Full opinion text
FINDINGS OF FACT AND CONCLUSIONS OF LAW MEDICAL, DENTAL AND MENTAL HEALTH CARE MUECKE, District Judge. Having considered the evidence presented by the parties relevant to the medical, dental and mental health care issues in this case, the Court concludes as follows: Background This action was filed on January 12, 1990. The plaintiff class alleges that the defendants are deliberately indifferent to their serious health care needs including medical, dental and mental health care needs. The plaintiff class further alleges that the defendants discriminate against female prisoners in the delivery of mental health services. Defendants respond that their health care system complies with constitutional standards. Findings of Fact 1. DEPARTMENT OF CORRECTIONS At the time of trial in this action, January of 1992, the Arizona Department of Corrections (ADOC) consisted of nine prison facilities within the state of Arizona. On January 22,1992, the total male population was 14,424 and the total female population was 922 inmates. The nine facilities had the following populations on January 22, 1992: Douglas 1,957 Gila Unit Mohave Unit Maricopa Unit Cochise Unit Papago DWI Unit Florence 4,727 Women’s Division Central Unit North Unit South Unit East Unit SPU CB6 SMU Rynning Unit Fort Grant 632 Globe 120 Perryville 2,210 Santa Cruz Unit San Juan Unit San Pedro Unit Santa Maria Unit Phoenix 962 Alhambra Flamenco Aspen DWI Picacho 203 Safford 476 Tucson 2,398 Cimarron Unit Echo Unit Santa Rita Unit Winslow 1,308 Kaibab Unit North Unit South Unit Coronado Unit Yuma 243 The facilities are classified for security purposes as level one (minimum security) through five (maximum security). A. Douglas The main prison complex at Douglas has: (1) the Gila Unit which is a level two unit with a capacity of 626 inmates; (2) the Mohave Unit which is a level three unit with a capacity of 662 inmates; (3) the Maricopa Unit which is a level two unit with the capacity of 129 inmates; and (4) the Cochise complex detention unit located outside of the Mohave yard with a capacity of 66 inmates. The Douglas Complex also contains the Pa-pago DWI Center located in downtown Douglas with a capacity of 208 inmates. B. Florence The Florence complex also contains numerous units. The Picacho Unit is a work camp located 20 miles from the main Florence prison. It has the capacity to house 203 inmates who work in the communities around Picacho. The Women’s Division is a level three/medium custody women’s unit with a capacity of 186 inmates. The South Unit is a men’s level three facility with the capacity of 408 inmates. The South Unit also contains the Special Programs Unit (SPU) with a capacity of 137 inmates. CellBlock 6 (CB6) has the capacity to house 186 inmates. CB6 is comprised partly of death row inmates. The remainder of CB6 is a lockup detention facility for the complex. The Central Unit is a level four/five maximum security unit with a capacity to house 710 inmates. The infirmary is located in the Central Unit and contains 22 inmate beds. The North Unit is a level two/minimum custody unit with a capacity to house 386 inmates. The East Unit is a level two/three facility with the capacity to house 534 inmates. The Rynning Unit is an 800-bed level four unit that was very new at the time of trial. The Special Management Unit (SMU) is a level five/maximum security lockup unit with a capacity of 895 inmates. C.Fort Grant The Fort Grant facility is a level two institution with the capacity of 632 inmates. D- Perryville The Perryville facility has a capacity of 2,210 inmates. The mens’ facilities are level three/two facilities and include the Santa Cruz, San Juan and San Pedro Units. The Santa Cruz Unit is a level three unit with a capacity of 740 inmates. The San Juan Unit, also a level three unit, has a capacity of 740 inmates, including 185 protective custody inmates. The San Pedro Unit is a level two facility with a capacity of 431 inmates. The new complex detention building has a capacity of 40 inmates. The women’s unit, Santa Maria, is a level four/five facility with a capacity of 269 inmates. E. Phoenix The Phoenix facilities contain the Alhambra reception center, Flamenco Mental Health Unit, B Ward, the Aspen DWI Center and the New Dawn Release Center. Alhambra is the male reception center and has the capacity to house 192 inmates with 30 resident workers. B Ward is the licensed psychiatric hospital with a capacity of 28 male inmates. G Ward, in the women’s unit at Flamenco, has the capacity of 20 inmates. The Aspen DWI Center, also in Phoenix, has the capacity for 248 DWI inmates. The New Dawn Release Center is a release center for women who are coming out of the system and need a temporary residence. The Arizona Center for Women (ACW) is a level two/minimum custody women’s facility with a capacity of 359 inmates. The Globe facility, located in Globe Arizona, is a level two facility with a capacity of 150 inmates. Although not in Phoenix, ADOC has made the Globe facility part of the Phoenix complex for administrative purposes. F. Safford The Safford facility is a level two, dormitory setting facility, with 476 inmates. G. Tucson The Tucson complex has the capacity to house 2,398 inmates. The Cimarron Unit houses level four inmates with a capacity of 748 inmates. The Echo Unit houses level two inmates with a capacity to house 249 inmates. The Santa Rita Unit has the capacity to house 660 level three inmates. The complex detention unit, located in the center of the complex, has the capacity to house 71 inmates. H. Winslow The Winslow prison is divided into two units; the Kaibab Unit and Coronado Unit. The Kaibab Unit is further divided into the North and South Units, each having a capacity of 400 inmates. The Kaibab Unit is a level four institution. The Kaibab Unit also has a complex detention unit in the yard with a capacity of 36 inmates. The Coronado Unit has the capacity to house 400 inmates and is a level two/minimum security unit. The majority of the inmates in the Coronado Unit work in the surrounding community. I.Yuma The Yuma facility is a 250-bed level two/minimum custody unit. II. MEDICAL CARE SYSTEM A. Generally Thomas Lutz, D.O., is Chief of Health Services for the Arizona Department of Corrections and has held that position since November of 1989. Dr. Lutz participates in continuing medical education, attending conferences and professional seminars a minimum of 25 hours per year. He averages approximately 50 to 75 hours a year in continuing medical education. In his role as Director of Health Services, Dr. Lutz directly supervises program managers, key central office management level professionals representing various disciplines of the medical profession, including medical, dental, mental health, pharmacy, medical records, administrative, and behavioral health. Twenty percent of Dr. Lutz’ time is spent in the field taking care of patients. Dr. Lutz seeks out individual patients who have complaints of medical care, examines them and makes recommendations based on his physical examination. Additionally, he can provide services throughout the state when other physicians are absent or positions are vacant. He visits all of the facilities at least two or three times a year. B. Statistics Regarding Inmate Use of Health Facilities 1. Medical The Health Services Bureau prepares a statistical activity report to chart the activities of health service professionals within the Department of Corrections. A nursing encounter by definition is any time a nurse does anything regarding patient care. This could involve hands-on treatment, chart review, medication review, renewal or making appointments. There were 1,073,951 nursing encounters in 1990 and 1,729,068 nursing encounters in 1991. In 1990, there were 34,664 direct physician-patient encounters, in which inmates were seen directly by the physicians. In 1991, there were 58,483 physician-patient encounters. In 1990, there were 78,019 physician’s assistant or nurse practitioner/patient encounters. In 1991, there were 90,137 physicians’ assistant or nurse practitioner/patient encounters. In 1990, there were a total of 21 inmate deaths in the Arizona Department of Corrections, including, ten deaths by natural causes, two deaths by homicide, two deaths by suicide and seven accidental deaths. In 1991, there were a total of twenty-six inmate deaths. Of these twenty-six, twenty deaths were by natural causes, three deaths were by homicide, one death was by suicide and there were two accidental deaths. ADOC dispensed 621,393 prescriptions in 1990 and 678,673 prescriptions in 1991. 2. Dental In fiscal year 1991, there were approximately 29,066 patient visits at the various dental clinics in the system. The cost of dental procedures conducted in the fiscal year 1991 was $3,887,248. In the fiscal year 1991, dentists in ADOC saw an average of 1.86 patients per hour. Each patient had an average of 3.8 procedures performed each visit. There were 19,550 dental encounters in 1990 and 21,966 dental encounters in 1991. In 1991, ADOC performed over 17,-000 periodontal treatments, including 6,454 gross scalings, 6,706 oral hygiene instructions, 142 gingival curettages, 4,292 scaling/root planings and 18 splintings. In 1991, ADOC dental staff performed 4,572 one surface fillings, 3,128 two surface fillings, and 1,798 three surface fillings, and 926 four or more surface fillings. 3. Mental In 1990, there were 18,356 psychiatrist/patient encounters and 111,624 mental health encounters by psychologists or other mental health staff; 621,393 prescriptions dispensed and 231,035 psychotropic medications dispensed. In 1991, there were 19,071 psychiatrist/patient encounters; 109,689 mental health encounters; 678,673 prescriptions dispensed; and 70,332 psychotropic medications dispensed. Psychotropic medication usage went down in 1991 when Bena-dryl and Vistaril were eliminated from the definition of a psychotropic medication because they are used for nonpsychotropic purposes. C. Experts Both plaintiffs and defendants presented expert testimony regarding whether the medical care system met the serious medical needs of the inmates. Plaintiffs presented the testimony of two experts. One of plaintiffs’ experts was Dr. Kim Thorburn. Dr. Thorburn, reviewed the medical facilities at SMU in Florence, Douglas and Tucson. Dr. Thorburn was guided in her testimony principally by the community standard for the delivery of health services. Additionally, she was guided by the National Commission on Correctional Health Care standards and the American Public Health Association standards. The National Commission on Correctional Health Care Standards consist of 71 goal standards for correctional health care that are “quite high.” There are no correctional health standards that are more stringent or more difficult to fulfill than the National Commission on Correctional Health Care Standards. The National Commission on Correctional Health Care has a certification program for institutions that meet the standards. According to Dr. Thorburn, the prison system that meets the National Commission standards has a fairly decent system of health care delivery. Plaintiffs’ other expert, Charles Braslow, evaluated the health services at Phoenix, Perryville and Florence, with the exception of SMU. Dr. Braslow evaluated the health care within ADOC based on the general community standard for, acceptable medical practice. This standard is a nationwide standard. Dr. Braslow selected records by going through sick call lists, medication lists and pulling files with color coded markers indicating a particular disease. Dr. Bras-low did not do a physical examination on any of the inmates. Defendants’ medical expert was Dr. Michael Warren. Dr. Warren is a physician who is a faculty member at University of Texas. The University provides consultation and treatment care for inmates in the Texas Department of Corrections and supplies the top personnel to the Texas DOC for medical purposes. Dr. Warren was also the acting deputy director for health services for the Texas Department of Corrections for two year beginning in 1986. To form his opinions, Dr. Warren reviewed policies and procedures and the map to determine the facilities and their locations. Over a period of six days, Dr. Warren visited Alhambra, ACW, Douglas, Tucson, Florence and Perryville. Dr. Warren also met with staff that he considered to be “key staff,” including Dr. Lutz. To measure the system, he relied on the standards of the National Commission on Correctional Health Care. D. Medical Staff 1. Generally Each prison facility within the Arizona Department of Corrections has a physician. In order to be employed by the Department of Corrections, physicians must be licensed in the state of Arizona and hold a current valid Arizona license. The Department of Corrections also utilizes certified physician assistants (PA). A certified physician’s assistant is an intermediary or secondary care provider that has graduated and been certified as a physician’s assistant. A PA assists the physician in the practice of medicine and is directly supervised by a physician. The PAs within the Department of Corrections are supervised at a weekly meeting and through a chart review, either random or by specific patient. The Department of Corrections also utilizes nurse practitioners (NP), registered nurses (RN), licensed practical nurses (LPN) and nursing assistants (NA). A nurse practitioner is licensed and does not need direct immediate supervision of a physician. A supervision of weekly chart review or patient review is not required for a nurse practitioner. ADOC uses the nursing assistants in a pilot program in Winslow and Florence. A nursing assistant is licensed to perform almost the same duties as a registered nurse, except for giving shots. There is no state licensing requirement for nursing assistants, but ninety percent of the Department of Corrections nursing assistants are certified. The pilot program for using nursing assistants began in 1991 in Winslow and Florence and that program has allowed registered nurses to begin developing preventative medical programs. There are approximately 196 nurses within the Arizona Department of Corrections. Each institution has its own nursing supervisor. Thirty-two of the nurses are specifically psychiatric (psych) nurses. Although the state qualification for a psych nurse II is that they have at least one year of psych nurse experience, psych nurses are not hired unless they have at least'three to five years of psych experience or exposure. a. Florence Facility There are a total of thirty-five nursing staff at the Florence facility including twelve full-time RNs, nine LPNs, seven nursing assistants, four psych nurses and three nursing supervisors. CB-6, the Women’s Division, SPU, Central Unit, North Unit and South Unit share one nursing supervisor, three assistant supervisors and twenty-seven to twenty-nine nurses. The Rynning, East and Special Management Units in Florence share two assistant nursing supervisors, one nursing supervisor and twenty-three staff nurses. There is one physician, one full-time physician’s assistant — -and one full-time nurse practitioner at the Central Unit in Florence. b. Phoenix Facility The Phoenix facility, including Alhambra reception, the women’s facility (ACW), New Dawn, and Aspen, has twenty-five psychiatric nurses and a psychiatric nursing supervisor. Additionally, there are approximately seventeen nurses and two supervisors for regular nursing services. All of the units, except for Globe, have twenty-four hour nursing care. At the Arizona Center for Women, there are four RNs, one half-time LPN who covers nights between Alhambra and ACW, a medical records librarian, a physicians’ assistant, a nursing supervisor, a psychologist, a psychiatrist and a physician who spends half a day, once a week. Staff is insufficient to conduct sick call more than twice a week and the defendants have been unable to demonstrate to the Legislature the need to have sick call more frequently at ACW. e.Perryville Facility There are two full-time physicians and sixteen nursing positions at Perryville with no vacancies. There are three dentists and one pharmacist working at Perryville. d. Tucson Facility The Tucson facility has a physician, nursing supervisor, three assistant nursing supervisors and fifteen staff nurses. e. Winslow Facility The staff at Winslow includes two psych associates, one psychologist, the facility health administrator, the medical records librarian, ten nurses, one nursing supervisor, two dental assistants, one dentist, one pharmacist, two pharmacy technicians, a mental health psychotherapist, a physician and two nurse practitioners. f. Safford Facility Safford has one physician, one nursing supervisor and seven staff nurses. g.Ft. Grant Facility The Ft. Grant facility has one physician, one nursing supervisor and six staff nurses. h.Yuma Facility At the Yuma facility, there are four staff nurses, one physician and one nursing supervisor. i.Douglas Facility The Douglas facility has one nursing supervisor and fifteen staff nurses. Since December of 1991, Douglas has been operating with one physician’s assistant and a halftime physician. Prior to that, Douglas had one physician and two physician’s assistants. To supplement the current shortage, the physician’s assistant from Tucson fills in part-time, one day a week. Douglas has two medical records personnel, two full-time dentists, two full-time dental assistants, thirteen nurses, two full-time pharmacists and a contract pharmacy technician. Additionally, Douglas has two psych associates and one radiology technician. j. Pharmacies The ADOC also has staffed pharmacies. The Winslow facility has one pharmacist and two pharmacy technicians. A pharmacy technician assists in the preparation of prescriptions, helps with inventory control, arid delivery of medications. The Perryville facility has one pharmacist and two technicians, with a pharmacist vacancy which is in the process of being filled. Phoenix has two pharmacists and one technician. Florence has three pharmacists and two technicians. Eyman has two pharmacists and two technicians. Tucson has three pharmacists and one technician. Ft. Grant has one pharmacist and a contract pharmacy technician. That pharmacy also supports the Safford facility. Douglas has two pharmacists and one contract pharmacy technician. 2. Staffing Problems: Numbers and Vacancies a. Numbers of Staff Defendants have requested additional staff to provide health services beyond the staff for whom they are currently budgeted, including physicians, nurses, nursing assistants, psychologists and psychological associates. Many of defendants’ requests for funding of these additional positions have been denied by the Legislature. According to Dr. Thorburn, there are an insufficient number of nurse positions at Douglas and Tucson. In addition, Dr. Warren recommended in his report that the defendants unfreeze nursing positions in Florence and hire more nurses in Perryville. b. Vacancies of Staff There are vacancies in a number of health care positions throughout the ADOC, including the Mental Health Program Coordinator, nurses, physicians, physician assistants, psychologists, and psychological associates. The defendants have attempted to fill these vacancies. However, defendants have had difficulty filling these vacancies for various reasons, including difficulty in attracting qualified staff and retaining them in certain outlying areas such as Florence or Douglas; hiring freezes imposed by the governor; and limitations on salaries and benefits. As of December 2, 1991, the Arizona Department of Corrections Health Services had a 13.9% overall medical staff vacancy rate. This vacancy rate is much improved since December of 1989. At the time of trial, the only vacancies in the primary care physician field in the correctional health care system were at the Douglas facility. There were only one or two physician’s assistant or nurse practitioner vacancies throughout the state. Since November of 1989, the vacancy of registered nurses decreased from approximately 24 percent to 8.5 percent. Presently, there is not a significant nursing turnover due to the communication and reorganization of health services. In response to nursing vacancies for permanent positions that ADOC cannot or will not fill, the Department hires private contracting nursing agencies or registry nurses to provide nursing services. If a registry nurse does not perform up to the Department of Corrections’ standards, the Department of Corrections will request that the nurse not return to the facility. Vacancies at Douglas are covered by contracting with the nursing registry service. The nurses from the registry service are former ADOC nursing employees who are used to dealing with inmates and know the policies and procedures of the Department of Corrections. The quality of care provided by the registry nurses in Douglas is more than equal to the quality of care of regular RNs because of their years of experience and exposure to the correctional setting. The Department of Corrections also utilizes a stipend program for nursing positions in outlying areas, including Safford, Ft. Grant, Winslow, Douglas, Florence and Yuma. There are other medical stipends for health care positions ranging from $2,000 to $4,800 for positions that are hard to fill. Additionally, to recruit new nurses, the Department of Corrections advertises in newspapers, recruits at junior colleges and has an inter-agency agreement with the University of Arizona to obtain students to work in the facilities for clinical experience. The Department has successfully recruited health care professionals by virtue of aggressively pursuing recruitment through advertising, job fairs and word-of-mouth. There are seventeen pharmacy positions within the Arizona Department of Corrections and two vacancies which are in the process of being filled. The vacancy rate at the pharmacies is low and it is very rare that a pharmacy has any vacancies. c. Impact of Staffing Problems Plaintiffs’ expert, Dr. Braslow testified that there are delays in the assessment and evaluation of serious health needs of the inmates in the facilities and that those delays exist because sick call access is not frequent enough and there are not enough medical practitioners to take care of those needs when the people do come for medical services. Plaintiffs’ expert, Dr. Thorburn also testified that there are insufficient numbers of staff, exacerbated by vacancies that results in diverting professionals work from their work. For example, nurses perform clerical tasks and dentists perform dental hygiene services that would be better performed by dental hygienists. Some of the units had adequate staffing at the time of trial. In Dr. Thorburn’s opinion, health care staffing at the Special Management Unit is adequate. Dr. Thorburn also opined that there are an adequate number of physicians and physician’s assistants at Tucson. Plaintiffs presented examples of delays in assessment and treatment of medical needs including inmates # 66353, Thompson, Abernathy, Douglas, Saboria, Dennis, Hines, and Wilkerson. Inmates Douglas and Hines did not suffer any permanent injuries. Inmate Abernathy obtained 99% of his eye sight back after the detached retina surgery. Inmate Soboria did not suffer any injuries.- • Plaintiffs also presented instances of alleged deficient evaluations of inmates including inmates Lasoya, Harriss, # 67720, Romney, Ison, Furr, Bradford, Li-cano, Culling, and Mendoza. Inmates Mendoza and Licano suffered no permanent injuries. Inmates Romney and Bradford suffered no injuries. Other than Mr. Lasoya, there is no evidence of any injury or serious medical problem resulting from the medical treatment administered to inmates within the Arizona Department of Corrections. Relevant to injury, Dr. Braslow felt improper treatment caused serious medical problems for Mr. La-soya. However, Dr. Warren testified that treatment received by Mr. Lasoya was appropriate. Thus, Dr. Palmer’s treatment of inmate Lasoya was at most a disagreement between Dr. Braslow and the treating physician as far as how to treat a patient with symptoms exhibited by inmate Laso-ya. In addition, there is no evidence of long-term injury resulting from the care received by inmate Lasoya. Other problems exist because of staff shortages. The shortage of staff has caused sick call to be cancelled and appointments to be cancelled and rescheduled. Further, nurses make errors in medication, including giving the wrong medication or dosage to the inmates. Finally, the Globe unit does not have 24-hour nursing coverage due to a shortage of nursing staff. E. Medical Care Programs 1. Entry Procedure/Preventative Care a. Entry Procedure Upon entry into the system, inmates within the Arizona Department of Corrections undergo a physical examination. Health services run a complete blood count, urinalysis, serology syphilis, TB, measles, mumps and rubella tests on each inmate. Within twenty-four hours after the inmate is transferred to a permanent housing facility, the nurse performs a chart review. Based upon that nursing assessment, prioritization is made as to when the inmate should be seen by a provider. The provider determines how often an inmate should visit to have his blood pressure checked. The nurse will establish a hypertensive flow sheet which is not initially a permanent record of the inmate’s file. The hypertensive flow sheet is kept at the nursing stations where the nurses record the high blood pressure readings of the individuals when they come in specifically for the test. The flow sheet eventually becomes a part of the permanent medical records. The PA or physician would have access to this flow sheet by simply asking the nurse for the information. b. Movement Between Facilities To ensure continuity of care, health services has established procedural guidelines for inmates that are moved inter-facility. Providers at the receiving facility respect the previous orders until they have an opportunity to review the medical record and the patient. This includes shaving waivers, prescriptions, and special orthotic devices. c. Chronic Care The Arizona Department of Corrections has implemented a limited tickler system to categorize and bring to the attention of the physician for review of inmates depending on their diseases. The system is used to schedule individuals that need physicals, TB tests and chronic disease management. This tickler file system is used only at Cimarron Unit in Tucson, the Rynning Unit and the East Unit in Florence. However, the system is in the process of being established at Perryville, Phoenix and Winslow and will eventually be used throughout the system. Along with the system, ADOC holds chronic clinics for inmates with high blood pressure problems, seizure problems, chronic obstructive pulmonary diseases or asthma, cardiac problems, diabetes and for any other inmates who need to be monitored to ensure their conditions are under control. Except for the limited pilot program in Tucson and Florence, defendants have no system to follow chronic conditions including obstructive lung diseases [such as asthma], hypertension, diabetes, elevated cholesterol, seizure disorders, HIV disease, tuberculosis, and glaucoma. In addition, defendants do not have a uniform system of patient education for diseases. Dr. Thorburn testified that the medical care provided in the facilities she reviewed, as far as management of chronic illnesses including obstructive lung disease, seizure disorders, HIV virus, and glaucoma, was not an optimal system. Inadequately treated chronic diseases can cause permanent damage to a patient’s organs or even death. Because the medical care system is based pn demand, Dr. Thorburn testified that defendants have substandard management of screening for tuberculosis which is transferred through breathing the air after an infected person breathes, coughs or sneezes. However, the Center for Disease Control in Atlanta has certified the procedures and guidelines followed by Arizona Department of Corrections Health Services for the treatment of tuberculosis. d. Periodic Physical Exams With the exception of the limited tickler system noted above in Tucson and Florence, defendants have no system of periodic physical examinations to detect the development of disease. Defendants know of the importance of periodic physical examinations in the delivery of health care. Dr. Lutz believes that prisoners should be called back periodically for a physical examination. Both Drs. Thorburn and Warren testified that inmates should receive regular physical examinations. Periodic physical examinations are particularly important since a patient may be asymptomatic but have diseases developing that are not detected if the medical staff is focusing only on a specific symptom. It is the responsibility of the ADOC health provider to detect the chronic illness before it becomes so advanced that symptoms are known to the patient. Prisoners have gone for a number of years without a physical examination. However, the ADOC has implemented a tickler system for pap smears and mammograms in the Florence Women’s Unit. At the time of trial, health practitioners in the Florence Women’s Unit were revising the tickler system and attempting to reduce the backlog of prisoners who had not received their scheduled pap smears. 2. Use of Outside providers a. System for Outside Providers The Department of Corrections Health Services utilizes outside health providers including both individual specialists and hospitals to provide specialty care that is not available to the patient population on site. Some specialists come on-site for treatment of inmates. In other situations, the inmates are taken to the specialists for treatment. Optometric services and mammogram services come on site. Pursuant to policy, outside referrals are prioritized on a one through three system with a maximum of eight weeks between initiation and the patient being seen by the outside provider. ADOC uses on-site institutional outside review committees to evaluate requests for a consultation and determine the priorities. The review committees meet on a weekly basis in the more populated facilities and on a three to four week basis at the less populated facilities. Medical care providers may accept or reject recommendations of an outside specialty consultant. b. Problems: Delays in Specialty Care Because numerous problems exist with the specialty system, inmates experience delays in specialty care. ADOC contracts with some specialists only once every few months or after they have a minimum number of prisoners on the waiting list. Appointments with specialists have been cancelled at the end of fiscal years because of funding; although, those with serious needs did see specialists. Specialist appointments are sometimes cancelled when inmates are transferred. In addition, ADOC lacks a mechanism to determine if specialty referrals are completed. According to Dr. Braslow, there are “frequently unacceptably long waits for specialist services and specialty clinic appointments for patients with significant medical conditions” including inmates Robertson; Harriss; Dennis; Powell; Lamson; Chavez; and Davis. Inmates Davis; Harriss; Chavez; Lamson; and Robertson suffered no injuries. Dr. Warren also stated that such delays exist at Douglas, Perryville and Florence. 3.Use of Sick Call System a. Sick Call System Defendants provide medical, dental and mental health care through a sick call system. An inmate can go to sick call and see a nurse at a pre-established day and time. In the event inmates have an illness or problem and it is not on a day with the established sick call, they can notify the correctional service officer that they need to be seen by a provider. The correctional service officer relays the request to nursing. Therefore, based upon the seriousness of the problem, an inmate can be seen seven days a week. b. Problems with Sick Call System Numerous problems exist with the sick call system. The system discourages use because inmates may stand in line two to three hours. If inmates leave the line, they may not see the provider. In Douglas, once an inmate checks in he cannot leave the area. In the Perryville Santa Maria Unit, after they sign up for sick call, the inmates must wait outside the units until seen. Once an inmate signs up for sick call, she must stay in the area or she will be considered a refusal. 4.Use of infirmaries The Department of Corrections utilizes an infirmary system for males located in Florence. The infirmary in Florence is fully operational. There is no women’s infirmary within the Arizona Department of Corrections. Rather, women who normally would be placed in an infirmary setting are kept in the hospital longer. Dr. Lutz testified that if an individual cannot return to general population by virtue of the fact there is not an infirmary at that particular facility, the individual inmate will be kept in the hospital until he or she is released. Because of the lack of infirmaries for women and limited space for men, prisoners stay in a hospital longer than necessary, or fairly sick people are returned to housing units. Defendants’ expert, Dr. Warren, has recommended increasing the capacity of the infirmary. 5.Emergency Care Emergency health care is available to inmates seven days a week, twenty-four hours a day, by land or air. If an inmate has a problem after hours and there are no doctors on-site, the nursing personnel would be notified about the problem by security staff. The inmate would then be brought to the health unit for a nursing assessment. If the nurse decides something needs to be discussed with the on-call provider, she will have a telephone consultation with a physi-cían. If the inmate has a life threatening problem, he can be referred to the emergency care facility associated with that prison. There are emergency care facilities contracted all over the state at every facility. Inmates will be transferred by a Department of Corrections’ vehicle, private ambulance service or paramedic service. 6. Specific Facilities a. Florence Facility (1) Unit Facilities (a) Central Unit The Central Health Unit is the primary location for health care at Florence. There are 62 satellite health units at SPU, CB6, the Women’s Division, the East Unit and the North Unit. The Central Unit health facility has x-ray capabilities, laboratory facilities, a medical records repository and an infirmary that serves the entire state. The capacity of the infirmary at the Central Unit is fifteen beds and it is fully operational. The infirmary is used in situations where an inmate is discharged from the hospital sooner than he normally would be discharged. Central Unit also contains Housing Unit 8, which is a long-term bed facility for inmates who are chronically impaired. Housing Unit 8 is an open room with twelve beds and a toilet and shower facility with easy accessibility to medical providers who work at the Central Health Unit, twenty feet away. Nursing assistants help inmates with personal daily care and other medical needs. The Central unit and the infirmary have twenty-four hour nursing coverage. The nursing assistant and infirmary nurse cover the infirmary and Housing Unit 8. The Central Unit, SMU and the Rynning Unit have twenty-four hour nursing coverage. Nurses undergo a one month orientation prior to employment at the prison. The orientation consists of three weeks of on-the-job training with a correctional nurse. Further, Nurses undergo educational and service training in cultural diversity, substance abuse, professionalism and ethics. Nurses also receive paid time off to attend outside seminars and the department offers updated assessment information, pharmacology updates and TB testing. The physician, PA and NP work out of the Central Health Unit Monday through Friday. When no provider is on-site, a medical provider is on call and may be reached through a beeper system. On-site contract services provided inmates at the various units within Florence include a surgeon, podiatrist, radiologist, optometrist, ophthalmologist and psychiatrist. If an inmate is in need of a specialty service which is not provided by on-site or contract physicians, the inmate may be referred to an outside medical facility. These appointments are made at the Maricopa County Hospital outpatient services as well as other specialty services that the Florence facility utilizes in Tucson. (b) Rynning Unit Health care providers at the Rynning Unit in Florence are on-call twenty-four hours a day seven days a week. When a mid-level provider such as a family nurse practitioner or physician’s assistant is on-call, there is always an M.D. on back up call. (c)Picacho Unit Inmates who are housed at the Picacho Unit obtain medical care through the Central Health Unit at Florence. Generally, the inmates at the Picacho facility have only minor health concerns. For non-emergency services, they are transported to the Central Unit complex medical by van. For emergency services, inmates at the Picacho facility are taken to Casa Grande Regional Medical Facility. (d)SMU The SMU health clinic is fully equipped and staffed twenty-four hours a day by the nursing staff with two providers on a full-time basis and a full dental operatory. Sick call is conducted five days a week at SMU. (e)Women’s Unit Gynecological exams are conducted on female inmates annually at the Women’s Division. The Women’s Division in Florence has a tickler system for tracking pap smears and mammograms. The tickler system was developed in 1988 or 1989. If the pap smear is abnormal, the patient is referred to Maricopa County Medical Center for a Ob/ Gyn consult. At the Women’s Division in Florence, every woman would have a baseline mammogram at age thirty-five, every two years after age forty and annually after age fifty. The mammogram is a mobile unit that comes to the grounds twice a year. An inmate who has a breast lump or discharge would be sent to Maricopa County Medical Center for the mammogram rather than waiting for the routine mammogram. (2) Intake Procedure When a new inmate comes into the Florence facility, the medical records librarian forwards the charts to the charge nurse. Either an RN or an LPN will review the chart and forward the chart for appropriate follow-up, including medical, dental or mental health care. (3) Sick Call Inmates are scheduled through sick call or a nurse’s line to see the doctor at a provider’s line. A provider’s line is conducted by a physician and a nurse practitioner or physician’s assistant. The provider’s line is held five days a week in the Central Unit, North Unit, Picacho work camp, South Unit and SPU; three days a week in the women’s division; and two days a week at Cell Block g The nurse’s line is held five days a week in the Central Unit. At Cell Block-6 in Florence, the nurse has daily rounds for sick call, going from cell to cell. Pill call at CB-6 is twice a day, seven days a week. Picacho work camp and the North Unit have sick call twice a week. The RN visits Picacho twice a week for the sick call and pill call. The North Unit has pill call seven days a week. The Women’s Division in Florence has sick call twice a week. The nursing assistant assists the provider by taking vital signs. Sick call at the South Unit is two days a week and pill call is five days a week. The Department of Health Services, in an effort to improve the sick call system, has implemented a self-referral system utilized at the Rynning Unit and Central Unit in Florence. This pilot program is designed to replace traditional sick call with the self-referral system. Before it was implemented, a video was shown over the in-house television system for inmates as to how the self-referral system works. The video continues to be shown for inmates that are new to the Central Unit. The video informs the inmates what forms are available in the cell block and how to request eye clinic, dental appointments, psych appointments, doctor’s appointments, over-the-counter medication or a nursing assessment. The format for the video is an inmate asking the nursing supervisor, Beth Cory, questions about the self-referral system. There is another inmate in the video who interprets the questions and answers in Spanish. An inmate writes down his problem on a self-referral form and drops the form in the medical box. The self-referral forms are in both English and Spanish. Illiterate inmates may drop an identification card in the medical box and the nurse will go to their cell that morning. The forms are picked up every morning at 6:00, stamped, dated and an RN triages them. She sends the dental referrals to the dentist, the eye clinic referrals to the eye clinic and the mental health referrals to the psych nurse. The prescription refills are sent directly to the pharmacy. The remainder of the forms are triaged by the nurse and either referred to the medical provider or to the nurse’s line for a nurse’s assessment. The form is then returned to the inmate informing him or her of the disposition of the referral. If the information on the self-referral form is inadequate, medical staff will request that security transport the inmate to medical to determine the problem. This form expedites inmate access to health care for treatment of non-emergencies. Anyone that needs to be seen that day will be brought up to the health unit. Because of the self-referral system, the health unit of the Central Unit has been able to expand health delivery services. They have been able to start a daily medication delivery at the North Unit and have been able to designate a nurse to go out and give skin tests for TB. The quality assurance audits are now being done on a more regular basis. In-service education is now being offered twice a month instead of once a month. Inmates do not have to wait in line for sick call. They do not have to wait to have an issue addressed until the next sick call happens, which was only twice a week prior to nurse’s line. The inmate population at Florence is currently giving favorable reports on the new self-referral system. Inmates like it because they don’t have to stand in line; it is easier for them to access health care on a needs basis; and it opens the line of communication between the inmate and health services. b. Perryville Facility (1)Medical Facilities The main medical unit at the Perryville facility is at the complex area and is comprised of a laboratory, x-ray, doctors’ exam rooms, emergency room, pharmacy, medical records and administration. Each unit at Perryville has a satellite health unit that includes a nurses’ office and exam room. At the satellite health units, sick call is conducted by a nurse practitioner or physician. An optometrist visits Perryville at least once a month. An orthotics specialist visits Perryville when there are a sufficient number of inmates that have been approved through the outside referral committee for special shoes, braces or prosthesis. (2)Sick Call Sick call at Perryville is conducted from 6:30 to 7:15 in the morning. The inmates come to the health unit to sign up and write down the reason why they need to be seen by the provider. The nurse triages the list and takes patients by priority. Sick call is conducted at Santa Maria five days a week and at the San Pedro, Santa Cruz and San Juan units four days a week. If the nurse determines that the inmate needs to be seen that day, she will call the main complex to let the doctors’ line nurses know an inmate needs to be seen. The doctors’ line nurse will schedule a time for the inmate to be transported to the complex to see the doctor or nurse practitioner. In addition to sick call, an inmate can obtain medical treatment by notifying the yard officer, who in turn notifies the shift commander who informs the on-duty nurses that there is a problem. After normal working hours, there are three nurses on-site and either a physician or nurse practitioner on call. In an emergency, the on-duty nurse will make an assessment of the inmate’s condition and notify the on-call provider, who will instruct the nurse as to what treatment to provide or whether to transport the inmate to an outside facility. If it is a severe emergency, the inmate is taken to West Valley Emergency Center, which is approximately five miles from the Perryville facility. (3)Female Reception Center The Perryville facility is the reception center for female inmates. The medical staff at Perryville performs complete medical examinations, medical history, routine laboratory work, and dental on every female inmate who is processed at Perryville. Gynecological exams are performed on female inmates upon initial intake and at the main complex one day a week. (4)Intake from Other Facilities When inmates are transferred to Perry-ville, an initial intake assessment is performed and medical records are reviewed to see if there is any ongoing medical treatment that has to be continued and if there are any mental health problems that might require psychotropic medication. The initial assessment is performed by nurses as soon as the inmate arrives at Perryville. If the nurse determines an inmate should be seen by a provider, the medical records are given to the physician or nurse practitioner for review, and the provider will determine if the inmate needs an appointment. c. Yuma Facility There is a contract physician who visits the Yuma facility two afternoons a week. d. Phoenix Facilities According to plaintiffs’ expert, Dr. Bras-low, the Alhambra facility provided adequate health services with the exception of the Aspen DWI Unit. Dr. Braslow found the Aspen Unit unacceptable as it has sick call only one day a week. 1. Aspen The Aspen Unit at Phoenix is a DWI center. The average stay for inmates at the Aspen DWI Unit is six to eighteen months. Medical coverage at Aspen includes a nursing triage line five days a week. The nurse sees all of the inmates who sign up for sick call or who have complaints, treats them with over-the-counter drugs and refers inmates who need further evaluation to the physicians’ assistant or physician at Alhambra. Inmates with routine problems are referred to the next physician’s assistant line, conducted twice a week. If necessary, an inmate can be seen by a physician or physician assistant at Alhambra within two hours after the nurses assessment. Inmates at Aspen with dental problems are seen by a dentist at the Alhambra Reception Center twice a week. If a health problem develops with an inmate at the Aspen Unit after hours, there is a nurse on duty twenty-four hours a day at Alhambra. There is a physician or a PA on call twenty-four hours a day. Emergency situations are taken to the emergency room at Maricopa County Medical Center. The Aspen Unit is a block and a half from the emergency room at the Maricopa County Medical Center. If an inmate at Aspen needs to see an outside consultant, the PA makes a referral to the outside referral committee. The outside referral committee prioritizes the visit to a specialist based on need. This prioritization should take place within the week. 2. ACW At the Arizona Center for Women, four RNs and one half-time LPN cover nights, between Alhambra and ACW and a physician spends half a day, once a week. ACW is approximately six blocks from Alhambra. Sick call is conducted twice a week. Defendants have an agreement with the administration at the Maricopa County Medical Center that if an inmate has a serious condition, needs to be seen at a particular clinic and the clinic is booked, the Department of Corrections physician makes a direct call to the physician’s supervisor in that clinic and the inmate receives a timely appointment. e. Douglas Facility (1)Facilities There is a health unit in each of the units within the Douglas facility. The Papago DWI Unit has eight-hour-a-day medical coverage on-site five days a week. The Marico-pa Unit has on-site coverage twenty-four hours a day seven days a week from the Mohave Unit. The Gila Unit has twenty-four hour coverage seven days a week and the Complex Detention Unit has twenty-four hour coverage seven days a week. (2)Sick Call System, Sick call at Douglas is held three days a week at all the units, with the exception of Maricopa. At the Maricopa Unit with a capacity of 125 inmates, sick call is held twice a week between 6:30 and 7:30 and is open to any inmate who wants to see a nurse or provider or make an appointment for a provider. The actual encounter with inmates at sick call goes from 6:30 until 11:00 or 11:30 in the morning. Inmates in the Cochise lock-down unit are seen door-to-door seven days a week. There is one nurse who is responsible for the lockdown unit. The nursing supervisor at Douglas is on-call twenty-four hours a day, seven days a week. In non-emergency situations, inmates are seen within a week to ten days by a provider. If an inmate has a severe problem and needs to be seen immediately, he will be seen by a provider. If there is no doctor’s line at the yard that-day, the inmate will be seen at the unit within a three to four hour period. In an emergency situation, if the physician is on-site he will immediately examine the inmate and make arrangements for the inmate to be picked up by the City of Douglas Fire Department ambulancé and transported to the Southeast Arizona Medical Center, ten miles away in Douglas. If further referral is needed the inmate is sent to Sierra Vista Hospital or St. Mary’s Hospital by land or air transport. It takes approximately 40 minutes to get from the Douglas facility to Sierra Vista by car or ambulance. If the physician is not on-site, there is a contact emergency physician at Sierra Vista Hospital who handles the problem. That physician will make a decision as to whether an inmate should be transported to Sierra Vista. (3)Chronic Care Clinics Staff run clinics for hypertensive, diabetic and chronically diseased individuals. A board certified orthopedic surgeon holds a clinic twice a month. The clinics for hypertensive and diabetic inmates are scheduled for every week. These inmates are seen individually on those days in addition to the daily medication encounters. Other chronic care clinics are conducted on a bimonthly basis. (4)Outside Providers In addition to on-site medical people and contract physicians who come into the facility, Douglas utilizes medical facilities at Sierra Vista Community Hospital and at St. Mary’s Hospital including cardiologists, dermatologists, general surgical consultants, radiologists, ophthalmological specialists, urologists, neurosurgeons, cardiovascular surgeons and anesthesiologists. An optometrist comes in twice a month for eye exams and glasses prescriptions. Inmates who need to be seen by an outside consultant on an emergency basis are seen within twenty-four hours. Douglas contracts with a board certified psychiatrist to follow inmates on psychotropic medication. (5) Expert Opinion Defendants’ expert, Dr. Warren, testified that at the time of trial, the Douglas facility was close to accreditation by the National Commission on Correctional Health Care and would only need to work on the sick call and chronic clinics areas to seek and receive accreditation. f. Winslow Facility Sick call at Winslow is conducted on Monday, Wednesday and Friday on the Kaibab yard and the Coronado yard. Providers lines are held the same days on Monday, Wednesday and Friday. If a nurse determines that an inmate needs to see a provider and the inmate is seen at sick call, the provider will generally see the inmate that day or at least within forty-eight hours. Emergencies are handled at Winslow by having the inmate brought to medical and providing treatment or medications if necessary. If the problem is more severe than the level of staffing can handle, the inmate is sent to the emergency room at Winslow Memorial Hospital, approximately five miles away. g. Tucson Facility Dr. Warren testified at the time of trial that the Tucson facility could seek accreditation by the National Commission on Correctional Health Care and obtain the accreditation with a modest amount of work. 7. Pharmacies a. Facilities The Arizona Department of Corrections has eight pharmacies located in Winslow, Perryville, Phoenix, Alhambra, Florence, Tucson, Ft. Grant and Douglas. Most medications are given to inmates with a one-week supply. Psychotropic medications, controlled substances and pain medications are distributed in a daily package or unit dose watch swallow, in which the nurse delivers the medication in one dose and waits until the inmate takes the medication. Some medications are given out on more than a seven-day supply because of their packaging, i.e., asthma inhaler or ointment. Vitamins are given out on a thirty-day supply. b. Delays in receipt of medication When inmates are moved inter-facility, the providers at the receiving facility respect previous orders until they review the medical record and patient. Non-psychotropic medications are part of the inmates’ personal property and if the medications are in a container produced from the pharmacy in the correctional system, they are transferred with the patient, subsequently given to nursing along with the medical record upon arrival. Inmates experience delays in receiving prescribed medications. However, there is no evidence of any damages as a result of the delays. Overall, medications within the Arizona Department of Corrections are being distributed in a timely manner, given the staff. The Department could use another three to four technicians to assist in the delivery of medication. 8. Problems with Security Involvement in Health Care The most serious problems with health care occur because of security involvement in health care. In some cases, lack of security staff causes delays in treatment of medical, dental and mental health care. Lack of security staff and transportation also delay care provided outside of the prison. Defendants are aware of the insufficient security staff and transportation problems. In some cases, security staff interfere with delivery of health care. For example, security staff sometimes do not allow prisoners from South Unit in Florence to pass through the gate to the Central Health Unit. Inmates are sometimes unable to receive medical care due to security lockdowns of the unit or complex. Security staff sometimes deprive prisoners of their medication. In addition, security staff sometimes fail to cooperate with health staff. Security officers are also involved with the provision of medical care, including performing periodic health and welfare checks on inmates with physical or mental health problems. Dr. Braslow testified that it is inappropriate for security officers to maintain health and welfare checks if it is suspected a prisoner will lose consciousness or have other medical problems. During non-sick call times, inmates must access care through security staff. Dr. Braslow also testified that it was inappropriate for security staff to control access to medical care. Finally, security staff are allowed to overrule medical judgments of health staff. For example, a psychiatrist, can recommend that a prisoner be released from lockdown for mental health reasons, but security may overrule that medical order. 9. Medical Records Medical Records are routinely transferred with the patient upon arrival at the facility. Some problems exist with medical records. In some cases, the medical record is not transferred with the inmate. In addition, medical records are not always available at sick call treatment. Further, medical records do not always have the appropriate or required documentation of treatment or assessment of medical problems. 10. Special Diets According to Douglas FHA Michael Schwegler, the Douglas facility has had problems providing “some of the esoteric diets” for prisoners. Problems do occur in provision of special diets. However, inmates generally receive the diets that are written for them. 11. Confidentiality In some cases, inmates have to list their medical problems on sign up sheets or state the problem in front of other inmates. III. DENTAL CARE SYSTEM A. Generally Dental services are available at all facilities in the State of Arizona. Dental clinics in all of the facilities operate ten hours per day, with the exception of Perryville. The Santa Maria Unit at Perryville has a satellite dental unit at which the dentists see the female inmates once or twice a week. The male inmates at Perryville seek dental treatment at the main complex. The Director of Dentistry for the ADOC is Dr. Scalzo. Dr. Scalzo, meets with the lead dentist of every facility every other Tuesday on a conference call. In addition, the lead dentists and Dr. Scalzo meet quarterly. B.Intake Procedure The Department of Corrections policy requires that each inmate at Alhambra reception be examined by a dentist. This examination includes recording of the soft tissue, recording of oral hygiene, and recording of the pocket depths as an indices of periodontal status in diagnosing the periodontal condition. A panoramic x-ray is taken of each individual. If any problems need attention, the intake dentist will call ahead to the facility to which the inmate is to be transferred to have that inmate called in for treatment. Dentists also give inmates oral hygiene instructions at the reception, center. ADOC hands out a pamphlet prepared by Colgate that gives an outline as to oral hygiene. The examining dentist has the discretion to instruct the individual in reference to oral hygiene practices. The chart will note “OHI” for oral hygiene instructions. If the dentist feels it is necessary for the treatment of an individual case, ADOC will provide dental floss to the inmates. Some institutions have dental floss available in inmate stores. ADOC will purchase specialty toothbrushes if the dentist feels a more specific type is necessary in the treatment of a case. At Perryville, the intake reception center for women, inmates are brought in for a panoramic x-ray and examined by a dentist. C. Experts Drs. Thorburn, Braslow and Easley testified for plaintiffs regarding the adequacy of the dental care system. Dr. Easley has a dental degree from Ohio State University and a Masters degree in public health from the University of Michigan. Relevant to prison dental care, Dr. Easley has three years clinical experience with the United States Federal Bureau of Prisons. Dr. Eas-ley measured the ADOC dental system against the basic community standard of care for dentistry. This is a nationwide standard. Dr. Easley based his opinion of the ADOC dental system on the January 6, 1992 testimony of Dr. Scalzo and two dental and medical records of inmates. Dr. Scalzo, the Director of Dentistry at ADOC, testified for defendants. D. Staff 1. Generally Dentists employed by the Department of Corrections provide on-site dental care and are licensed in the State of Arizona. There are sixteen full-time dentists employed by the Arizona Department of Corrections. At Perryville, there are three full-time dentists and staff. These dentists also provide care to the Yuma facility. There are five full-time dentists assigned to the Florence facility; one dentist assigned to the Phoenix facilities; two full-time dentists at the Tucson facility; two full-time dentists assigned to the Douglas facility; and one full-time dentist assigned to the Winslow facility. Ft. Grant and Safford share one full-time dentist. The Department of Corrections has two dental hygienist positions.