Reaves v. Department of Correction (195 F. Supp. 3d 383, 2016)

MEMORANDUM AND ORDER ON PLAINTIFF’S MOTION FOR PRELIMINARY INJUNCTION (Docket No. 14)

HILLMAN, DISTRICT JUDGE

Timothy M. Reaves brought this suit against the Department of Correction (DOC), the DOC’s contractual medical provider, and various individuals, asserting claims for deliberate indifference to serious medical needs and violations of Title II of the Americans with Disabilities Act, among other causes of action. He moves for preliminary injunctive' relief, seeking immediate chahges to his medical care and accommodations for his disabilities. For the reasons set forth and explained below, Reaves’s motion (Docket No. 14) is granted in part and denied in part.

I find that Reaves is likely to succeed on the merits of his claim that the DOC and its medical providers have been deliberately indifferent to his serious medical needs by failing to have his care overseen by a spinal cord injury specialist; failing to provide comprehensive physical and occupational therapy; failing to provide a comprehensive bowel program; failing to prevent and treat autonomic dysreflexia; and failing to maintain functioning hearing aids. I also find that the DOC’s current medical provider has made commitments in recent months to improving Reaves’s care. Due to the fluid nature of this situation, and because it is too early to determine whether these commitments are serious, comprehensive equitable relief is not appropriate at this time. Instead, I elect to give the DOC and its medical provider an opportunity to rectify the aspects of Reaves’s care that appear to be deficient. I use my inherent authority to appoint a monitor, who will receive and transmit to the court reports on Reaves’s ongoing medical care until the final resolution of this case.

I find that Reaves is likely to succeed on the merits of his claim that the DOC has violated Title II of the ADA by failing to provide him with outdoor and indoor recreation; socialization, access to programming, reasonable accommodations in the shower facilities, and confidentiality.in his mental health care. I find that the record is not sufficiently developed to determine his likelihood of success on his claims of insufficient access to a writing assistant and lack of appropriate confidentiality in his medical care. I further find that Reaves has shown a potential for ■ irreparable harm, that the balance of burdens tips in his favor, and that the public interest will be served by the issuance of an injunction. I order the DOC to remedy the above-noted violations, and I grant the monitor the authority to observe and report on the implementation of this remedy.

Background

Timothy M. Reaves (Plaintiff) is a fifty-one-year-old quadriplegic inmate serving a life sentence without the possibility of parole. He is currently incarcerated in the Health Services Unit of the Massachusetts Correctional Institution at Shirley (MCI Shirley). In 1994, he was involved in a high-speed motor vehicle chase, during which he was a passenger in the back seat of a vehicle being pursued by the police. The chase occurred immediately after a drive-by shooting and ended when the vehicle crashed at a high rate of speed. Reaves suffered a spinal cord injury, which resulted in quadriplegia. He was later convicted of first-degree murder on a theory of joint venture and was sentenced to serve the remainder of his life in prison. See Commonwealth v. Reaves, 434 Mass. 383, 750 N.E.2d 464, 466 (2001). In addition to the spinal cord injury, Reaves suffered a frontal-lobe brain injury. (Docket Nos. 15-6 at 5; 15-19 at 4.) He has been diagnosed with a personality disorder and episodes of atypical depression. (Docket No, 15-19 at 4, 5.) He is hearing-impaired and requires hearing aids. (P ex. 50 at 1.)

Reaves has been incarcerated for twenty years. For approximately the past seventeen years, he has been unable to use a wheelchair and has been confined to his bed. (P ex. 2.) The DOC has transferred him five times between three different correctional facilities in Massachusetts. He began serving his sentence in 1996 at MCI Shirley; in 1999, he was moved to Souza-Baranowski Correctional Center (SBCC); in 2007 he was moved back to MCI Shirley; in 2011 he was moved to Bridgewater State Hospital (BSH); in 2014 he was moved back to SBCC; and, most recently, on January 25, 2016, during the pendency of this lawsuit, he was moved back to MCI Shirley. He has also had several inpatient stays at the Lemuel Shattuck Hospital (LSH).

There are two groups of Defendants in this case—one group affiliated with the DOC and one group affiliated with the DOC’s contractual medical provider, Massachusetts Partnership for Correctional Healthcare (MPCH). The first group consists of the DOC and four officials: Carol Higgins O’Brien, Commissioner of the DOC; Michael Rodrigues, Deputy Superintendent of Programs and Treatment at SBCC; Pamela MacEachern, Deputy Superintendent of Programs and Treatment at BSH; and Stephanie Collins, Assistant Deputy Commissioner of Clinical Services and Director of Health Services Division of the DOC (collectively, the DOC Defendants). The second group consists of MHM Correctional Services, Inc. and MPCH, as well as five individual employees of MPCH: Geraldine Somers, MD, Medical Director at SBCC; Leigh Pariseau, RN, Director of Nursing at SBCC; Julie Ireland, RN, Health Services Administrator at SBCC; Khalid Khan, MD, Medical Director at BSH; and Bonnie Damigella, RN, Director of Nursing at BSH (collectively, the MPCH Defendants).

MPCH is a subsidiary of MHM Correctional Services. MPCH has been responsible for providing medical and mental health care for inmates in Massachusetts since July 1, 2013. Prior to that date, MHM provided mental health services and the University of Massachusetts Correctional Health Program was responsible for medical care. The bulk of the evidence presented in this case relates to MPCH’s care of Reaves during his most recent period of incarceration at SBCC, from January 13, 2014 to January 25, 2016. Some additional evidence predates his stay at SBCC, and some relates to his treatment at MCI Shirley since January 25, 2016. Six witnesses testified over the course of seven days of hearings, spanning nearly three months, in relation to the instant motion.

Two of Reaves’s former medical providers—who are also Defendants in this case—testified on behalf of MPCH. Geraldine Somers, MD, is the Medical Director at SBCC and was Reaves’s primary care provider from January of 2014 until January of 2016. Dr. Somers has no specific educational background in spinal cord injury medicine, and no significant experience treating patients with these types of injuries. She testified that when caring for Reaves she relied on outside consultations as she felt necessary, and she would implement the outside providers’ suggestions if she agreed with their recommendations. Specialists’ recommendations could not be implemented unless she or another MPCH provider wrote an order. The second medical-provider Defendant to testify was Julie Ireland, who is a Registered Nurse and a Health Services Administrator at SBCC. In this capacity, she administratively oversaw the medical and mental health care provided to Reaves while he was housed at SBCC.

Reaves’s condition has significantly deteriorated during his twenty years of incarceration. When he was in rehabilitation shortly after his injury, he was able to shave the left side of his face, brush his teeth, and feed himself. He could sit in a wheelchair and take a shower on a shower stretcher. Now, he is unable to do any of those things. His hip and knee joints are frozen and can no longer'be bent to sit in a wheelchair, while his elbows cannot be unlocked from a bent position. He cannot open his hands and fingers from clenched fists. The skin on his legs is susceptible to long-lasting open wounds and requires daily care and bandaging. He is underweight. He testified that his condition continued to worsen during his most recent stay at SBCC, during which he lost weight, muscle tone, and flexibility in his lower extremities, and incurred increased tightness in his arms and left wrist. He testified that he does not understand what it means to be “healthy” as a quadriplegic.

Dr. Morse’s Findings

In January of 2014, Reaves’s counsel retained Leslie Morse, DO, a physiatrist who specializes in-spinal cord injuries, to examine Reaves and write a report on his condition. She testified as a spinal cord injury specialist, and her report was admitted into evidence. Dr. Morse is board certified in physical medicine and rehabilitation. She is the Program Director of the Spaulding Harvard Spinal Cord Injury Model System, as well as an Associate Director of Research at the Department of Physical Medicine and Rehabilitation at Harvard Medical School and an Assistant Professor at Harvard Medical School. She sees spinal cord injury patients as a direct provider and also in the course of her research!. She supervises medical students and residents in the field of spinal cord injury; has produced numerous publications on the topic; and performs patient and provider education regarding the standards of care for spinal cord injury.

Dr. Morse identified Reaves’s injury as a “C6 ASIA B” spinal cord injury. “ASIA” stands for “American Spinal Injury Association.” “C6” refers to the injury’s level in the spine. “B” classifies the injury as motor complete, meaning that Reaves cannot contract any muscles below the level of injury; but sensory incomplete, meaning that he has some preserved sensation. According to Dr. Morse, a person with a C6 ASIA B spinal cord injury would be expected to achieve modified independence, including the abilities to sit in and operate a wheelchair, help dress and feed oneself, and exercise some control oyer one’s environment with the assistance of adaptive equipment. Reaves, however, cannot do these things, After examining Reaves, Dr. Morse concluded that he suffers from severe complications of his injury, which are due to a lack of proper medical attention. She explained:

Mr. Reaves is an extreme example of untreated secondary complications of spinal cord injury that were, for the most part, preventable with appropriate supportive care. These secondary complications were entirely foreseeable for a quadriplegic individual persistently left without the basic supportive care required, which is why care plans for individuals with spinal cord injury, under the care of a provider competent to care for such an individual, would always require this basic care.

(Docket No. 15-2 at 2.)

Reaves suffers from spasticity and contractures, which means that many of his joints are fixed in either extension or flexion. Some joints are completely fixed, while others retain partial mobility. He has contractures in his toes, ankles, knees, hips, elbows, wrists, and fingers. Because of the contractures, he is unable to bend at the hips, meaning that his body cannot be moved into a seated position. Dr. Morse explained that contractures are typically prevented and/or treated with daily range of motion (ROM) therapy, as well as heat, splinting, bracing, casting, Botox, medications, and surgery. Reaves’s contrac-tures have developed progressively over the past twenty years, and much of his decline occurred before MPCH began caring for the Massachusetts prison population in 2013. For example, in 2013 he had already lost the ability to sit in a wheelchair. Dr. Morse testified that, in her fourteen years of practice, she had never seen contractures to the degree of those in Reaves’s body. She attributed this to a lack of preventative therapies and treatments.

Dr. Morse testified that Reaves should be receiving ROM therapy twice per day to manage his contractures. This would involve moving the areas of his body that can be moved through their full range of motion. If this is not done, his joints will continue to fix, and his legs will begin to curl permanently inward, compromising his groin hygiene, and bladder and bowel care, and putting him at risk for infections. Dr. Morse explained that ROM therapy consists of specific movements; merely moving a patient’s limbs in the process of putting on clothes, for example, does not suffice. Moreover, she testified that uneducated implementation of ROM therapy could result in accidental fractures of Reaves’s delicate bones. The medical records reveal that Reaves did not arrive at SBCC in January of 2014 with a written ROM therapy plan in place, and the staff at SBCC were not formally trained in the performance of ROM therapy until nearly two years later, in December of 2015.

It is not clear how often Reaves was offered or received ROM therapy during his two years at SBCC. It is undisputed that only one nurse performed ROM therapy on his lower extremities. Dr. Somers testified that this occurred approximately four times per week, while Ireland testified that it was offered at least once per day. Despite the lack of a written order or any type of documentation, Dr. Somers also testified that Reaves had received ROM therapy on his upper extremities every day at SBCC. Ireland, on the other hand, testified that he was not offered upper-extremity ROM therapy until at least December of 2015. The upper extremity ROM therapy was allegedly performed by a Certified Nursing Assistant (CNA), during bathing or around Reaves’s mealtime. Reaves testified that a CNA performed ROM therapy on his upper extremities on only one occasion at SBCC, on his left arm in the fall of 2015. Dr. Somers did not write a physician’s order for any type of ROM therapy until January 22, 2016—six months after he had filed this lawsuit, and three days before he was transferred out of SBCC.

In addition to ROM therapy, Dr. Morse emphasized that Reaves should have a comprehensive physical therapy program that is developed, prescribed, and overseen by a medical professional who specializes in spinal cord injuries. Although much of his body is wrought by contractures, he currently retains some strength and mobility in his shoulders, upper back, and neck, which he will lose without ongoing therapy.

Dr. Morse also testified that Reaves should receive occupational therapy, which would involve an assessment for adaptive equipment and working toward achieving a more upright position for his body, with the goal of increasing his independence in the activities of daily living. Dr. Morse emphasized that this program should be constructed by an individual with spinal cord injury expertise and should be integrated with his physical therapy plan. Reaves testified that, at some point in the past, he had a “universal cuff,” which he used to brush his teeth, shave his face, operate a wheelchair, use an accessible remote control, and use the telephone. He testified that the cuff was confiscated in 2009. He had wrist weights that were also taken away. He testified that he was not evaluated for adaptive equipment at SBCC. He was given several adaptive feeding devices in December of 2015, but he is unable to use them his current condition.

Dr. Morse further explained that Reaves is at serious risk for autonomic dysreflexia (AD), which is a potentially fatal condition unique to individuals with spinal cord injuries. AD is a dangerous elevation in blood pressure in response to a painful stimulus in an insensate area. AD is considered a medical emergency, because it can result in a stroke or death. According to Dr. Morse, it is essential for Reaves’s healthcare providers to be fully educated regarding AD. Such knowledge includes symptoms, signs, triggers, and treatments.

According to Dr, Morse, the symptoms of AD are unique to each patient but can include headache, flushing, sweating, nasal congestion, goose bumps, and pounding in the ears. With the help of an educated provider, patients can learn to identify their own symptoms. The most significant sign of AD is an increase in blood pressure. AD is most commonly triggered by constipation, urinary tract infections, bladder blockages, ingrown toenails, or a sharp object in the patient’s bedding. Although these are the most common causes, any painful stimulus below the level of injury can trigger an AD response. Dr. Morse testified that the immediate response to an AD event should be to find and remove the offending stimulus.

Dr. Morse testified that any blood pressure reading that is twenty millimeters of mercury greater than baseline in the systolic reading should be cause for concern for AD, prompting medical personnel to conduct a full physical examination in order to identify the cause. Dr. Somers testified that she was aware of the risks of AD and that Reaves did not have any signs or symptoms during his two years at SBCC. However, the medical records show multiple instances of heightened blood pressures, which indicate potential AD events, with no corresponding notes of an assessment for the offending stimulus. Dr. Som-ers explained that she considered any blood pressure reading above 120/80 to be high for Reaves, but that if he “otherwise looked perfectly fine,” she would not do anything except continue to monitor him. Dr. Somers did not formally instruct her staff about AD or write a care plan to address AD until January of 2016—two years after she began caring for him and six months after the initiation of this lawsuit.

When Dr. Morse examined Reaves in 2014, his finger and toe nails were overgrown. She explained that this presents a risk of AD, because the nails could grow into his skin, causing a painful stimulus in an insensate area. Constipation presents a similar problem. After examining Reaves, Dr. Morse concluded that he suffers from chronic constipation. In addition to being a trigger for. AD, constipation can cause a life-threatening obstruction or rupture, as well as a loss of appetite.

Reaves has a neurogenic bowel, which means that he cannot control his bowel movements. Dr. Morse testified that all spinal cord injury patients, including Reaves, need a comprehensive bowel plan to manage bowel movements and prevent constipation. She explained that an appropriate bowel plan for Reaves would include scheduled laxatives, stool softeners, and digital stimulation, with a goal of achieving regular and predictable bowel movements every other day. Dr. Morse emphasized that educating Reaves about the need for a bowel plan would be crucial, because spinal cord injury patients are often initially reluctant to accept bowel management. Dr. Morse explained that if Reaves were not open to adopting a bowel management plan, it would not be sufficient for providers to merely offer him as-needed laxatives, which is the current mode of treatment. Rather, he should be part of a patient-provider partnership, with a provider who is skilled in this particular area of medicine, so that he can be made to-appreciate the life-threatening nature of having an unmanaged neurogenic bowel. She emphasized that patient education is crucial to many aspects of his care, and she opined that his brain injury makes this type of education especially important.

Reaves does not currently have regular, predictable bowel movements. According to Ireland and Dr. Somers, he is not constipated and there is no problem with his present situation. Dr. Somers explained that nurses and CNAs are supposed to keep track of his bowel movements in a nursing log, but they do not always do so. According to Dr. Somers, he had a bowel movement every two to three days at SBCC. According to Ireland, he had a bowel movement every other day, Ireland explained that if he did not have a bowel movement after three days, he was offered Milk of Magnesia or a laxative suppository. His medical records show periods of five or more days with no documented bowel movements and no laxatives provided, both at SBCC and more recently at MCI Shirley.

In addition to preventing constipation, regular bowel movements are necessary to avoid infection. Reaves defecates in his bed, and he must call staff to come to his cell to clean him after he has had a bowel movement. The unpredictability of this situation means that his skin is vulnerable to infection, because it is exposed to fecal matter after every evacuation.

According to Dr. Morse, it is necessary that a physician who has expertise in spinal cord injury medicine direct Reaves’s care. She testified that he is at risk of further serious and potentially irreversible injury if his medical care does not improve. She explained:

A spinal cord injury specialist is an absolutely critical component of Mr. Reaves’ care at this point in time, as his condition has deteriorated so far and the complications he is experiencing are so grave that he requires prompt spinal cord expertise in managing these complications to avoid premature death.

(Docket No. 15-2 at 5.)

Dr. Morse’s report was given to Dr. Somers in June of 2014, approximately five months after Reaves arrived at SBCC. Dr. Somers did not respond to Dr. Morse’s suggestions.

Pre-Lawsuit Medical Care at SBCC

The medical records show a marked increase in medical care after Reaves filed this suit on July 7, 2015. In the eighteen months during which he was housed at SBCC before he initiated the suit, he was treated inpatient at LSH for dermatitis and had one physical therapy assessment at SBCC for neck pain. One nursing plan was drafted in relation to his ongoing care, which did not address his hearing deficit, bowel care, or AD, In the six months after he filed suit, he was admitted to LSH for a short inpatient stay to “start rehab” and was then seen by three physiatrists, an audiologist, a podiatrist, a urologist, and an orthopedic surgeon. Additional appointments were scheduled in the future for further testing. He had two mental health consultations and was given several adaptive devices. Three additional care plans were drafted, which addressed AD and bowel care. The medical staff were trained, for the first time, on AD and ROM. Despite this precipitous uptick in interventions, the MPCH Defendants maintain that Reaves’s care has always been adequate. Reaves’s pre- and post-lawsuit care is explained in more detail below.

In the spring of 2014, Reaves had a one-month inpatient stay at LSH to treat his lower-extremity dermatitis. (D ex. 1 at 9.) While at LSH, he had a nutritional assessment and was deemed to be underweight. (D ex. 1 at 13-14.) Dr. Somers testified that, when he returned from LSH, he was offered a health shake three times per day. He also had an occupational therapy assessment at LSH, in which he was assessed for hand-splinting. The splinting was deemed unsuccessful on his left hand. (D ex. 1 at 9.) Dr. Somers testified that the occupational therapy consultation was provided at LSH’s initiative, not her own. The discharge notes from this in-patient stay at LSH also contain a recommendation that Reaves see a podiatrist every six to eight weeks for nail care. (D ex. 1 at 9.) According to Dr. Somers, Reaves was already receiving this frequency of nail care. However, the medical records indicate that aside from his two inpatient stays at LSH he did not see a podiatrist at SBCC until the fall of 2015.

The pre-lawsuit records contain one “physical therapy progress note” from September of 2014.. The purpose of this visit was apparently to address pain and stiffness in Reaves’s neck. The physical therapist noted that, in order for Reaves to achieve a sitting position, he would need intensive physical therapy involving equipment that was not available at SBCC. (P ex. 9.)

One nursing care plan, dated December 1, 2014, predated the initiation of this lawsuit. This plan provided for “joint ROM” but did not contain any specifics regarding which joints, how to perform the ROM therapy, or for what duration. The plan contained no mention of AD, bowel care, or Reaves’s hearing deficit. (D ex. 2 at 43, 46-47.)

Medical Care during the Pendency of this Lawsuit

Reaves filed this lawsuit on July 7, 2015. Approximately three weeks later, he was admitted to LSH to “start rehab.” (D ex. 1 at 15.) He remained at LSH for three weeks and was discharged on August 21, 2015. Dr. Somers testified • that she requested this inpatient stay after speaking with the prison’s physical therapist, who said that it would not be possible to conduct the therapy necessary to improve Reaves’s mobility while he' was at SBCC.

While at LSH, Reaves had a physical therapy evaluation, during which he reported to the therapist that he wanted to get stronger and regain the ability to sit in a wheelchair. The therapist concluded that he should receive thirty minutes of ROM therapy three times per week. (D ex.- T at 21-22.) The notes for this evaluation do not specify the parts of his body on which the ROM therapy should be performed or the specific types of movements. Reaves testified that medical staff at LSH performed ROM therapy for thirty to forty-five minutes at a time during his stay, and that his flexibility increased as a result. The physical therapy discharge notes from LSH indicate that he had a spasm during, a physical therapy session. (D ex. 1 at 18.) He testified that, since approximately 2010, he ■has been having spasms that cause his back to arch. At least one such spasm occurred during his testimony in this case.

According to Dr. Morse, the physical therapy that Reaves received at LSH during his inpatient stay in the summer of 2015 was inadequate. No formal program was created to increase his range of motion or strength; LSH is not a hospital that normally provides rehabilitative therapy to quadriplegic patients; and the providers do not have experience with spinal cord injury patients. According to Dr. Morse, an order for unspecified ROM therapy three times per week is not sufficient to maintain Reaves’s physical condition, let alone improve it.

Reaves also had an occupational therapy evaluation at LSH. The occupational therapist fitted him with a palm protector and hand splints. The splint on his left hand caused skin irritation and was discontinued. (P ex. 13 at 2-3.) According to Reaves, no work was done at LSH with adaptive tools. In December of 2015, two weeks before the hearings began in this case, he was given a Velcro strap for utensils to slide into, but it was not properly fitted onto his hand. He was also given an adaptive spoon, bowl, plate, and cup. According to Reaves and Dr. Morse, Reaves is unable to use these devices in his current condition.

On October 8, 2015, approximately two months after Reaves filed the instant motion for preliminary injunction, Dr. Somers sent him to Anthony Lee, MD, who is an outside provider unaffiliated with MPCH. Dr. Somers testified that she sent Reaves to Dr. Lee because she felt that he should be seen by a physiatrist. Dr. Lee is a physiatrist, but he does not specialize in spinal cord injuries. He noted this in his report and suggested that Reaves see a provider with the appropriate expertise.

Although Dr. Lee is not a spinal cord injury specialist, he evaluated Reaves and made a number of suggestions for changes to his care. (P ex. 28 at 1-3.) He noted irritation around Reaves’s penis and scrotum and recommended switching to a non-latex catheter, as well as a urology followup. Dr. Lee noted extensive skin breakdown on the fronts of Reaves’s legs, as well as an ulcer in his sacral area, and he recommended continued wound care and regular turning. Because there were small areas of dried blood on Reaves’s feet, Dr. Lee recommended that he see a dermatologist, as well as a podiatrist every two-to-three months for nail care. He recommended a follow-up-with an ear, nose, and throat.doctor (ENT) to unclog his left ear and noted that he should see an ENT at least once per year. Dr. Lee recommended ROM therapy on all joints, as well as one full contraction of each muscle group to prevent atrophy. He also recommended “tilt table” training to increase Reaves’s tolerance for being upright. He noted that this would take some time, because Reaves has been lying down for approximately seventeen years. Dr. Lee noted as a long-term goal that Reaves should be able to sit upright and feed himself with an adaptive cuff. He recommended that Reaves see a surgeon to discuss possible surgical release of his contractures and noted that “[tjhere was a question of amputation,” but he did not recommend it.

After Reaves visited Dr. Lee, Dr. Som-ers requested an in-house podiatry consultation; issued an order for repositioning; scheduled a surgical consultation; scheduled an orthopedic consultation; scheduled an appointment with an audiologist; and scheduled a urology consultation. The orthopedic consultation occurred at LSH, with Adriana Carrillo, MD, who is not a spinal cord injury specialist. Dr. Carrillo evaluated Reaves for potential surgical release of his contractures and determined that he would not benefit from this treatment. Dr. Carrillo noted that she was familiar with Reaves and that he had previously been “deemed not a candidate for any rehabilitation.” (P ex. 8 at 1.)

Dr. Somers also testified that she provided ROM therapy in response to Dr. Lee’s recommendation that Reaves should receive physical therapy to exercise his joints. However, the medical records do not indicate the frequency of ROM therapy, nor do they indicate that Reaves received ROM therapy on his upper extremities. Reaves was also given a feeding cuff, although it appears that he is unable to use it in his current condition.

On November 13, 2015, Reaves saw an audiologist who characterized his hearing loss as “moderately severe” to “profound” in both ears. The provider noted that Reaves needed new hearing aids but had to have wax removed before he could be fitted. (P ex. 48.) He saw an ENT for wax removal and was then fitted with' new hearing aids on December 11, 2015, the week before the hearings began in this case. (P exs. 51, 52.) After several nurses tried unsuccessfully to insert the hearing aids into his ears, Ireland had a phone consultation with the audiologist to assist with the process. Reaves cannot insert the hearing aids himself because he cannot use his hands. The hearing aids were adjusted for feedback issues on December 28, 2015.

Reaves had previously been seen by an audiologist in 2013, who similarly found that his hearing loss was “moderate to severe” in his right ear and “moderately severe to severe” ,in his left hear.. This provider noted that Reaves had been wearing hearing aids for more than ten years. (Docket No. 15-7.) He arrived at SBCC in 2014 with five individual hearing aids, but they did not work properly or were not consistently and/or correctly inserted. into his ears. Reaves testified that, when his hearing aids are not inserted correctly or are not functioning properly, he becomes frustrated because he cannot hear what people are saying to him. According to Reaves, medical personnel do not always check to see if he can hear them. He testified that, prior to December of 2015, the last time he was given new hearing aids was after a hearing in Superi- or Court in 2013.

Although the medical records unquestionably indicate that Reaves is hearing impaired, Dr. Somers testified that she performed a “whisper test” several months before the hearings began in this case. She testified that she conducted this test because Reaves would often “ignore her” when she spoke to him. Having recently suggested that Reaves share his room with an inmate in a vegetative state as a response to his request for socialization, and knowing that Reaves was adamantly opposed to this idea, Dr. Somers walked into his room and “whispered” to the *nurse, “Today we’re going to get Mr. Reaves a roommate.” According to Dr. Somers, Reaves “exploded” in response.

In response to Dr. Lee’s recommendation that Reaves see a physiatrist who specializes in spinal cord injuries, on December 2, 2015 Dr. Somers sent him to Faren Williams, MD. Dr. Williams is a physiatrist, but it is riot clear that she has any appreciable experience treating patients with spinal cord injuries. Dr. Williams noted that Reaves’s risk for AD is low because he “is supine most of the time.” (P ex., 29 at 3.) According to Dr. Morse’s description of AD and its causes, the fact that Reaves is confined to a supine position does not eliminate his risk. Dr. Williams also noted that Reaves would not benefit from physical and/or occupational therapy, because his contractures are longstanding and fixed, and she did not recognize a need to work on his functioning muscle groups for atrophy prevention. She did recommend a urology assessment.

On December 8, 2015, Ireland authored a “feeding procedure.” This procedure listed the adaptive bowl, plate, cup, utensils, and Velcro strap that Reaves was given, at around the same time, which were the first adaptive devices he received at SBCC. The feeding plan also stated, “Bilateral upper extremity passive range of motion to be offered and provided before or after noon meal,” and “Passive range of motion to include wrist, elbow, shoulder and fingers.” (P ex. 14.) This is the first record to indicate provision of upper-extremity ROM therapy at SBCC. No further description was given regarding the duration of the therapy, the specific movements to be performed, or whether staff were instructed on how to perform the ROM therapy.

On December 15, 2015—the day before the hearings began in this case—Reaves was taken to a third physiatrist, Heidi Wennemer, DO. Unlike Drs. Lee and Williams, Dr. Wennemer is a spinal cord injury specialist. Dr. Somers testified that she sent Reaves to Dr. Wennemer because Drs. Lee and Williams had disagreed with one another in their findings and recommendations. Dr. Somers provided Dr. Wennemer with the notes of Drs. Lee, Williams, and Carrillo, as well as a list of “Specific Physiatry-related questions pertaining to patient Tim Reaves’ care plan”:

• Bowel Management Plan

• Autonomic Dysreflexia

• Sacral Ulcer

• Dynamic Splinting and/or Serial Casting

• Adaptive Equipment

• Nutritional Needs

• Nail Care

• Sleep Surface

• Repositioning

• Physical and Occupational Therapy (including frequency and type of care)

• Frequency of follow-up care w/ spinal cord injury expert

(D ex. 13 at 480A.)

Dr. Wennemer examined Reaves and issued a written report, dated December 15, 2015. (P ex. 32.) Her overall impression was as follows:

C5 Asia A complete tetraplegia[] with worsening orthostatic hypotension, worsening autonomic dysreflexia and worsening spasticity. The patient has severe contractures in all 4 extremities. No functional use of arms and legs. Neuro-genic bowel and bladder. Bilateral lower extremity skin breakdown and wounds consistent with a fungal dermatitis, healed stage IV sacral ulcer and obvious psychologic overlay. Severe hearing loss.

(P ex. 32 at 3.)

Many of Dr. Wennemer’s recommendations mirrored those of Dr. Morse, who is the only other spinal cord injury specialist to have evaluated Reaves in recent history. In her report, Dr. Wennemer noted that Reaves had an AD event during his visit, with no clear inciting source. His supine blood pressure readings were 154/100 and 140/88. Because the event corresponded with urination, she suspected that he had a urinary tract infection. She was also concerned about incomplete bladder emptying and recommended bladder studies to ensure that he is not retaining urine, as this would increase his risk of reflux to the kidneys, kidney damage, and pyelonephri-tis. She noted that although he is at a high risk for pressure ulcers on his skin, his skin appeared to be well cared for. She found that he may benefit from spasticity treatments for his contractures, although his options are- limited because he has severe orthostatic hypotension. She recommended a Baclofen pump trial. She suspected that his spasms, as well as his shoulder and neck pain, may be caused by a posttraumatic syringomyelia. She recommended an MRI.

Regarding Reaves’s bowel, Dr. Wen-nemer recommended that he take a daily suppository to schedule his bowel movements. She noted, however, that he did not seem open to this suggestion. (P ex. 32 at 4.) She recommended an annual x-ray of his kidney, ureter, and bladder (KUB) to check for obvious obstructions, noting that patients with inadequate bowel evacuation are at risk for developing megacolon. She recommended an annual EKG to assess his heart function. She recommended that medications be available as needed for AD, including nitroglycerin paste to lower his blood pressure. She noted that the most likely triggers for AD are bowel and bladder issues and pressure ulcers, and that staff should be educated on the signs and symptoms of AD. Because AD is potentially fatal, she was concerned to learn from Dr. Somers that Reaves often refuses.to have his blood pressure checked.

Dr. Wennemer further recommended an annual chest x-ray and pneumococcal vaccination and an antifungal cream for a rash on his lower extremities. She recommended physical therapy and hand splints for 'his contractures. She noted that his spasticity and contractures would need to be addressed with physical therapy by a spasticity specialist before he could begin to attempt to sit up. After addressing the contractures, medications could be used to combat his orthostatic hypotension. She noted that if physical therapists were able to address his hip and knee contractures, and if his spasticity could be controlled to prevent back extension spasms, he may achieve the ability to use a wheelchair. She noted that he has “clear anger and frustration with his current situation” and a history of noncompliance, and that he would benefit from psychological support. (P ex. 32 at 4-5.)

At the time of Dr. Wennemer’s evaluation, Reaves was already scheduled to see a urologist pursuant to Dr. Lee’s recommendation. The urologist’s notes, dated December 18, 2015, indicated that he was referred for irritation on his penis; not for bladder studies, According to Dr. Somers, the urologist reported that Reaves should have an ultrasound before beginning bladder studies. The report made no mention of bladder studies but did state that Reaves- should have a yearly renal ultrasound to check for changes in his upper urinary tract, and that he had not-had a renal ultrasound in approximately six years. (D ex. 13 at 486.) Reaves had this ultrasound on February 2, 2016, and the report showed no evidence of hydrone-phrosis. (D ex. 19E at 758.) The report made no mention of bladder studies, and the records do not indicate whether Reaves has since been evaluated for bladder studies, as Dr. Wennemer recommended.

In response to Dr. Wennemer’s recommendations, Dr, Somers provided Reaves with a mental health consultation on December 22, 2015. This appears to be his first mental health visit since arriving at SBCC. Reaves told the clinician, “I don’t talk to Mental Health. I talk to myself,” and “Stay out of trouble, don’t talk to too many people.” (D ex. 13 at 488.) Reaves had a second mental health consultation on January 15, 2016, for the purpose of addressing his refusals of medical treatments and interventions. Despite Dr. Somers’s testimony that Reaves often refuses beneficial treatments, this appears to be the only time that she referred him to mental health to address his noncompliance. Reaves told the clinician that he does not refuse treatment, and that adequate treatment has not been offered to him. He explained that mental health staff would not be of use to him unless he is seen at least five days per week, a frequency that the provider told him “was not feasible.” The clinician noted that Reaves appeared angry with his access to mental health services and that he “employed sarcasm as [a] means of conveying this.” The clinician noted that Reaves’s “presentation appeared to soften” when she attempted to learn what had been helpful to him in the past. (P ex. 78.)

Reaves also complained to the mental health clinician about the lack of confidentiality in his care. All of Reaves’s medical and mental health care occurs with a correctional officer in the room. Ireland explained that able-bodied inmates are shackled to a chair during their mental health visits, without a correctional officer in the room. With- Reaves, who cannot be shackled to a chair because he cannot sit up, the presence of the correctional officer is purportedly for the safety of the mental health professional, because he has a history of “verbal outbursts” and “spitting.”

Dr. Somers also scheduled an MRI in response to Dr. Wennemer’s recommendation. Reaves was not told about the appointment until 12:30 a.m. on the day that it was to occur, and he refused to go. (D ex. 19G at 771.) It is undisputed that Reaves does not react well to being woken up during the night. He had an arrangement with staff at SBCC to not wake him for repositioning. The MRI incident occurred after his most recent transfer to MCI Shirley. It is not clear from the medical- records whether the MRI occurred at a later date and, if so, what the test revealed.

Dr. Somers testified that she scheduled an appointment for Reaves to see a neurosurgeon to evaluate him for hand splints and a possible Baclofen pump trial. The records do not indicate whether this appointment occurred or what the results were. Dr. Somers ordered nitroglycerin paste to have on hand for AD episodes, although she maintains that she has never seen Reaves have any signs or symptoms of AD. Dr. Somers testified that she wrote an order for laxatives but Reaves refused to take them, as he. has done many times in the past. There is no indication of any other interventions for the purpose of establishing a bowel program. Reaves was offered a chest x-ray and a pneumococcal vaccine, but he refused both. Dr. Somers ordered a KUB, and Reaves initially refused that as well. He later agreed to have the KUB after being educated about its benefits. This test revealed that he has a “[possible megacolon,” with “[l]arge amount of fecal material present in colon,” The radiologist noted that a prior x-ray from January of 2011 had “showed the presence of marked, acute distended colon,” and that there were “marked degenerative changes and loss of joint space of both femoral heads.” (Docket No. 75-1 at 1.) It is not clear what, if anything, has been done in response to these findings.

In response to Dr. Wennemer’s recommendation, the staff at SBCC were trained on the signs and symptoms of AD. This training occurred in late December of 2015 or early January of 2016 and included written materials. (D ex. 16 at 521-24.) There was also an in-service training on ROM therapy, which was referred to as a “read and sign” training and included written materials with instructions for performing ROM. (D ex. 15 át 504-20.) According to Ireland, staff read the materials, signed off in acknowledgment of having done so, and then a physical therapist assistant spoke to them about what they had read. The •written materials are not specific to Reaves, nor are they specific to spinal cord injury patients. The list of exercises includes movements that Reaves is unable to do in his current condition, and which could be dangerous if attempted. According to Ireland, both of these trainings have also been conducted at MCI Shirley.

Dr. Somers testified that Reaves is a difficult patient and often refuses care. Pursuant to the DOC’s policies, medical staff are required to document such refusals, indicating what care was refused, and that the medical provider attempted to counsel the patient and explain the benefits of the proposed care or treatment. 103 DOC 630.19. The record contains 470 “release of responsibility” forms dated April 14, 2014 to February 5, 2016. Of these refusals, 247 were for vital signs; 167 were for repositioning; and 159 were for tooth brushing. During those twenty-two months,- Reaves refused ROM therapy nineteen times. With the exception of one ROM therapy refusal in September of 2015, the remainder occurred between December of 2015 and February of 2016, Reaves testified that he refused ROM therapy only when it was offered late at night, because the physical stimulation prevents him from falling asleep.

Reaves acknowledges that he sometimes refuses to have his blood pressure checked. He explained that in the past when his blood pressure was high or low, nothing was done about it. He is aware that blood pressure variations are potentially dangerous. Unless some action will be taken as a result, he prefers not to know about the fluctuations because they make him anxious. He, has also, refused some medications because he is concerned about side effects and liver damage. He does not take vitamins because he thinks that they cause liver damage and blurred vision. He testified that he is interested in improving his health, and he denied having refused care for the purpose of hurting himself. He acknowledges that he refused food for a period of time after he learned that his mother had passed away. He testified that he was not aware of any of the hundreds of release-of-responsibility forms that were completed as a result of his refusals of care.

It is undisputed that Reaves has special medical needs. The DOC’s policies require written treatment plans for each individual who has special medical needs, including:

[S]hort-term and long term goals, adaptation to the correctional environment, specific interventions, instructions about diet, exercise, and medication, the type and frequency of laboratory and diagnostic testing, the frequency of follow-up for medical evaluation, and provisions for referral to supportive and/or rehabilitative services when necessary.

103 DOC 620.04. The records do not indicate that Reaves arrived at SBCC with a written treatment plan. During his stay, three “nursing plans” were drafted. Ireland explained that nursing plans are written documents that include identification of patient problems, goals for resolution or mitigation of those problems, and interventions designed to accomplish those goals.

The first nursing plan, dated December 1, 2014—approximately eleven months after Reaves arrived at SBCC—listed the following problems: impaired physical mobility; bilateral foot drop; wrist and hand contractures; spasticity; self-care deficit; “patient established bed rest limitation”; sensory deficits; labile emotional stability and mood irritability; impaired coping; impaired decision making and problem solving; anger at staff; “instutionalization syndrome” and refusing treatment; knowledge deficit; risk for impaired skin integrity; low weight; urinary and bowel incontinence; venous insufficiency lesions; and non-healing wounds on lower extremities. (D ex. 2 at 43, 46-47.) For interventions, the plan included a directive to “assess level of ROM / joint mobility to establish a baseline” and to “give joint ROM during complete care and dressing changes using gentle PROM.” (D ex. 2 at 43.) The plan also directed the staff to “periodically encourage wheelchair use (stored in cell) as an alternative positioning option.” (D ex. 2 at 43.) It is undisputed that Reaves cannot be moved into a seated position, and that this has been his condition since before he arrived at SBCC. The plan does not mention bowel care, AD, or Reaves’s hearing deficit. The plan refers to use of adaptive devices; however, Reaves was not provided with any adaptive devices at SBCC until approximately one year after the plan was written.

The second nursing plan was dated in the late fall of 2015, after Reaves’s visit with Dr. Lee. This plan listed the following problems: deafness and wax buildup; impaired dentition; risk for constipation and bowel incontinence; and risk for impaired skin integrity. (D ex. 2 at 42, 44-45, 48.) This is the first plan to address Reaves’s bowel management. As a goal, it stated “maintain passage of soft, formed stool every 1-3 days without straining.” (D ex. 2 at 45.) As interventions, the plan provided: “document bowel movement frequency,” “encourage fluid and fiber intake,” “listen to bowel sounds,” “provide incontinence care as needed,” and “encourage frequent repositioning and attempts to get out of bed.” (D ex. 2 at 45.) Once again, it is undisputed that Reaves is unable to get out of bed in his current condition, and that it would be unsafe for him to try to do so. This plan did not mention laxatives or stool softeners and contained no reference to AD.

The third nursing plan was dated January 6, 2016, approximately two years after Reaves arrived at SBCC. This plan addressed AD. (D ex. 14 at 503.) The plan stated that AD is considered a medical emergency and listed numerous interventions, including monitoring sudden changes in blood pressure, checking urinary drainage, and checking for fecal impactions. The plan specified that a blood pressure elevation of 20-40 millimeters of Mercury above baseline would be cause for, concern. The plan did not provide a baseline and listed “establish a baseline blood pressure” as a needed intervention. Ireland, Dr. Somers, and Dr. Morse each testified that Reaves’s baseline blood pressure is approximately 100 in the systolic reading.

On January 25, 2016, Reaves was transferred from SBCC to MCI Shirley. Neither Dr. Somers nor Ireland are in charge of Reaves’s care at MCI Shirley, but the recommendations and treatment plans from SBCC traveled with him, and Ireland met with staff to ensure that there is continuity of care. On the day of the transfer, Maria L. Angeles, MD, who is the primary care provider at MCI Shirley, completed a “physician’s order form.” (D ex. 19C at 752.) This form provides that an MD should be called if Reaves’s blood pressure is higher than 160 in the systolic reading, which is twenty-to-forty millimeters of Mercury higher than what is listed as a risk for AD on the January 6, 2016 nursing care plan, using Ireland and Dr’s. Somers and Morse’s estimated baseline. This form also contains an order to assist Reaves into a chair, which, as noted above, is not possible or safe for him at this time. The order contains no entries relating to bowel management.

Ireland created another care plan, also dated January 25, 2016, which was crafted in response to Dr. Wennemer’s report for the purpose of establishing continuity of care between SBCC and MCI Shirley. The plan contains cut and pasted items from Dr. Wennemer’s report, organized by category, with MPCH’s response or plan for each item. The plan includes Reaves’s then-upcoming appointments, including an MRI, a renal ultrasound, and a neurosurgical consultation. Regarding physical therapy, under Dr. Wennemer’s opinion that Reaves could achieve a seated position with appropriate therapies to address his contractures, the plan states “potential future goal.” (D ex. 19B at 751.) The plan contains no upcoming physical therapy appointments or plans for treatment other than twice-daily ROM therapy on his upper and lower extremities. MPCH employs one physical therapist who works on a per diem basis and a physical therapist assistant who is at MCI Shirley three-to-five days per week. As of February 22, .2016, Reaves had not seen either of these providers, and no physical therapy appointments had been scheduled. The plan makes no mention of occupational therapy. Regarding bowel care, the plan notes that “a suppository was ordered on 1/11/16 to provide a bowel regimen. [Reaves] is currently refusing.” (D ex. 19B at 749.)

This Lawsuit

Reaves filed this lawsuit on July 7, 2015, asserting the following claims: cruel and unusual punishment by deliberate indifference to serious medical needs, in violation of the Eight Amendment to the U.S. Constitution and Article 26 of the Massachusetts Declaration of Rights (counts I & II); violation of Title’ll of the Americans with Disabilities Act (ADA) (count III); violation of the Rehabilitation Act (count IV); violation of Article 114 of the Constitution of the Commonwealth of Massachusetts (count V); cruel and unusual punishment by conditions of confinement, in violation of the Eighth Amendment to the U.S. Constitution and Article 26 of the Massachusetts Declaration of Rights (counts YI and VII); cruel and unusual punishment by failure to protect, in violation of the Eighth Amendment to the U.S. Constitution and Article 26 of the Massachusetts Declaration of Rights (counts VIII and IX); violation of procedural due process pursuant to the Fourteenth Amendment to the U.S. Constitution and Articles 1, 10, and 12 of the Massachusetts Declaration of Rights (counts X and XI); violation of the Massachusetts Civil Rights Act (count XII); medical malpractice (count XIII); and intentional infliction of emotional distress (count XIV).

Reaves moved for a preliminary injunction on August 13, 2015, seeking immediate changes to his medical care and accommodations for his disabilities. This Court conducted seven days of hearings between December of 2015 and March of 2016. Although his medical care has been ongoing, the parties have been unable to agree to supplement the record since the final day of the evidentiary portion of the proceedings, which was February 22, 2016.

The parties submitted revised proposed orders in March of 2016. In regard to his medical care, Reaves seeks an immediate but temporary transfer to a healthcare facility that specializes in the care of patients with spinal cord injuries. Upon release from this facility, he requests that MPCH engage a specialist in spinal cord injury, with expertise in treating and managing the care of motor complete tetraple-gic patients, to direct all aspects of his care. He further requests that MPCH shall take all necessary steps to ensure the maintenance of his functioning; that MPCH shall have him assessed annually by an audiologist and provide him with working hearing aids; and that MPCH shall provide care performed by medical staff who have been trained by a spinal cord injury specialist. He further requests that the DOC and MPCH ensure that all necessary medical care, hygiene care and activities of daily living occur on a regularly prescribed schedule that will not be interrupted as a means of behavioral management.

Standard of Review

When considering a motion for a preliminary injunction, this Court weighs four factors: “(1) thé plaintiffs likelihood of success on the merits; (2) the potential for irreparable 'harm in the absence of an injunction; (3) whether issuing an injunction will burden the defendants less than denying an injunction would burden the plaintiffs; and (4) the effect, if any, on the public interest.” Jean v. Massachusetts State Police, 492 F.3d 24,-26-27 (1st Cir.2007) (citation omitted). This Court is also guided by the terms of the Prison Litigation Reform Act (PLRA), 18 U.S.C. § 3626, which provides in pertinent part:

Preliminary injunctive relief must be narrowly drawn, extend no further than necessary to correct the harm the court finds requires preliminary relief, and be the least intrusive means necessary to correct that harm. The court shall give substantial weight to any adverse impact . on public safety or the operation of a criminal justice system caused by the preliminary relief ....

18 U.S.C. § 3626(a)(2).

Discussion

1. Likelihood of Success on the Merits; Deliberate Indifference to Serious Medical Needs

“Prisoners retain the essence of human dignity inherent in all persons.” Brown v. Plata, 563 U.S. 493, 510, 131 S.Ct. 1910, 179 L.Ed.2d 969 (2011). This precept finds constitutional support in the Eighth Amendment, which prohibits the infliction of “cruel and unusual punishments.” U.S. Const. Amend. VIII. The Eighth Amendment is the source of “the principles that govern the permissible conditions under which prisoners are held,” including “the medical treatment those prisoners must be afforded.” Kosilek v. Spencer, 774 F.3d 63, 82 (1st Cir.2014), cert, denied sub nom. Kosilek v. O’Brien, — U.S.-, 135 S.Ct. 2059, 191 L.Ed.2d 958 (2015).

“To incarcerate, society takes from prisoners the means to provide for, their own needs,” rendering each inmate entirely dependent on the State for his or her medical care. Brown, 563 U.S. at 510, 131 S.Ct. 1910. “Just as a prisoner may starve if not fed, he or she may suffer or die if not provided adequate medical care.” Id. at 510-11, 131 S.Ct. 1910. “Undue suffering, unrelated to any legitimate penological purpose, is considered a form of punishment proscribed by the Eighth Amendment.” Kosilek, 774 F.3d at 82 (citing Estelle v. Gamble, 429 U.S. 97, 103, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976)). A prison that deprives inmates of adequate medical care “is incompatible with the concept of human dignity and has no place in civilized society.” Brown, 563 U.S. at 511, 131 S.Ct. 1910.

Because the Eighth Amendment is focused on punishment, however, “not all shortages or failures in care exhibit the intent and harmfulness required to fall within its ambit.” Kosilek, 774 F.3d at 82. Moreover, “[cjourts must be sensitive to the State’s interest in punishment, deterrence, and rehabilitation, as well as the need for deference to experienced and expert prison administrators faced with the difficult and dangerous task of housing large numbers of convicted criminals.” Brown, 563 U.S. at 511, 131 S.Ct. 1910. Nevertheless, courts “must not shrink from their obligation to ‘enforce the constitutional rights of all persons’” and “may not allow constitutional violations to continue simply because a remedy would involve intrusion into the realm of prison administration.” Id. (quoting Cruz v. Beto, 405 U.S. 319, 321, 92 S.Ct. 1079, 31 L.Ed.2d 263 (1972)).

In order to prove an Eighth Amendment violation based on inadequate medical care, a prisoner must satisfy two elements: “(1) an objective prong that requires proof of a serious medical need, and (2) a subjective prong that mandates a showing of prison administrators’ deliberate indifference to that need.” Kosilek, 774 F.3d at 82; see Estelle, 429 U.S. at 106, 97 S.Ct. 285. When analyzing an Eighth Amendment claim, “the subjective deliberate indifference inquiry may overlap with the objective serious medical need determination,” and “similar evidence ... may be relevant to both components.” Kosilek, 774 F.3d at 83 n. 7 (quoting Leavitt v. Corr. Med. Servs., Inc., 645 F.3d 484, 498 (1st.Cir.2011)).

As a threshold matter, the DOC argues that it cannot be held liable for any Eighth Amendment violations because MPCH is solely responsible for providing medical and mental health care to the DOC’s inmates. The DOC’s contract with MPCH provides:

The Contractor ... shall be solely responsible for making all decisions with respect to the type, timing and level of Services needed by Inmates covered by the Program. This includes, without limitation, the determination of whether an Inmate is in need of clinical care, inpatient hospitalization, and/or referral to an outside specialist or otherwise needs specialized care. Except as herein otherwise provided, the Contractor shall be the sole supplier and/or coordinator of all medical, mental health, forensic mental health and dental programs constituting services under this Contract, and, as such, shall have the sole authority and responsibility for the implementation, modification and continuation of any and all health care for Inmates.

(Docket No. 37-1 at 7-8.) The DOC Defendants' also cite to the DOC’s policies, which provide that “Matters of medical, mental health and dental judgment are the sole province of the responsible physicians, psychiatrists or dentists.” 103 DOC 610.01(2). In response, Reaves argues that the DOC has a non-delegable duty to ensure the provision of constitutionally appropriate care.

I agree that the DOC’s duty to provide medical care to incarcerated individuals is not absolved by contracting with an entity such as MPCH. See Ancata v. Prison Health Servs., Inc., 769 F.2d 700, 705 (11th Cir.1985).