.

In 2006, a federal judge appointed a receiver to combat substandard medical care in California prisons. Clinics were upgraded, services added and wages boosted – usually well above rates paid in regular hospitals. Incompetent doctors and nurses were ousted, and many new clinicians were hired. Care improved.

Yet, three years into the expensive overhaul, California's prisons in 2008 spent $60 million on health care overtime. That doesn't count an additional $111 million in overtime for guards who protect on- and off-site health workers during medical appointments – more than double the amount being spent when the receiver took over.

Rampant overtime, mostly for nurses, is the norm in this state, accounting for nearly 20 percent of all wages for prison nursing care. Nursing assistants logged the most overtime, equivalent to 1 1/2 extra work weeks a month, followed by licensed vocational nurses and registered nurses.

In New York prisons, by contrast, nursing overtime accounted for just 10 percent of wages. As a result, New York prison nurses earned about $100 per inmate in overtime for the full year, compared with about $300 per inmate in California.

Hundreds of California's prison nurses pulled down salaries more commonly associated with bankers. Three physician assistants and 52 nurses earned more than the $187,535 salary of Matthew Cate, corrections secretary and overseer of the prison system. (Most prison doctors also made more than Cate, without overtime.)

Compared to other state departments, the prisons stood out.

About 95 percent of prison nurses worked overtime last year – a higher proportion than for employees of any other state department, including those known for extreme schedules, such as the Department of Forestry and Fire Protection, the California Highway Patrol and nurses in state mental institutions.

Even temporary employees, supplied by employment agencies called registries, have managed to cash in – earning millions of dollars in overtime paid at up to twice the normal wage.

Vanessa Avila, a registry medical assistant at Deuel Vocational Institution in Tracy, worked a schedule that, even by prison standards, was superhuman: 26.5 hours a day on average. At least that's what the state paid for her. Avila could not be reached for comment; her registry said its books indicate that she worked fewer hours than the state's payment log indicates.

Deuel topped $4.3 million in health care overtime last year – among the most for any prison and more than double the average for the California Department of Corrections and Rehabilitation. Officials suggested that Deuel's demands may be greater because it processes new inmates before they are sent to other prisons, and those newcomers often arrive sick. But San Quentin, another intake center, spent just $1.3 million on overtime, far below the state average.

Officials in the receiver's office discounted the prospect that huge overtime claims might be fraudulent, because supervisors closely monitor and confirm time sheets.

Last year, however, six physicians – five from registries, and their supervisor, a state employee at Salinas Valley State Prison – were indicted for allegedly filing false work-hour claims. That case is still in court.

J. Clark Kelso, appointed in January 2008 as receiver to manage prison care, said he recently hired an internal auditor to check for possible fraud and find out "where do we have vulnerabilities?"

Kelso told The Bee he was most concerned about small but frequent fraud that can be hard to detect. "We don't have good systems in place," he said.

Suicide watch

Inmates use rampant fakery to manipulate the suicide watch program – one of the systems enhanced by the receiver to reduce inmate deaths – in ways that vastly increase unnecessary overtime.

Rayshawn Taylor, 30, an African American gang member from the Meadowview neighborhood in south Sacramento, said a recent cellmate at Deuel was a white man festooned with swastikas and racist tattoos.

"You want me to go to sleep (in that cell)? Hell no," said Taylor, who said he's in prison for kidnapping.

To prevent someone from being hurt – himself or his cellmate – Taylor said he told a doctor that he was ready to kill himself. He was switched to a private cell and watched 24 hours a day by a medical worker.

Since the receivership began, Deuel has seen an epidemic of such "suicidal" inmates, said James Simmons, a supervising nurse there. A daily average of three or four inmates in the suicide ward has jumped to eight or nine.

Simmons has seen it as high as 26, he said in an interview at the prison. Inmates "know that game," he said. "Less than 1 percent are actually suicidal."

Suicides are rare at Deuel. None was recorded in 2005 or 2006, before the receiver's program took hold, according to the California Department of Justice. Two inmates killed themselves in 2007, one in 2008, and none through June of this year.

Michelle Gorman, director of nursing at Deuel, said the prison recently brought in temporary nursing assistants for suicide watch to cut back on using nurses for the job. But union rules allow staff nurses to bump any temp.

Karen Rea, statewide nursing director, said she is considering hiring more assistants as state employees, who can't be bumped.

That's because, for a nurse, the seemingly mind-numbing work has a special allure: It pays up to $84 an hour.

According to internal tracking documents obtained by The Bee, Deuel spent more than $250,000 on suicide-watch salaries in December 2008 alone.

Effects on patient care

The impact of extreme work schedules is more than financial.

When clinicians are exhausted, "you don't see sharpness, the excellence in the workplace," said Dr. Jack St. Clair, chief medical officer at the Sierra Conservation Center, a prison in the foothills east of Stockton. "It's not safe."

Yet prison nurses said they routinely grab extra shifts to recoup wages lost on furlough days. Those with stamina treat overtime as a fast track to a higher standard of living, sometimes working 16-hour shifts five days a week.

"It doesn't leave a lot of room for rest," acknowledged Orlene Sargenti, licensed vocational nurse and union shop steward at Deuel, who averaged about 56 hours a week in 2008.

"Last year we had a couple of nurses who collapsed due to exhaustion," Sargenti said. Ironically, overwork generates more overtime, she said, when nurses working extreme hours call in sick from fatigue.

Gorman said nurses who sleep on the job jeopardize their licenses. "Nurses do tell us that 'I'm tired and I can't work,' " she said.

The request is granted, she added, only if another nurse is available to take over. Staffing gaps often require forced overtime.

Union contracts allow unlimited voluntary overtime. Last year Marie Punla, 37, a registered nurse at the California Substance Abuse Treatment Facility and State Prison in Corcoran, Kings County, took advantage of that provision to log 93 hours a week – more than all but seven prison clinicians in the state. That's equivalent to six 16-hour shifts every week.

Including benefits, Punla earned $300,000, or almost $5,800 a week.

"I had my goals," she said, noting that before she started at the prison, she worked two or three jobs for similar pay. Now, she gets home, eats with her family and is in bed within an hour.

"Sleeping five hours in a night is pretty good," Punla said. "My house is stable, my family emotionally stable. So when I go to work I don't have to think about my personal stuff."

Jose Nuñez, 43, an RN at California State Prison, Centinela, in Imperial County, said he loves the work. "Anytime someone calls in sick, I'm there."

In one recent, typical week he logged 72 hours by taking shifts around the clock, changing his sleep schedule from night to afternoon to morning as needed. A temporary medical registry employee, Nuñez earns time-and-a-half after eight hours and double time after 12. That week he pulled in $3,496.

"Last year we had the worst Christmas ever," said the father of three, "but this Christmas will be the best ever."

Last year some 240 prison clinicians routinely logged more hours than experts consider safe. Twenty exceeded 80 hours a week, and a handful, like Punla, topped 90.

A landmark report from the independent, nonprofit Institute of Medicine, the health arm of the National Academy of Sciences, says prolonged wakefulness has the same effect on skills and judgment as drunkenness.

Citing decades of research, it calls for regulators to cap daily shifts at 12 hours, weekly totals at 60.

Punla and Nuñez, like others who constantly bail out short-staffed prisons, claimed to be as effective working 16-hour shifts as nurses on a more normal schedule. Prison medical work is slower, they said, and errors are less likely than in a busy hospital.

But several others said fatigue-induced lapses are common.

"Some RNs tell the supervisors, 'I'm way too tired to work. If anything happens to me or these inmates, it's not my responsibility,' " said an LVN who until recently worked as a temp at the California Institution for Women in Corona. She would not be quoted by name for fear of being blacklisted for future hiring. She added: "They warned (supervisors), 'I'm documenting this to protect my license.' "

The receiver's acting chief executive for medical services, Dr. Dwight W. Winslow, acknowledged that sleeping on the job and related errors do occur, but he was unsure of how often.

"Employees are required, especially in a correctional setting, to be alert at all times," Winslow said. "It's called dereliction of duty. … It's a patient-safety issue."

At Deuel, sleeping nurses are awakened and sent back to work, given a break or, when possible, sent home, Gorman said. Both statewide officials and Deuel officials acknowledged that there are no special efforts statewide to monitor nurses who work extreme schedules.

The receiver's office cites improved access to care, better qualified clinicians and new equipment among its innovations. Winslow said they have led to a precipitous drop in deaths – one common measure of a prison health care system.

Prison death rates did fall from historic highs in 2006 but have plateaued this year, based on data through June 30 supplied by the state attorney general's office. The current rate – about 205 deaths per year for each 100,000 inmates – is 9 percent higher than the average rate from 1996 to 2001, when medical lapses prompted federal court intervention.

Winslow said current death rates may be explained at least partially by larger numbers of older inmates.

The receiver's most recent report on prison deaths was for 2007, after many improvements were in place. There were nearly 300 "extreme departures from the community standard" of care that year, according to the report.

Scores of those errors – including key symptoms missed, communication breakdowns between providers and medication blunders – also are the kinds of mistakes that numerous studies link closely to fatigue.

"Above eight hours a day the errors start going up exponentially," particularly medication errors, said Charlene Harrington, a professor at the University of California San Francisco School of Nursing and co-author of the Institute of Medicine study. She called the treadmill workweeks of many prison nurses "dangerous territory."

"If the administration actually condoned it," Harrington said, "it raises questions about oversight and judgment, and would be grounds for removing the managers."

Intractable hiring quandary

Kelso blamed prison health care staffing problems on a state budget that routinely understates the actual need. Work-arounds – including massive overtime – have become the norm because jobs haven't been budgeted, he said. "The people who are writing the budgets aren't acknowledging the reality."

Yet Kelso has embraced that unreality in his own calculations. He sees no recruitment crisis, he said, because he's filled nearly 90 percent of the authorized nursing jobs – a total he regards as phony. About 85 percent of jobs for doctors, nurse practitioners and physician assistants are filled.

Finding that last 10 percent to 15 percent of even an artificially low total remains challenging, because correctional health care is a hard sell.

Some clinicians don't like the constant vigilance about security. Others worry about the lingering stigma of prisons as dumping grounds for inferior providers.

And many prisons are in remote locations, such as Corcoran or Susanville.

"There's no prison in Beverly Hills or in downtown Sacramento or San Francisco," where well-paid doctors and nurses usually want to live, said Dr. Michael Sayre, chief medical officer at Pelican Bay State Prison in Crescent City, near the Oregon border.

Amid the state budget mess, Sayre said he's given up on ever being fully staffed.

Furloughs chopped salaries by 14 percent, and morale sank. By August, staffing for mid-level providers – physician assistants and nurse practitioners – had dropped more than 7 percent, and the ranks of pharmacy employees had fallen by almost a third. As of the end of November, 230 of some 3,400 prison staff nurses had quit.

Yet, the prisons should be particularly successful at recruiting nurses now. Some are scrambling for work for the first time in recent memory, and even after the furloughs, most prison jobs pay better than comparable posts statewide.

The receiver also has neglected an obvious alternative to some of the extreme overtime and profligate use of nurses in lower-skilled jobs, such as suicide watch: Open more jobs for nursing assistants, who usually earn $13 to $17 per hour. Just a handful are now employed.

Kelso said he might try to improve hiring by moving the sickest inmates to prisons near areas where doctors and highly skilled nurses want to live.

Another priority has been automated competence testing and applications.

"That is one of the things the receivership was established to do, was to break through those type of state barriers," Kelso said. "We are doing that."

Yet, only 62 of the state's more than 400 vacant prison nurse positions are posted on the receiver's career Web site. Kelso and his assistants said they were unaware of that disconnect. Later, his office said any omissions eventually would be corrected.

Add a hiring process that applicants claim still can take more than a year, and prison nurses who want to take on extra shifts should have a rich year ahead.

State prisons always have been inept at attracting clinicians, said attorney Steven Fama of the Prison Law Office, whose lawsuit on behalf of inmates led to the receivership. "The receiver was supposed to change that."

ABOUT THIS SERIES

These stories are based on a review of thousands of pages of research studies, audits, legal filings, financial and payment data, licensing reports and evaluations by and about the California Prison Heath Care Receivership Corp., and the state Department of Corrections and Rehabilitation.

Other California sources included the state auditor, Senate Office of Oversight and Outcomes, state controller, boards of vocational and registered nursing, and Department of Justice. Data also were supplied by the New York State Department of Correctional Services.

Reporting included more than 50 interviews with officials of employment agencies for medical workers; temporary prison clinicians and clinicians employed by the state; leaders of medical, nursing and psychiatric care for the prison system and for individual prisons; and inmates and their advocates.

An inmate rests under suicide watch at the Substance Abuse Treatment Facility and State Prison in Corcoran. Prisoners believed to be suicidal are moved into private cells and monitored 24 hours a day by a health care worker. The program, enhanced by prison receiver J. Clark Kelso to reduce inmate deaths, has greatly increased overtime costs for state prison medical staffs.

Nursing employees, such as this one at the California Substance Abuse Treatment Facility and State Prison in Corcoran, often work extreme schedules to keep up with the health care needs of inmates. A few nurses earn more than $300,000 annually by working 16-hour days.

Vladimir Denia, a licensed vocational nurse, monitors an inmate on 24-hour suicide watch at the Substance Abuse Treatment Facility and State Prison in Corcoran. Using temporary nursing assistants could save money, but temps can be bumped by staff nurses, who may earn up to $84 an hour for the task.

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