Exhibit Solitary Lockup Mentally Ill Prisoners Sc

Exhibit Solitary Lockup Mentally Ill Prisoners Sc

• Topics: Mental Health

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Exhibit 1

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OPERATIONS

SPECIAL MANA::~f~MENT INSTITUTIONAL CLASSIFr:~:::~1'ION REVIEW'

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_ _ _ _ _ _ _ SCDC#:

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InstihJtlon:_ _\...~_c=-,:t===o.._ _ _ _ _ _ Ilnte Inmllte Plllced in SpecilllMllnllgement: 09
Security Detention Level Assign,ment of Inmate (if applicable):

'SIl-Level I

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~vel II ''0 'SD-L~~el U?j:'

------------~~---------------.--.---------------------7-------------------:-:.--i~!,

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0 Ten-day Due1proc'ess Review:

The Institutional Clnssificntion Committee met on .lL!.;ro',n to conduct a

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~Iarly Scheduled ggDay Review '~,'

The Committee recommends the above referenced inmMe to be:

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Released from Special Management and Returned to the General Population.
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Be INITIALLY Placed in Security Detention in the following SD-Level:
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o SD-Level I
0 SIl-Level n '
' 0 SO-Level ITT
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(NOTE: INITIAL Placement in Security Detention Requires State Classification Approval. See *NOTEbelow)ii,~~

classifici~~on·A~~o~~U~lt,r

Released from Security Detention. (NOTE: Release from Security Detention Requires State
, See **NOTE below) and Reduced in Custody to
(List RecommenqedCustody).~:,;

~ AdvanceiR<~"" in Socudty Dotentlon Lev" A"ignment

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The Committee further recomfuendedthat the inmate:

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ro.! I "t'lu$

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~2#u.J-ti·N~"""'-·

(list any other special restrictionslneeds here) ';':,

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. ,*NOTE: Until this form is automated, ifth~ Committee recommends the inmate to be initially placed in securitY detention,:the ICC '"
Chairperson/designee must immediately. notify State Classification via CRT Messaging for final appro"a1.State '(:!Iassification'\
.officials wi Ii respond'via CRT and a copy of their CRT message must be attached to this form. **NOTE: Tfthe inmate)~being; "
recommended for release from security dcteillion stntps, the TCC Chuirperson/designee must immediately notify State Classifi'-;;. '
cation via CRT Messaging for final approval. State Classification officials must respond via CRT and a printout of their CRT ';,
Message must be attached to this form.
,';:
FOR STATE.CLASSTFICA1'!ON USE ONLY:
';

Concur with the recommendation ofTnstitutional Classification Committee.
Concur with the recommendation of TCC; however, place the inmate in the
following Security Detention Level upon Initial assignment to security detention:

Disapproved. Return inmute to Geneml PopUlation.

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SI _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date _ _1_ _' _ _.:
Reviewing Stale Clnssilicnlion Officinl
cc: Warden
:.,

.: Institutional Record
, Central Record , .
Inmate
. .;, ICC
:" ;:~
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SCDC Form 19·30 (Temporary, IApril,1997)

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ENCOUNTER 00.249 MENTAL HEALTH CLI.D7/12{Q5 15 ~J8 KIRKLAND <::ORR INST
GOMP'
TREATMENT TEAM!I/M ROBINSON WAS STAFFED FOR A TX PLAN.MEMBERS PRESENT·!,
T . NICKENS, S ,.WOOD,NARD c K .,MOORE t T., NICKS t LJ?N K .ROBINBGN {L. MO,ORE.! T ~ JACKSON t
P. DENNIEl~,P,JONlil5,S.ROBERTS( MAJOR V "JACI<SON/.R,WRIGHT tLT J. GIBSON r & ,1. SHEALY.
l'IQTE:;J{ARP COP;?, O,F TX PLi\\N IS ON FUE ;IN 'J2fiE.MEPlCAL RECORP.
JUNItJ$ V. SHEALY T ,JR. t HS.C
SIGN.ED OF.F ON Q7/I2} 05. @,15.;4:\l BY JQNWS· V SHEALY l JRr HUM,i\N ,sE;RV;r.C;ESQQOB,D
ENCQUNTE~ .o024f3. LA,8 CLINIG
.07/U/O? OS:)!3 (\IRKLAND CORR INST
C;OMP
URINE QBTAINED FOR un.,
KI:.EVANS
.$IGNED QFF ON 97(12/05 .0.$ r.Z4 BY. KATRINA LEVANt?/ MEDIGAb A&SIS,TANT TECH I
ENCOUNTER 00.24 7 LAB CLINIC07/12{OS 08 :1.6 :lHRKLAND CORR INSTC.oMP
LABS WERE OBTAINED FROMI/M ROBTNSONrE'AS-TnTG eBC 1.EVEL, LITHIUM LEVEiL(tE'T
LEVEL/AND CHSHliL
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KLEVANS,

SIGNED on~ at'! 07/12/05 @ 6~11 B':{ I\ATI~JNA L EVANS., tv\1']I{ICAl,. A$s;rSTANT TECa I
NJ\'RR,A.T IVE () 024 q NARRAT I V E O ' 7 I l o/o.;i 1? ~ 14~rf'KLA:NDt;:Of'R INST·QOMP
BEING STARTEI! 01\1 :LITHl\JM Nr;;EDS 8.TAN.'DA'RD LAEQ
L.fT ,.8M-Ie', GEG· f~IOR'.J;'9 APMIN,1\Nl) L1::rIl,IUM LEVELFGRQ WE'EK~ K 3 'I'liENQ 3. Mq

NT:HS
$IGNED OFF ON 01/10/05 .~ 1$:18 BY ROSA N WILEY',
DO ABOVE LABS.

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.a:tG.NED OFF ON tl711i/05@ 16~31 ElY: ,IAMH A ElL:SBAMl.! NQRSE PRAC'I'l1ION'ElR 1:.11
ABOVE NIL.LBE SCHEDULED FOR 7114/05
$IGNEP OFF ON Q7!13/Q5 @ n~33 By ANN,E f' JA1I1I$QN,LICENS$D J;tRAQTIC}I(L NU~SE
ENCOQNTE~ (:)0.245 MENTAL flEtl;;LTH: eLI 07/0S/(l515 ~ 41 r';:I.RKI,.ltNJ;l CORR INSl'COMP
;I;.CS!J;NTAKE l.I.S6E$SMEN'r. (LATE .NQTESQLY
;ZOOS)
I.ltvl. ROBI.N;'lON IS A F{jR,:]:,Y '!'fiREE YEAB 'OLD W/M WHQ rs $ERVIN:G A. L:I]!'E SENTENI':,;E
Ii'DR ::rWq MURDER!? lE Ip;S. FARJ(:N':]:'8. !\WD .O'+'l-lE;R; QFEEN$ES, HE HA,s m;E;N INC~CERATEJ)
SINGE .1986 .li;ND HASSJ,>Et\lT raE MAtJ0.rUTY 9F rHIS TI.ME; ON SECURIT¥ DETENTWTiI lE
'1·4 YEAR, .lIM ROBINSON HAil A EX: OF SEXUAL AGGRESSIQN TqWARD FEMALE $TAE'F THAT
HAS RESULTHI$PROLONG CQNFlNEMENTTO SECURITY DETENTH)N. THERE HAS BEEN
Mu.TInE J?SYCHIA1RrC 110SPl-'.rALIZATIONS wnlLE tNCARCERATEHj. THERE IS A Hi\. OF
NQN..,.CQHJ?LIANCE WITH M.lwrCATTONAND SYMPTOtVlOLGJGY TNC:r;UPES DEL1J$iONAL TlilNKIN
G IE.A BELIEF THAT HE its JESUS CHRIST, CbNFQSIQN CONCERNING THE NATUR:e OF
HIS RE;Lb'J2IOWS.Hr? .wITH: FEMALE STAFF,DISORGANIZED THOUGHT PROCE$$,DRINKING
H.IS OWl:\[ U1;{INE,A_UDIOll.NP VliilGA;:, l.li\LLUC;INA:'pIQNiii.rET.t::;.pLEz.i;SE REFE.R TO ElNGOVl'fTE,R,
;N.4JfOR TI:iE P~YCI:iIATRI ST M.E]:'JTALHE~LTR: AS3E~2JM.Eb'!T,
PXSCHIZOAFEEGTIV;E DISOIU;lER BIPOLf.>;R ':f:fPE ,.P.;3YC;:f(I.#\T~IC SYMl?TQM;S ARE l>.CT:J;Vli:
.1I~ND I!M :r3 IN PARTIAL COMPLIANCE WITH MEDICATION IE NUMERIOD/il HALPOL PILLS
FOUND'
HIS POSSESSION. riM 1-13 'EASILY REDIRECTEIT.HIS COMPREHENSION LEVE
L IS GUESTiONED AND DORSN' T APPEAR TO BE PROCESSING 'INFORMNrI·ON APPROPRIATE

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NQRSE ADMINISTRlVL'QR/MGR .II

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P; ASS!GN TO J?RIi<mRYCQUNSELOR AND pROVIDE FOt.LOW UP $1>:RVrCE .•
SIGNED OFE' oN 07/0ili/05@ .9.:30 BY KEytN
r;.iOOREi HQMAN ~ERVIcES CooRp. 11
~* ENCOVNTEB 00.244 DOCTOR'S CLINJ:¢
(n/05/0S 14!lQ KIRKLANDCORR ;rN.$'I'GQ~p·

S It1 $E)i.:N FQR IN;I;.'J;'Il.I.L P.$,yGH~ITRTC 1\S.SE;SSJ:IlENT AFTE.B.TRANS,FER, E:RQ&! ):>GI/LQCKU1?
WllERE HE '$ BEEN M1:\.INTAI.NEOlfQR THE BES!? ]?1)RT OF 1.5 YEARS. HE HA$ HA,IT 9 i\IlM
;rSSIONS TOGER: ;AND 1$ Pi\~'l;ICULA.RLY PRONE TO Ass;AULTING FEM1:\.LE STAFF.
0 2 AmUSqIONS. fRI.QE!J,'O]?lHSQN AT WSIJP:r< .liE! J;$. -$S.RVING l\LIFIi)SEN~mNC;E E'QR: \'1.
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Q'RDERING HIS FA-THER, FEE'LING HIS FATHER WOULD BE BETTER Q-FF IN HEAVEN .• THER
o E IS ALSO. 1>. HISTQR¥QE BEING SEEN IN MILITARY J:;'ACILITIE3 nURING WHAT HE EST
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I.MATES AS 20 .MOg SERVICE IN THE NAVY" ARJ:.1Y., AIR FORCE, MARINES AND COAST ,GO
a UARD. .HE GI\tES DATES QiT .SERV:LCE IN THE)BEBRANCHE8'I'HAT tN'Dr.CATBS HEi SERVED
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IN M.L SIMULTANEo.USIi¥.
111 ALSO BMJi'ffiS.$ES TO HAVE l:3.EENSflOT IN :r'HEHEA.,LL TN FAC'L't liJi; SEMSTO I,l'EAR

0 , , " , SEMI~:tB.qJLAR SGAR THA'l;' ISC;DNSI!!!TE;NT W 1\ SKULL FLll.P.

CONFIDENTIAL

l:\[OSC::ll.R$CON;SI(?TEm;:

WITH BULLET HOLES ARE NOTED, NO MOT·OR DEFICITS ARE SEEN • DENIES SENSORY DE
.FI:CITB BUT CLAI!YIS 1.0 FEEL EtECTICITY IN IUS BODY', AND BELIEVES tIE EM A COM
PUTElR CHIP .Ir::1PLAlIJTED IN HIS :RIGE1'!: WRIST. HE ALSOBElLIEVmS HE IS JESUS CHRIS
T BECAUSE HE ONCE ATTEMPTED TO HAllE SEX WITH .A WOMAN NAMED MARY bGDELENE

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HE)\QTIVELY ffALLUOIN.<\TE$ AT

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wrTB YOICESCQ0t"lE.NTING. QNH;rSt\:QTIVrTXE

S.HE BE;L,IEVES. HE [3.1!;ES DEMONp A;ND 1l;;NGEL.$·, MQ'QIl OrrllJ;r;; lSR,ELl:\.:TED TO .l:\.: BELI
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EF THAT .wE ARE :n\l THE ' RA!?TURE l •
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IN11.A!J:'E SAYS SXSIMPROVE.D 1,'lIN.c;E 13EING ON .H.ALDOL ( IT 1\.PPE~? I~,E W}\'SAL,SO 'IRE:
o ATEDWITH STELAZINE ANDPROLIX'IN AS WELL. NO HX GIVEN OF ,TX wi LITHIUM, OR
o DEPAKOTE.
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LDEAT'IONALL¥,PT IS GRANDIOSE AND$EXtJALLY PREOCCUPIED .w ASTRiJNG HIST€lRY
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OF VOLATILEl AN1! ASSAULTlVEEEffAVIOR,' orTEN DIRECTED AT Ii/OMEN"
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Q: ON .EXA.M PT' IS CON$T1\.NTLY RE,STLESSAND FIPGETY. HE 1S GROSSLY DEtus:r;ON)\L
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AND SHOWS FLIGHT OF IDE~lt(. LOOSEI\SOClAT:J;ON,S, !?Rp'SSUREP SPEECH; SE}4U:/iL PREP
OCCUl?AnON. l\.T';l'ENTIOl':! Slt.AN I.S VER):FORESHORTENED,CANNOT :PQ
OF .YEl\.F,F,EVE
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l}.SED~ Is, NQT ORIENTEO. Hl):S m;fJi'lt:lJLTy W/REGA.LL l):ND fiiHoRTTER~. MEMORY,
G13QQMING AND H,YGI:El::lE ARE POQR. l\FFECT FLl\:'l; .ANP UNW1WERING.
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A; filCfIJ;:Z0l\.Flj'EGTIV.E DlO r j5IPOLl'i.R T¥PE; pOSSIBLE TjO\D; AJ'CATHlpIJ\; TJ\;RDIVE DYS;K

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INESIA,
P: TRIAL ON IJEPAKOTE AND LITHIUM. OBTAIN PRIOR RECORDS TO VERIFY HX, ESPECI

ALLY AS CONCERNS A POSSIBLE HEAD IN'JURY. cO.NTINUECURRENT NEUROLEPTIC8 AND
1:RElAT AKA'I'BtSIA. tITltltJM r.B~EL 11IJ ONE. WEEire REAS:ESS tN'I'WO YJElE1(S.

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VALPRQIC ACID
$IGiTWQ CABSQLES

AM~:P

2:!:iOMG
THREE .eM.SULEn,

pIG!

OJ?> S'rART DA'J?E.:.

07/0'5/05

TQT~L Dl:\YS;

[JF> MD ~ KIMY, MTC;HAEL -'
OF> ESKl';LLTH t;R
OP> 81,(3 fONE TfI;I?L,Eq: PO J;jIl)

i!$O:MG

OF> $IG.f.
OP> START DATE~ 07/05/0.5 TOTAL Dl'.YS:90
MD:KIRBcY,MICHAEL .Dl?> :rrSHQIL
50'0/;1.(;
JJJ?> SrG.: 'THREE GELCAPS. NQ AM

OF> $IG;
OJ?> ST.ARf' DA:;r!E:. 07/0'5/05 TOT.(I;L DAYS;
90
pp:;c ~~D;:KIMY, I"lICHA,EL [J
STGNE.D Oll.F ON Q7/0.'?/05 @ 14::40 BY ,MICHAEl, J ~URBY; FH¥.")ICIAN 1;
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STGNE,D OFf ON Q7IO~/05@ 16 154 BY ANNE PJAMI$QN, LICEJ:ifBED PRACTlqAL NURSE
o MAR AND PACKS UPDATED, LAB SLIP MADE GUT TO DR1\v.J LITHIUM LEVEL 7/i$/b5, WIL
0
LHAVE K. EVANS OBTAIN OLD RECORDS.
0
S!GNED OFf ON Q7/d5/05@ 17 :;09 B1 hNNE F JAMISON(L1CEl\ISElD PRACTICAL NORSEl
ENCOUNTER ·OQ243 MENTAL HEALTH CLI07/05J05, QS:51!.EE CORR INST
COMP
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I.MR~CE:rVED HALOO!. DEC 2 OOMG 1M RtGfiT GLUTIU\L MUISCL~.
1M TOLERATED INJECT
0
::CON WELL. I.M IS BEINE! TRAN$FEjiREOTO TBE res BROGBAM TODliY.
PSYCH lm\R. GJ:v
0
EN TO L'tS D1\V1:; t c::N1\Tg PLAGE 1'N' .t:::iJA~T. 'C, MC;:PQf'.jA;LD, .RN.
p
SIGNE,D OFFQN in/Q:5/P£i @ a:;52 BY YVQNN:E
j:vlCDONALD, UNCLA$~TE11EP
CQMP
** El'l'GQ.QNTER00:342 l1El'N'TAL. HEALTH ~LI .07/01/05 15;,4.9 J"EE ~ORR IN{jT
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eGC NOTE
I/O $E$8TON (SMU)
D: 11M WAS PLAt;ED IN SMU DUTY OFFICE FOR SESSION. THIS WRITER INF(;7RMED fILM
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THAT HE HAD BEEN ACCEPTED TO leg (HE REFERS TO IT M TCU). HE SEEMED
0
PLEASED. ASKEl:D IF HEC(i)ULD BUY C:TGARETTES & SODAS .s'rs HE GETS ,"VA
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COMPENsA1:lON.•.•• NOT MUCHlf', DUE TO PRIOR HEAD INJURY tNMrtIreARY T "SHOT
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THROUGH MYEELM.IT'f, FIE ASKEO IF HE WOULD HAVE AOQCTOR" IfA FEMJi.LEl DOCTOR".
A'SI\Ep rF THIS WRlTER WOOLQS.m f,IlSQOQNSELo.R,QCG ~l?LJl,.;rNjilp TEAT .H~ WOlJLP
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HhVE .AM/¥LE ·C;O]:JNSELOR.. r:fl:',S~lJ.g$ED 1\;T LE'ti/G':PHTl'lAT HE SHOULD NdT TOQc::I~ oR PQT

CONFIDENTIAL

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IUS HANDS ON ANY STAFF MEMBER
E23PECIALLY FEMALES. HE' RESPONDED( rl I r VE
LEARNED MY tESSON ... ,.AFTE:R 14 YE:ABS"" MIKED IF ITv~bULD BE !'TeU LOCK UP".
tee EX)?LAtt{ED Ic.aDORM SITUATION. 11M THOUGHT TODAY I S DATE WAS MONDAY t AND

1)ID NOT KNQWTHE MONTH. HE ASKED,"D0 1 LOOK TERRIBLE'?", eec LET RIM KNOW
TO .SHl\VE .&'SROWEB BEFO~ BEING TBl';:Ns.F.EE~.n •. I:IE WAS CALM &: RjiiSPONSrVE, SONE
,):,H<NGl1T .CONFQSlON ~ REPO.RTE.D P·QOR MEHOEY. S.l?E.ECH WAS )?}URJ;,Y LOGlCAJ;,TOD.~Y.
A.: OX·"" CHRONIC SC;HIZQPHE.E\\lTlI;. 11M I1l~INTA.INS SAME LEVE,L OlfWI'ABILJ;::l,'Y QN
CURRENT MED;;. I/~ HAli> BEEN RELEASEr) FROM $D C{jSTqDY j\FTER;l.4 Y'R.S Of
D.
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GONFIJ\tE~NT! DUE TO BE rRA:NSFERRED TO .IGS./Kq ON 7(5/0$,
P: Gec HAS ARRANGED FOR T/M TO BE TRANSFERRED TOKCI BY VAN. TRAN{)POR'l' BUS
0
WOULD BET()O OVERWHEl:iMING. WILL NEED MALE COUNSELOR AND VERY LIMITED
0
.cONTACT WITII FEMALE STAFF - AS HE gETS CONFUSED ABbUT THE NATURE OF Hts
0
n B}1!iLATIONSHIE' TO THEM. Wrt1cJBVIOUSLY NEED VERYGRADOAL IN'1ElGRAl'ION BACK TO
0
GEl'IEB,AL POP RQuTrNES..
G. BREONI .ccc:rtI
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S.IGNED O.FF ON QlI(JlJ05 (ij 16; 05 BY S\J$l\N V BREON, HUM1\W SEEVIC\'l$ COQR]) I
'/;.*. ENC01JNTER 00241 MENTAL H)!:AL'l'H: CLI 06/2.8/051.5: 2Q J;,EEtZ;ORB INST
COMP

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TRl\NS)fERf{EQPEST NQTE~

TRAN.SFEJ~ of INJl1ATE RO)?INSON TQ'I:HE Il'JTERMEj}I.ArE GARE
BE;ENTRAN:GMITTEJ) TO $TA1Ec;LAI3SJ;FICMH)N..
r;;IGNED .oFF ON 96/28/05 @, 161'22 BY ERNE Sir
SHAW, HUMAN SERVICES· GOaRD. II
D
COMP
** ENCOUNTER 00.240 MENTAL HEALTH GLT 06/22/05 11'~09, LEE GORR INS'l'
n :rGS A.PPROVAt NOTE:
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INMATE ROBINSON 1.8 REFERRAL
IC.S HAS .BEEN APPROVED" THE REFEBRINGSTAE'F
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WILL eN llSKED TO (';HANGS HIS MED.r:cALCLA;$SIFTCMION.
0
$IGNEiIl· OFF ON O·6IZ2JQ5 (lj n;ll BY EB~EST
.sal\W, aUli.;lA,N SERVICffi$ COORD ;t;I:
**. El'lcjOU"NTE~ 00239 MENTAL rIEf(D'l'H: CLI 06/;1.3/0510:07 L8£ ~OR~ IN$T~OMP

1\ NOTE. REQUEI)TIN:G THE

S,ERVJ;.GE~ 1~A.9

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1\ BEFERR1'1<1 .RE.QUEs.rr:nu~ IN:'1'ERI:1E,DIATE·cA;RE BERVICESHA.S liEEN RECEIYED, THE; r:cs
TRli;ATM.E;NT TEAM wr~L COJ,if$!DBB.1'fHS REE'ER~L.

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.RE;FER~l\.L

NOTE.:

SI,GNEJ) OFF ON Q9/1~)05 @ lQ; 09 8Y1i;RNEST
SHAW, I)U!'1Ar-r $E;lWICES CooR.D II
ENCOUNTER oe2~l;l MENTAL HEALTH eLI 06/091()·511'~42 LEE GORR INST
COMP
D.
THIs' IS A 44 YEAR OLD,S INGLE.. 'WHITE :MALE. HE HAS BEEN INCARCERATED
.IN LOCKUP FOR A.PPRQXIMA,TELY 15 YEARS.
HE IS .DIAGNOSED i-vI'tH SCHIZOPHR.ENIA.
HE ENpORE$ AUDITORY HALL)J(:INt\Tlb):l1;S AND PEJ,USJONS OF aELIEVJ:NG HE nj
,JESU$ AND "NERvon8 EXTREMI.TU:S." HE IS S.ERVING A I,Iil'E SENTF~CE .FOR
TaE MURDER OE

RI8FA'l'HER.

!:lEi rS COMPL!ANl'

WITH PSYCHOTROPICMEPICJ\.TIOlfS,

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Jl:!E;1'f'l':!5L STATyS EV¥UA.')?ION ~EVE;lI;LEP A WqRNAWD WE?\'J?HER.E.D l\J;tPEAlU;.NG
GLDERr W.HIT~ 'MAUiL
HE W:ASUNl$JiAVBt:I A,ND QNj'{EMJ?T.. l'lG S IH,
SFEEGH IS
VAG{)E hNP HESITAN'l'..
HltLr,uqNAnoN9 ANDOJi1LYSIQNS PER:;> 1ST .
THOUG1HS
R1(:.MA~NSOMl1;WflAT pIS,QRGi\NIZED"
HE ISFEl\RfUL,
A.

.9CHI:ZOPHREN~A,

8UGGE23T RECHECK

RECONMElNb :

~GHRONIG I

UNDIFFE·RENT lATE]}

NEEDED.

THIS PATIENT IS AN EXCELLEt;iT CANIDATE. tOF) IeS.

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J.B.CUSACK,

D.O.

SIGNED OFF ON O.(ifO.fJ/OS @ 11: . 5;3 BY \IOIfN¢QSAcKj. PHY$:tCJlili I
!'* ENCOU.NTEB 00237 MENTAL HE!1:LTH: c,LJ; 05/07/05 08: 5Q J;,EECQRR INST
CO}jP
0
J;MRE~EJVED ljALDdL DEG 400 MG IMlRrGHT DELTOI)J.
I:Mrv.L):i;R1\TED IN;JEGTIONW'EL
o. L. NEXT IN.;r~GTION DUE .Ql~Q.§-Q5, Iflt $TATE,9.HE ..1;lEARS VorCE,9. S~RE~It:IG AT HI.M
, 11':1 ,sTATEp HE 1.8 HEARING THE VOTe!;:;;; NON ! I { E DENIE~ WANTIl'JG TO HYR! l;lEL;F 0
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R ,OTHER,:$.
WUiLWqRWAJ,m Tf:) cer; fQRrrQLLOW UJr r y, tl.CDQNA.L.!), RN ..
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,'}IGNED OFF ON 06/0Jj05~,ai51 BY YVONNE
MCDONALD, UNGLASSIFIED
FORWARD TO cCe FOR FlU.
0
TERltt HUF.F I PN)?
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oWNED OFE'ON 06/07/05@ 16 :03 BY-TERRIL HOFF-SHiMON;), UNGLASSlFIED
0
WILL F/U. IiH IS ALSO SCUEDULED FOR .,P$YCH MP C:L.lJ:iIIC ON ftl9l05.
0
G. BREON, OCeln
SIGNEQ OF:F ON OE/O~!Q5 @.. fJ ;.!;l1 I3'rSQ§>AN V BREQN, H\)~IAN ,$EJ\VrC;ESc;CiQRD I
0

.CONFIDENTIAL

6875..AAAA·':Z610

Exhibit 2

Disproportionate Occurrences of Lockup
for Inmates with Mental Illness
Category
Percent of Group in Lockup
. Percent of Group with DO Sentences
Exceeding Projected Release Dates
Percent of Group with Security Detention

Differences in Occurrences Between
Mentally III and All Other Inmates

201 0/0
2500/0
312%

Source: Pitts' Ex. 301

PLTF. DEMO.

PX164 18

Disproportionate Occurrences of Punitive Measures on Inmates With Mental Illness

Percent of
Percent of Total
t

Group in
Lockupl

, Percent of Group with
.
DD Sentenc,es
Percent of Group
Group Use of
Exceeding Projected Percent of Group Lost With 'Security
2
3
4
Detentions
Good Time
Release Date
Force Rates

Groups

Inmates

Inmates with Mental
IIlness6

12.65%

15.81%

0.91%

4.65%

45.70%

8.66%

All Other Inmates

87.35%

7.85%

0.19%

1.86%

34.34%

2.78%

Differences in
Occurrences
Between Mentally III
and All Other
lnmates

201%

479%

250%

133%

312%

1 Excerplsfrom Plaintiffs' Exhibit 219
2 Excerpts from Plaintiffs' Exhibit 228
3 Excerpts from Plaintiffs' Exhibit 235
4 Excerpts from Plaintiffs' Exhibit 239
5 Excerpts from Plaintiffs' Exhibit 231
6 Inmates with an "L ff classification on September I, 201" SeDe Electronic Database produced on September 9, 2011

PLAINTIFF'S
TRIAL EXHIBIT
200S.CP-4().(I2925

301

P301-001

Exhibit 3

Lee

Lieber

Perry

Total Inmates

1715

1449

995

Inmates Diagnosed MI by SCDC

272

292

240

Percentage of Inmates Diagnosed
Mentally '" by SCDC

160/0

200/0

240/0

Total Inmates in SMU

237

135

144

Inmates in SMU Diagnosed MI by
SCDC

27%

42%

40%

Percentage of SMU Inmates
Diagnosed as MI by SCDC

Source: SCDC Electronic Database produced September 9,2011

PLAINTIFF'S
TRIAL EXHIBIT

345

P34S-001

Exhibit 4

INTERVIEW OF JANET WOOLERY, MD
BY

JEFFREY METZNER, MD AND RAYMOND PATTERSON, MD

LEE CORRECTIONAL INSTITUTION
SEPTEMBER 15,

~008

ALSO PRESENT: KENNETH WOODINGTON AND DAN WESTBROOK

File No. 11998/05049

-1I4823-3945-31Q1 v.2-#4823·3945-3101 v.2-

PLAINTIFF'S
TRIAL EXHIBIT

173

P173-001

PLT.3358

Woolery:

That are psychotic.

Metzner

That are psychotic. Not that have a psychotic diagnosis but are demonstrating

3
4

psychotic symptoms that you believe. .
Woolery:

hear voices, but when you talk with them they seem pretty ...

That demonstrate psychotic symptoms. Okay, so you know, they could say I

Metzner:

If they say they're hearing voices and you don't believe it, then I wouldn't say
they're psychotic.

Woolery:

Right.

Metzner:

But if their presentation is that you think. . .

Woolery:

If they're actively psychotic in the room when I'm seeing them - no.

Metzner:

No, no, no. Just that someone comes in and they give you a history, and based

on that history and based on their presentation you say - you're psychotic.

That's what I mean.

Woolery:

Okay. And so you want to know the percentage of people in SMU? .

Metzner:

Yes.

Woolery:

It may be 40 to 50 percent.

Metzner:

Okay. Any ...

Patterson:

[inaudible] transfer to Gilliam - if you recommend that you see someone

[inaudibIe] .

Woolery:

Oh, yes.

Patterson:

[inaudible] Metzner just described. You recommend transfer. How long does it

22
23

take for them to get there?
Woolery:

That day. So far, it has.

31
- #4823-3945-3701 v.2-

P173-031

PLT.3388

Exhibit 5

(~:pa81D
UMINMDCA
SCDC~
$$

181186

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
scnc HEALTH SERVICES; MEDICAL SUMMARY
BARTON,EDWARD E.

05/13/08
C029511

PAGE

ENCOUNTER:
665 NARRATIVE
05/12108
22:01 LIEBER
COMP
11M SIGNED UP FOR SICK CALL.
COULD NOT SEE TODAY FOR SICK CALL PER C/O DUE
TO SECURITY STAFFING ISSUES.
SIGNED OFF ON 05/12108 @ 2Z:0Z 9Y . MELISSA A WEAVER, REGISTERED NURSE I

** ENCOUNTERJ

664 MENTAL HEALTH CLINIC 05/12/08 15:21 LIEBER
COMP
1M WAS ASSESSED AT CELL DOOR AT SMU. HE REPORTS NO AH THAT IS DISTURBING NO
w- DOING WELL WITH SEROQUEL.MOOn- HAPPY. ADEQUATE-SLEEP, ENERGY AND APPETIT
E. NO SI, NO SIDE EFFECT5- REPORTED. NO ISSUES TO DISCUSS. SPOKE ABOUT CURR
ENT EVENTS.
o GROOMED. COOPERATIVE, PLEASANT, HOOD-SilO. NO NEUROLEPTIC INDUCED PARK.
SX. NO AKATHISIA, MOTOR- FLUID- TP- LOGICAL, TC- NO SI, STABLE AH, NO DELUS
IONS rAND J- FAIR
AI PSYCHOSIS NOS - IN REMISSION- SEROQUEL
p~ SCHEDULE FU AS PLANNED
SEROQUEL 400 MG BID- RENEWED THRU- 7/08
SIGNED OFF OM 05/12108 @ 15:26 BY PRESTON BFITZGERALD, NURSE PRACTITIONER II

** ENCOUNTER:

663 MENTAL HEALTH CLINIC 05/12/08
9143 LIEBER
NURSE
PTS SEROQUEL WAS INCREASED IN FEB. BUT FOLLOW-U~ HAS NOT OGCURED. MEDS
HAVE TERMINATED. WILL RENEW SEROQUEL AND REQUEST TIMELY FOLLOW-UP.
P: SEROQUEL 400MG BID
("> SEROQUEL
400MG
"I> SIG:TAKE ONE EID
P) SIG:

P> START DATE: 05/12/08 TOTAL DAYS~ 90
P> MD:HIGGINS,EDMUND SIGNED OFF ON 05/12/08 @ 9:f4 B1 EDMUND S HIGGINS, LrCENSKD P!YCHOLOGIST
*t

ENCOUNTER:
662 MENTAL HEALTH CLINIC 04/29/08 141+1 LIEBBR
COMP
D= . l/M STATED THAT HE WAS A LITTLE UPSET DUE TO HOT GETTING ENOUGHT SLEEP T
HE LAST PAST FEW DAYS. HE DID NOT NO IF HE NEEDED MORE MEDICATION OR HE NEE
DED HIS MEDS ADJUSTED. HE STAT~D THAt WAS HIS ONLY .PROELEM.
A:DX. IMPRESSION: AS LISTED PREVrOUSLY FROM THE DR.
INMATE WAS A BIT ADJITATED AND ANGRY But HE WAS ABLE TO COMMUNICATE WITH CO
UNSELOR EFFECTIVELY. HE APPEARED TO BE IN NO IMMEDIATE STRESS OR MENTAL HEA
LTH EPISODES. HE DID NOT SHOW ANY SIGNS OF DECOMPENSATION OR AIV HALLUCINAT
IONS.
.
P: NEXT APPT: 5/08.
MELVIN RANSOM,HSCII
RANSOH, HUMAN . SERVICES COORD II
SIGNED OFF on 04/Z9/08 @ 15: 17 BY [~ELVrN

III.,

661 NARRATIVE·
04/15/08
1: 4 8 LIEBER
ENCOUNTER:
COMP
REFUSED TO COME TO SICK GALL.
SULLIVAN, REGISTERED NURSE I
SIenED OFF ON 040/15/08 @ 1:409 BY COLLEEN

ENCOUNTER:
660 NARRATIVE
04/10/08
14:44 LIEBER
COMP
APPOINTKENT RESCHULED FOR AFTER X-RAY IN MAY
SIGNED OFF ON 04/10/08 @ 14:45 BY CHESTER
OGRODNIK. REGISTERED NURSE I
6875-DD-002

CONFIDENTIAL

PLAINTIFF'S
TRIAL EXHIBIT

130

P130-001

MDCPS81D
OMUIMDC.A.

05/13108

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCDC HEALTH SERVICES: MEDICAL SUMMARY

(JDC# 181186

COZ9511

BARTON, EDvlARD E.

PAGE

** ENCOUNTER:

65~ NARRATIVE
04/03/08
ND APPT SCHEDULED FOR TODAY HAS BEEN R'S"JD AS

8:19 LIEBER
COMP
HAS Nor HAD XRAY DONE YE

I~M

SIGNED OFF ON 04/03/08 @ 8:19 BY DEBRA

ENCOU~TER:

COMP
658 MENTAL HEALTH CLINIC C3/Z5/0a 10:25 LIEBER
Dc 11M STATED THAT HE WAS FEELING ALRIGHT AND TAKING IT ONE DAY AS IT COMES
. STATED'THAT HE WAS GETTING HIS MEDICATION AND NOT HAVING ANY MENTAL STRES
S AT THIS TIME. HE IMPLY THAT HE WAS READY TO GET BACK ON THE YARD.
A: DX.IMPRESSION: HI OF SCHIZOPHRENIA PARANOID TYPE
INMATE WAS VERY APPROPRIATE AND CALM WHEN COMMUNICATING WITH COUNSELOR. HE
DID NOT SHOW ANY SIGNS OF DECOMPENSATION OR A/V HALLUCINATIONS DURING THE S
ESSION. HE WAS ALERT AND DEMONSTRATED THAT HE COULD COMPREHEND WITHOUT ANY
DIFFICULTY.
.
P: NEXT APPT: 4/0B.
MELVIN RANSOM.HSCII
SIGNED OFF ON 03/25/08 @ 10:3Z BY MELVIN
RANSOM, HUMAN SERVICES COORD II

** ENCOUNTER:

657 NARRATIVE

03/10/08

11M HYDROCERIN CREAM EXPIRED AND I/M WANTS

AUSTIN. REGISTERED NURSE I

, Y NOW.
SIGNED
HAS TO
SIGNED
NOTED
SIGNED

6:06 LIEBER
COMP
HYDROCERIN NON-FORHULAR

RENEWED~

WOULD YOU LIKE TO ORDER SOMETHING ELSE?
OFF ON 09/10/08 @ 6:07 BY MELISSA A WEAVER. REGISTERED NURSE I
BE BOUGHT IN CANTEEN.
OFF ON 03/10/08 @ 15:43 BY ROBERT E BABE. UNCLASSIFIED
OFF OM 03/10/08

15':48 BY KATHY

MCCULLOUGH.

LI~ENSED

PRACTICAL NURS

ENCOUNTER:
656 MENTAL HEALTH CLINIC OZI29/08 15120 LIEBER
COMP
0: 11M SEEN FOR HIS MENTAL HEALTH FlU. 11M STATED I AM DOING THE SAME THE M
rmI'CSTION IS NOT HELPING ME, I HAVE BEEN ON ALL T'{PES OF MEDICATION AND SEE
N EVERY DocrOR AT SCDC A.ND NOaODY OR IJOTHING IS HELPING ME. I WANT YOU TO T
AKE ME OFF MENTAL HEALTH. I WANT TO SIGN MYSEtFOFF MENTAL HEALTH. I/M COMP
LAINS or HEARING VOICES TELLING HIM THAT SCDC HAS THE WRONG PERSON AND WE A
RE HOLDING AGAINST HIS VILL. 11M REPORTS FEELING FIRE IN HIS BODY.
A: ox: SCHIZOPHRENIA PARANOID TYPE
GAF-50
11M APPEARED TO BE AID X3_ MOOD APPEARED TO BE ANGRY. COOD EYE CONTACT. 11M
REQUESTING TO BE TAKEN OFF MENTAL HEALTH. DUE TO HIS HX OF MENTAL ILLNESS
HE WILL REMAIN ON MENTAL HEALTH. I/H REPORTS COMPLIANT WITH MEDS.
P: WILL F/U IN 30 DAYS
SIGNED OFF ON 02/Z9/08 ~ 15:31 BY TANYA F MCCANTS. HUMAN SERVICES COORD I

** ENCOUNTER:

. 555 MENTAL HEALTH CLINIC OZ/25/08 10:04 LIEBER
COMP
GLUCOSE AND FASTING LIPIDS tOR YRLY SDA MONITOR WERE- WNL-Z/ZZ/08
P: ADVISE 1M OF FINDINGS- NL
NO FURTHER MONITOR FOR zooa REQUIRED
SIGNED OFF ON 02/25/08 @ 10,06 BY PRESTON B FITZGERALD. NURSE PRACTITIONER II

ENGOU~TER1·

LAB

R~SULTS

654 LAB CLINIC
02/25/08
REC'D FOR LIPID PROFILE AND FES
687S-DD·003

CONFIDENTIAL

P130-002

7: 4-8

LI EBER

COMP

f ''\

)CP881D
"OM INt·IDeA
SCDC* 181186

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
seDC HEALTH SERVlCES: MEDICAL SUMMARY

05/13/08
C029511

PAGE

BARTOH ,ED',1ARD E.

FILED IN CHART FOR DR'S REVIEW AND SIGNATURE
SIGNED OFF ON 02/Z5/08 @ 7:48 BY GWENDOLYN
TAYLOR-BISHOP, MEDICAL ABsrSTAN
WIL L REVI I!:W.
SIGNED OFr ON 02125/08 @ 8;33 BY PRESTON B rrTZGERALD, NURSE PRACTITIONER II
ENCOUNTER:
653 LAB CLunc
OZ/2S/,OB
7: 46 LIE:'BER
FOUND OPEN. CLOSED
SIGNED orr ON 02/25/08 @ 7147 BY DEHPSEY C HOWARD. UNCLASSIFIED

** ENCOUNTER:
652 DENTAL CLINIC
A> OTHER DENTAL DISORDER*

02/22/08

15:39

LIEBER

CONP

COMP

COMPLAINTS or *10. FOOD PARTICAL STUCK BETWElHi THE TEETH
SIGNED OFF ON OZlZZ/08 @ 15:39 BY CARDACE A WIGFALL, ME-DICAL ASSISTANT TECH I
:U ENCOUNTER:
651 DOCTOR'S CLINIC,
oz/zz/oa 121·41 LIEBER
CaMP
S} I/M SEEN IN MAX EXAM ROOM. HE C/O) 2 YRS OF PAIN ON LT SIDE OF ABD. HIP 1 A

S) ND BACK. STATES HIS KIDNEYS WERE CHECKED IN THE PAST AND WERE APPARENTLY AL
9) RIGHT. RECORDS SHOW HE HASN'T SBEll A MEDIC./I.L DOCTOR IN OVER Z YR'S. OFFICER

STATES T~AT 11M HAS TROUBLE SITTING AND WALKING.
TEMP=OOO.O
PULSE: 0
RESP: 0
BP= 0/ 0
WEIGHT: 0
PPD= 0
0:- ABD IS SOFT AND NONTENDER. NO eVA TENDERNESS. PAIN WITH MANIPULATION OF LT
,...--,0 > HIP.
") LT HIP PAIN
\
't;l > XRAY LT HIP AND LUMBAR SPlNE. UtA. MOTRIN BOOMG TID WITH'FOOD. RECHECK AFTE
R XRAYS.
SIGNED OFF ON OZIZ2/~B @ 12:51 BY ROBERT E BABB, UNCLASSIFIED
XRAY FORM SUBMITTED FOR SCHEDULING
FlU APPT SCHEDULED
MEDS DIRECT TRANSMIT TO KCI PHARMACY
SIGNED OFF ON 02/22/0B @ 13:04 BY DEBRA
AUSTIN. REGISTERED NURSE I
S)

(

** ENCOUNTER:

650 MENTAL HEALTH CLINIC OZ/ZI/OB 15:3& LIEBER
COMP
, INC IrOTE J
TX TEAM UPDATED TX PLAN. I/M MENTAL HEALTH STATUS WILL REMAIN MENTALLY ILL
WITH A DX; PSYCHOSIS. PLEASE SEE HARD COpy OF TX PLAN IN MEDICAL RECPRDS; N
EXT UPDATE WILL BE 5/21/08.
TEAM MEMSERS-----T. MCCANTS,CCC AND C. BYNES,CCC
TANYA MCCANTS,CCC
SIGNED OFF au OZ/21/0B @ 15:37 BY TANYA F MCCANTS, HUMAN SERVICES COORD I

ENCOUNTER:
649 LAB CLINIC
02121/08
<JIZZ
LIEBER
COMP
LABS DRAWN FOR FBS AND LIPID PANEL AS ORDERED
FASTING
SIGNED OFF ON 02/21/08 @ 9:22 BY GWENDOLYN
TAYLOR-BISHOP 1 MEDICAL ASSISTAN

** ENCOUNTER,
(-"

648 MENTAL HEALTH CLINIC ai/li/0S 1~151 LIEBER
CaMP
1M IS SEEN FOR FU AT SHU. HE HEARS VOICES, INSIDE HEAD. UNFAMILAR, HE HEARS
VOICES TELLING HIM THAT HE IS NO GOOD. HE STARTED HEARING VOICES FOR 1995.
HE HAS TAKEN MEDS OF ALL KINDS AND NOTHING HELPED. HE HEARS VOICES ALL THE
rIME EXCEPT AT SLEEP.5L'EEP- OK. ENERGY- OK. "OOD- HAPPY, FULL OF ENERGY.
6815.DD-004

CONFlDENTrA.L

P130-003

MDCPB81D
OMUfMDCA
CDCft 181186

P)
P)

,-,

\.j*

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCDe HEALTH SERVICES: MEDICAL SUMMARY

Os/lUOS
CO.z9511

PAGE

BARTON, ED'llARD E.

HE HAS ONE CHILDREN- GOING TO SCHOOL, MAX OUT IN 6 IRS.
0: ALERT, COOPERATIVE. COGNITIVE CAN CONCENTRATE, IF VOICES HEARD- IP- BLOC
KING, NO PSYCHOMOTOR AGITATION, D~LUSIONS OF PARANOIA, AH P05. I AND J- IMP
AIRED. LOW MENTAL APTITUDE.
A: SCHIZOPHRENIA PARANOID TYPE, PARTIAL REMMISISON WITH SEROQUEL AT 600 MG.
P START 400 MG BID - TOTAL BOO MG TRIAL TO REDUCE AH FROM 18 HRS TO lZ MRS
PER DAY.
SEROQUEL
400HG
SIG:TAKE 1 TABLET BID.
S IG:
START DATE: 02/11/09 TOTAL DAYS: ~o
MD:FITZGERALD.PRESTON LAB FOR FASTING GLUCOSE LEVEL NOW FOR SDA MONITOR OF SEROQUEL AND FACTING L
1PID5,
SIGNED OFF ON 02/11/08 @ 15tUB Br PRESTON B FITZGERALD. NURSE PRACTITIONER II
COpy TO PHARM
LABS IN LAB BOOI{
SIGNED OFF ON 02/12/08 @ 8:17 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NURa
ENCOUNTER:
647 MENIAL HEALTH CLINIC 01/31/08 13:31 LIEBER
COMP
INC NOTE,
11M SCHEDUEL TO BE SEEN IN PSC! CLINIC ON 2/11/08.
TANYA MCCANTS,eec
SIGNED OFF ON 01/31/08 @ 13:37 BYTAN!A F MCCANTS. HUMAN SERVICES coaRD I
El-ICQUNTER:
646 MENTAL HEALTH CLINIC 01/Z~/oa
12:040 LIEBER
COMP
UM SEEt" FOR HIS MENTAL HEALTH FlU. UM COMPLAIN'S OF HEARING VOICES, FEE
LING FIRE IN MY BODY AND BUGS CRAWLING OVER ME . I CAN'T SEE THE FIRE OR TH
E BUGS. I SEE SHADOWS IN MY ROOM. 11M REPORTS TAKEN SEREQUEL, BUT REPORTS I
WANT TO GET BACK ON MY STELAZINE AN DBENEDRYL TO HELP WITH THE VOICES TELL
ING ME TO HURT MY SELF AND THAT I AM A PROPHET.
A: UK APPEARED TO BE A/O X3, l<tOOD APPEARED TO BE PLEASANT WITH GOOD EYE CO
HTACT. WE DISCUSSED HIS CONCERNS AND SOME COPING SKILLS IP DtAL WITH HIS 01
AGNOSIS.
P: CCC MADE REFERRAL TO BE SEEN IN PSYCH CLINIC. WILL F/U IN" 30 DAYS OR PRN

TANYA MCCANTs.cec
SIGNED orF ON 01/25/08 @ 12:15 BY TANYA F

~CCANTS.

HUMAN SERVICES COORD I

ENCOUNTER:
~t5 NARRATIVE
11/27/07
4:39 LIEBER
COMP
11M SEND REQUEST TO STAFF STATING THAT HE DO NOT WANT DOUBLE PORTIONS ANY M
ORE STATED THAT KE HAS NOT BEEN GETTING THEM FOR OVER A YEAR. AND SINCE SOM
10NR ELSE HAS BEEN GETTING HIS FOOD HE WANTS IT TO STOP. VOICED NO OTHER
COMPLAINT.
SIGNED orF ON 11/27/07 @ 4:41 BY SANDRA
JONES, LICENSED PRACTICAL NURSE
SIGNED OFF ON 11/17/07 @ 18:57 BY BRENDA K KEAi. LICENSkD PRACTICAL NURSE.

ENCOUNTER:
644 MENTAL HEALTH CLINIC 11/19/07 13:55 LIEBER
COMP
1M WAS sEEI·' AT LOCKUP. HE SAID THAT SEROQUEL CAUSES TO REDUCE VOICES AND PS
YCHOSIS. OTHERWISE GOOD, NO CONSTANT VH HE CAN DISTSRACT VOICES TEMPORARY.
687S.DD-OOS

CONFIDENTIAt

P130-004

NDCPS81D
/--''1INMDCA

seDCt 181186

SOUTH CAROLU{A DEPARTHENT OF CORRECTIONS
seDe HEALTH SERVICES: MEDICAL SUMHARY

05/13/09

C029511
PAGE

BARTON,EDWARD E.

DENIES 51, OR HI, OR DELUSIONS. STILL THINKS ABOUT STARTING FIRES.
0: GROOMED, COOPERATIVE. MAKES LIMITED EYE CONTACT, TP- LOOSE ASSOC, Te- NO
SI, AVR POS. DELUSION OF SITTING FIRES STILL APPARENT.I AND J- IMPAIRED. 5
AID HE IS READY TO GO THE YARD. NO EPS.
A PSYCHOSIS NOS
P: DC BENADRYL IT ADDS TO CONCENTRATION SIDE EFFECTS AND CONFUSION
INCREASE SEROQUEL TO 600 MG AT NIGHT.
P> SEROQUEL
400MG,
p> SIG;TAKE 1 TABLET AT BEDTIME
P} SIG~
P} START DATE: 11/19/07 TOTAL DAYS: 90
P) MD:FITZGERALD,PRESTON P> SEROQUEL 200MG
P) SIG:TAKE 1 TABLET ,WITH +00 MG AT BEDTIME.
P> SIG,
,
P> START DATE: 11/19/07 TOTAL DAYS: 90
P> MD:FITZGERALD.PRESTON SIGNED OFF ON 11/19/07 @ 14:01 BY PRESTON B FITZGERALD, NURSE PRACTITIONER II
SIGNED OF.F ON 11/21/07 @ 18:37 BY DENISE
NORWOOD, LICENSED PRACTICAL NURSE
A* ENCOUNTER:

6+3 MENTAL HEALTH CLINIC 10/22107 11:Z7 LIEBER
COMP
INC NOTE;
TEAM UPDATED TX PLAN. I/M MENTAL HEALTH STATUS WILL REMAIN MENTALLY ILL WIT
H A DXJ PYSCHOSIS. PLEASE SEE HARD COPY OF TX PLAN IN MEDICAL RECORDS. NEXT
UPDATE WILL BE 12/5/0'.
TEAM MEMBERS----T. MCCANTS.CCC AND C. BYNES,CCC
TANYA MCCANTS,CCC
SIGNED orF ON 10/22/07 @ 11:28 BY TANYA F MCCANTS. HUMAN SERVICES COORD I

A* ENCOUNTER;

P)
P}
P)
P>
P)
P}
P>
P)
P}
P)

642 MENTAL HEALTH CLINIC 10/04/07 lZ:Z3 LIEBER
COMP
RENtV MEDS.F/U IN .0 DAYS
DIPHENHYDRAMINE ELIXEI
1Z.5MG/5CC
SIG:TAKE SOMG IN THE AM AND AT BEDTIME PO DAILY
SIGI
START DATE: 10/04/07 TOTAL DAYS: 90
MD:FITZGERALD,PRESTON SEROQUEL ZOONG
SIG:TAKE Z TABLETS PO AT BEDTIME
SIC:
START DATEI 10/04/07 TOTAL DAYS, 90
MDrFITZGERALD,PRESTON SIGNED OFF ON 10/0+/07 @ lZ~2e BY PRESTON B FITZGERALD, NURSE PRACTITIONER II
NOTED
SIGNED OFF ON 10/04/07 @ 13;3Z BY JOSEPH H POWELL, NURSE ADMIN[STRATOR/MGR II

** ENCOUNTER:

6.1 MENTAL HEALTH CLINIC 081Z+/07
38 YEAR OLD AAM SEEN IN SMU FOR PSYCH FlU. WITH
IN ON FIRE AND HE SMELLS FIRE. CIO A/H BUT SAYS
LL A/H ARE INTERMITTENT SO NOT REALLY TRUE A/H.
A STABLE FOR HIM
687S.DD-006

CONFIDENTIAL

P130-005

13:50 LIEBER
COMP
'C/O THAT HE FEELS HIS.ROOH
VOICES ARE CONTINIOUS. USUA
NO 51. HI.

MDCP881D
,?.LJUnmCA
\

l:iCDC# 181186

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
seDC HEALTH SERVICES: MEDICAL SUHMARY
BARTO~l,ED""ARD

05/13/08
COl9511

PAGE

P CONT MEDICATION SEROQUEL 500 MG KS AND BENADRYL 50 MG BID.
STEPHEN K BAKER MD
SIGNED OFF ON 08/Z4/07 @ 13:57 BY STEPHEN K BAKER, PHYSICIAN II

** ENCOUNTER:
640 SICX CALL
08/23/07
Z3:51 LIEBER
COMP
S) I/H SEEN FOR SICK CALL STATING HE HURT HIS ARM AND WANTING SOMETHING FOR DR
S) Y SKIN
0> TEMP=D98.3
PULSE= 12
RESP=20
BP=1321 70
WEIGHT=la2
PPD= 0
D) 11M APPEARS TO HAVE DRY SKIN ON, HIS UPPER EXTREMITIES AND TRUNK. ARM DOES N
0> O~ APP.AR SWOLLEN OR BRUISED AT PRESENT TIME.
A) REQUESTING HYDROCERIN CREAM FOR SKIN
P} TOLD TO TAKE TYLENOL OR MOTRIN FOR ARM PAIN.
SIGNED OFF ON 08/23/07 @ 23:58 BY DARREL~ A BASINGER, UNCLASSIFIED
H!DROCERIN eR ORDERED.
'
SIGNED OFF ON 08/Z4/07 @ 13150 BY ROBERT E BABB. UNCLASSIFIED
NOTED
SIGl..tED OFF all 08/27/07 @ 1+:22 BY KATHY
MCCULLOUGH. LICENSED PRACTICAL NURS
U

ENCOUllTER I
639 l~ENTAL HEALTH CLUlIC oa/13/07
13:!)6 LIEBER
COMP
D: 11M SEEN FOR HIS MENTAL FlU. 11M COMPLAINS OF FIRE IN HIS BODY. AND HIS
ROOM CATCHING ON FIRE. I/M REPORTS HEARING VOICES AND SEEING SHADOWS IN HIS
ROOM. I STOPPED GOING OUT FOR REC BECAUSE OF THE HEAT AND THE THINGS CRAWL I
NG ON MY BODY I CAN'T SEE THEM BUT I FEEL IT.
A: DX: PYSCHOSIS
G'AF- 50
11M APPEARED TO BE A/O X3; MOOD APPEARED TO BE ANXIOUS WITH GOOD EYE CONTAC
T. 11M REPORTS COMPLIANT WITH MEDS.
P: WILL F/U IN 30 DAYS OR PHN.
TANYA MCCANTS.CCC
SIGNED OFF ON 08/13/07 @ 14:09 BY TANYA F MCCANTS, HUMAN SERVICES COORD I

** ENCOUNTER:

63B.MENTAL HEALTH CLINIC 07/Z0/07 14:45 LIEBER
COMP
S)38YOAAM WITH DX PSYCHOSIS VS DELUSIONAL DO. 1M IN FOR ROUTINE FOLLOWUP.
1M BELIEVED HE WAS BEING SEEN EY MEDICAL. 1M RPTS CONTINUING TO HAVE
AVH OF SPIRITS IN CELL. 1M RPTS VOICES TELL HIM TO KILL SELF. 1M RPTS
THAT HE CAN FEEL AND SMELL FIRE IN HIS CELL. 1M HAS BEEN IN ICS IN PAST A
ND REQUIRED TX AT GILLIAM.
O)APPEARS OLDER THAN STATED AGE. MOOD IRRITABLE t RPTS AH OF VOICES TELLING
HIM HE FIREBOMBED A CHURCH. HE ALSO RPTS va OF SHADOWY FIGURES.
DENIES 5I/H1.
A) PSYCHOSIS
P)INCREASE SEROQUEL TO 600MG QHS
RTC lHO.
P} SEROQUEL 300MG
P) SIG:TWQ TABLETS PO QHS.
P> 5 IG:

STAR~ DATE: 07/20/07 TOTAL DAYS:
90
P) MD:MEtIKIAN,MARGARET SIGNED OFF ON 07/20/07 @ 1+,50 BY MARGARET
NOTED TO MAR. A. DOLPHIN,' LPN

6875-DD-007

CONFIDENTIAL

P130-006

.MELIKIAN. PHYSICIAN II

MDCP881D
OMINMDCA

C_~~DC#

1811 a 6

PAGE

BARTOH,EDVIARD E.

SIGNED OFF ON 07/23/07 • 10:03 BY ARLOA

P)
P)

DOLPHIN, LICENSED PRACTICAL NURSE

** ENCOUNTER:
p>
P}

05/13/08
COZ9511

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
sene HEALTH SERVICES: MEDICAL SUMMARY

637 DOCTOR'S CLINIC
06129/01
13:53 LIEBER
RENEW MEDS
SEROQURt
400MG
SIG:TAKE ONE TAB AT tHGHT
SIG:
START DATE: 061Z9/0? TOTAL DAYS~ 90
MD:COBI3.THOMAS SIGNED OFF ON 06/19/07 @ 13:55 BY THOMAS
COBB. PHYSICIAN II
NOTED ON MAR.
SIGNED OFF ON 06129/07 @ ZI:Z0 BY LYNNE H MALDEN. REGISTERED NURSE II

COMP

** ENCOUtfTER I

COMP
636 DOCTOR'S CLINIC
06129/07 13:49 LIEBER
RENEW 11£DS
P> DIPHENHYDRAMINE ELIXER
12.5MG/5CC
P} SIG:TAKE 50MG QAM AND QHS
p> srG:
P) START DATE: 06/Z9/0? TOTAL DAYS;
90
P) MD:COBB.IHOMAS INMATE DOING WELL. HAD NO COMPLAINT OTHER THAT NOT GETTING HIS BENADRYL.
OTHEREWISE STRAIGHT.
A•• PSYCHOSIS NOS,
P. CHANGE BENADRYL DOSE,
TGCOBBMD
SIGNED OFF ON OS/~9/07,@ 13:5Z BY tHOMAS
COBB, PHYSICIAN II
NOTED MED RENEWED ON MAR. 11M HAD SIGNED A REFUSAL FOR RISPERDAL AND
BENADRYL ON 6/14/07 AND THIS IS WHY 11K DIDN'T RECEIVE HIS BENADRYL.
STATES DOSE CHANGE ABOVE BUT 11M WAS ON THIS SAME DOSE PREVIOUSLY.PLEASE
CLARIFY,
SIGNED OFF ON 06/19/07 @ ZI:16 BY LYNNE M MALDEN, REGISTERED NURSE II
ERROR WITH ABOVE 11M SIGNED REFUSAL FOR BENADRYL AND SEROQUEL NOT RlSPERDAL
SIGNED OFF ON 06/19/07 @ ZI:19 Bf LYNNE M MALDEN. REGISTERED NURSE II
TANYA MCCANTS,CCC
SIGNED OFF ON 081Z1/07 @ 8138 BY TANYA F MCCANTS, HUMAN SERVICES COORD I

•• ENCOUNTER:
635 MENTAL HEALTH CLINIC 06/18/07 15:19 LIEBER
.
COMP
0: 11M SEEN FOR HIS MENTAL HEALTH FlU. 11M SEEN AT HIS CELL DOOR ALONG WITH
CPL. SMITH. I/MBARTON STATED I STOPPED TAKEN MY MEDICATION BECAUSE IT'S N
OT HELPING ME WITH THE BURNING IN MY BODY AND THE STUFF THAT'S CRAWLING QVE
R ME. 11M STATED I NEED TO SEE THE DPCTOR. 11M DENIED A/V HALLUCINATIONS AS
WELL AS HIS THOUGHTS. liM AGREED TO TAHE MEDS IF ecc CAN MAKE AN APT TO SEE
DR. COBB.
A: 11M APPEARED TO BE AID X3: MOOD APPEARED TO BE PLEASANT WITH GOOD EYE CO
NTACT. 11M SPOKE IN A CALM VOICE. I1f<1 AGRE-ED TO TAKE HIS ['1EDS.
P; 11M SCHEDULE TO BE SEEN IN PYSCH CLINIC 6/27/07. WILL FlU AS PHN.
TANYA MCCANTs.cec
SIGNED OFF ON 06/16/07 @ 15:32 BY TANYA F MCCANTS. HUMAR SERVICES COORD I

:Ie. ENCOUNTER:

6~4

NARRATIVE

06/14107
'6875·DD-008

CONFIDENTIAL

P130-007

3: ZZ

LIEBER

COHP

MPCPS811)
OMUINDCA

t/-'

\,. ~ ~ 0 C'" 1811 B6

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
scoe HEALTH SERVICES: MEDICAL SUMMARY

05/13108
COZ9511

PAGE

BARTON.EDWARD E.

11M REFUSED MEDICATIONS AND REFUSED TO SrGN REFUSAL SLIP
SIGNED OFF OM 06/14/07 @ 3:23 BY TERESA ARLENE HICKEY, REGISTERED NURSE I
ecc WILL FlU.
TANYA MCCANTs.ecc
SIGNED OFF ON 06/18/0? @ 12144 BY TAIIYA F MCCANTS. HUMAn SERVICES COORD I
lUI<

ENCOUNTER:
633 MENTAL HEALTH CLINIC 05/03/07 10146 LIEBER
cor~p
0: 11M SEEN FOR HIS MENTAL HEALTH FlU. 11M REPORTS AIV HALLUCINATIONS SEEIN
.G PEOPLE AND SHADOWS 1M HIS ROOM AND HEARING PEOPLE TALKING IN KIS ROOM. ,
11M WROTH A REQUEST TO STAFF TO ASW MR. BODISON STATING SOMEONE STOLE HIS
IDENITY AND THEY ARE IMPOSING AS HIM. 11M REPORTS TAKEN HIS MEDICATION BUT
FEELS IT'S NOT WORKING BECAUSE OF THE VOICES. 11M REPORTS HE SHELL FLESH
BURlfHfG AUD THINGS CRAWLU{G OVER HIS BODY.
A: 11M APPEARED TO BE AID X3~ MOOD APPEARED TO BE NORMAL WITH GOOD EYE CONT
ACT. 11M STATED THE VOICES TOLD HIM TO WRITE THE LETTERS AND SEND THEM OUT.
I CAN'T CONTROL THE VOICES.
P: WILL FlU AS PRN.
TANYA MCCANTS.CCC
SIGNED OFF ON 05/03/Q7 @ 10:57 BY TANYA FELICIA MCCANTS p HUMAN SERVICES COORD'

** ENCOUNTER:

r-"

P>
P>
P>
P>
P>
P)

63Z MENTAL HEALTH CLINIC 05/0Z/07

P> START DATE: 05/0Z10? TOTAL DAYS:
P) MD:MYERS.CHRISTOPHE ~

6875-DD-009

CONFIDENTIAL

P130-008

LIEBER

COMP

TO HIM. WHICH TALK TO HIM "ABOUT THE END OF THE WORLD" HE ALSO REPORTS OLF
ACTORY H.a.LLUCINATIONS OF THO.SE EXPERIENCES. HIS REPORT OF HIS HALLUCINATIO
NS IS HIGHLY SUGGESTIVE OF MALINGERING. PARTICULARLY GIVEN HIS REPORT OF TH
E SEXES OF THE VOICES AND THE INCONSISTENCIES IN HIS REPORT. HOWEVER, HE A
LSD REPORTS, ONLY AFTER CONFRONTATIOU, HIS BELlEF THAT SOMEONE HAS STOLEN H
IS IDENTITY, AND THAT THERE IS AN IMPOSTER IN IHE PUBLIC. HIS ACCOUNT OF
THIS IS MUCH MORE RELIABLE AHD IS COt{SISTE,NT WITH PAST REPORTS AND WITH DIS
ORGRANIZED WRITINGS WHICH HAVE BEEN REGULARLY PRODUCED. HE IS OTHERWISK WI
THOUT C/O.
MSE: WD/WN AA MALE~ APPEARS OLDER. GOOD W{GIENE. THOUGHTS INITIALLY LINEA
R, BECOME DISORGANIZED. PERCEPTUAL DISTURBANCES REPORTED AS ABOVE. HO SI/'
HI. MOOD IS "OKAY." AFFECT EUTHYMIC.
AJ ASPD.
LIKELY UNDERLYING PSYCHOTIC DID WITH ELEMENT OF MALINGERING. PRO
BABLE PARANOID SCHIZOPHRENIA VS. DELUSIONAL DID.
P: CONTINU~ SEROQUEL. INCREASE TO tOOQRS. CONTINUE DIPHENHYDRAMINE. I/U 4
TO 6 WEEKS OR SOONER PRN. CHRISTOPHER MYERS. M.D.
SERoQUEL
tOONG
SIGtON! TAB PO QHS
SIG I
START DATE: 05/0Z/O? TOTAL DAYS: 90
MD:MYERS.CHRISTOPHE OiPHENHYDRAMINE ELIXER
12.5MG/5CC
SIG:50 MG PO QNOON AND 50 MG PO QHS FOR EPS

P> SIC:

\ ..

1+=15

1M IS A 38 YEAR OLD AFRICAN AHERICAN HALE WITH A HISTORY OF ASPD. lED, EXMI
BITIoNISM WHO IS SEEN FOR FlU. 1M CURRENTLY ON SEROQUEL 300 QHS. DIPHENHYD
RAHINE 50 QNOON AND 50 QRS. HE PRESENTS WITH cia SEEING SHADOWS THAT TALK

I'1DCPBBID

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCOC HEALTH SERVICES: MEDICAL SUMMARY

r_OMIJ~MDCA

\~~

SCDCtt 181186

05/13/08
COZ9511

PAGE

BARTON.EDWARD E.

SIGNED OFF ON 05/02107 @ 14:21 BY CHRISTOPHE
MYERS, PHYSICIAN II
SIGNED OFF ON 05/08/07 @ 8:08 BY TERESA ARLENE HICKEY, REGISTERED NURSE I
CaMP
631 MENTAL HEALTH CL Bnc 04/Z7/07
15: 36 LIEBER
INC NOTE;
LATE ENTRY FOR .125/07,
11M WAS SCHEDULE ~O BE SEEN BY DR. COBB TODAY. BUT DUE TO HIS ILLl~ESS HE HA
S TO BE RESCHEDULE !i/Z/07.
TANYA MCCANTS,CCC
SIGNED OFF ON 04/27/07 @ 15:37 BY TANYA FELI CIA MCCANTS. HUMAN SERVICES COORD

** ENCOUNTER:

** ENCOUNTER:
INC ~fOTE;

630

MENTAL HEALTH CLINIC

O~/17/0?

10101

LIEBER

CaMP

11M SCHEDULE TO BE SEEN IN PYSCHE CLINIC ON ~/Z5/07.
TANYA MCCANTS,cee
SIGUED OFF ON 04/17/07 @ 10:01 BY TANYA FELICIA MCCANTS, IIUMAN SERVICES COORD

-- ENCOUNTER:
629 MENTAL HEALTH CLINIC ot/09/07 16:03 LIEBER
CaMP
INC NOTE;
11M IS SCHEDULE TO BE SEEN BY DR. coaB ON 4/Z5/07.
TANYA MCCANTS,CCC
SIGNED OFr ON 04/09/07 @ 16:04 BY TANYA FELICIA MCCANTS, HUMAN SERVICES COORD
••
--\
C.

ENCOUNtER:
628 MENTAL HEALTH CLINIC 04/06/07
14133 LIEBER
COMP
0: 11M SEEN PER REQUEST OF MR. BODISON DUE TO STAFF REQUEST WRITTEN to HIM.
11M SEEN AT HIS CELL DOOR ALONG WITH OFC.
11M STATED CAN'T YOU SEE THESE PEOPLE IN MY CELL YELLING AT ME TELLING ME I
AIN'T SHIT. 11M STATED I GOT THESE THINGS CRAWLING ALL OVER MY BODY AND I S
MELL MY FLESH BURNING.' 11M STTED YES I AM TAKEN MY MEDICATION SEREQUEL 300
MG AND BENEDRYL.
A~ 11M APPEARED TO BE AID X3; NOOD APPEARED TO BE NORMAL WITH GOOD EYE-CONT
ACT. 11M APPEARES TO BE HAVING SOME-PARANOIA. 11M REP ROTS TAKEN HIS MEDICAT
ION WITH NO PROBLEM. CCC RECEIVBD A MESSAGE STATED 11M HAS DENIED HE SERRQU
L CRUSHED.
PI cee MADE A REFERRAL TO BE SEEN BY DR. COBB. WILL FlU IN 30 DAYS.
TANYA MCCANTs.cec
SIGNED OFF ON 04/06/07 ~ 14,39 BY TANYA FELICIA MCCANTS. HUMAN SERVICES COORD

** ENCOUNTER:

627 NARRATIVE
ot/Ol/07 23:39 LIEjia
CaMP
11M REFUSED IO TAKE SEROQUEL CRUSHED.
SIGNED OFF ON 04/01/01 @ Z3:40 BY PENNY
MARTIN, LICENSED PRACTICAL NURSE
NOTED RECOMMEND DC 5EROQUEL
SIGNED OFF ON 04/02/07 @ 7:57 BY lOSE~H H POWELL, NURSE ADMINISTRATOR/MGR II
eec EXPLAINED TO 11M HE IS AWARE THAT HIS SEREQUEL WILL BE CRUSHED.
WILL FlU.
TANYA MCCANTs.eec
SIGNED OFF ON 04/02107 @ 13:49 BY TANYA FELICIA MCCANTS. HUMAN SERVICES COORD

a. ENCOUNTER I
6Z6 DOCTOR'S CLINIC
03/30/07
P} DIPHENHYDRAMINE ELIXER
lZ.5MG/5CC

c.
P130-009

6875-DD-01

CONFIDENTIAL

15:20

LIEBER

COMP

!"",
\..JCP881D
OMINMDCA

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCDe HEALTH SERVICES; MEDICAL SUMMARY

SCDC# /181186
p>

SIG:~OMG.

SICI

BARTm) .EDll1ARD

NOOl~

05/13/08

C029511

PAGE

MiD KS (EPS)

P} START DIt.TEI 03/30/07 TOTAL DAYS: 90
P) MD:CUSAK.JDHN J.R. CUSACK. D.O.
SIGNED OFF O~ 03/30/07 @ 15:21 BY JOHN
CUSACK, PHYSICIAN I
NOTED
SIGNED OFF O)J 04/09/07 @ a: 58 BY JOSEPH H POWELLI NURSE ADMINISTRATOR/MGR II

** ENCOUNTER:
625 MENTAL HEALTH CLINIC 03/Z7/07 13:51 LIEBER
COMP
INC HOTEl
LATE ENTRY FOR 3/5/07;
TX TEAM UPDATE TX PLAN. 11M MENTAL HEALTH STATUS WILL REMAIN MENTALLY ILL.
PLEASE SEE HARD cOpy OF TX PLAN IN MEDICAL RECORDS. NEXT UPDATE WILL BE
6/5/07.

TEAM MEMBERS-----T. MCCANTS,CCC AND C. BYNES,CCC
TANYA MCCANTS,cec
SIGNED OFF ON 03/Z7/07 @ 13:5~ BY TANYA FELICIA MCCANTS, HUMAN SERVICES COORD

** ENCOUNTER:
624 MENTAL HEALTH CLINIC 03/26/07 15:44 LIEBER
COMP
0: 11M SEEn FOR HIS MEtfTAL HEALTH FlU. IIM SIiEN AT HIS CELL DOOR COMPLAIns
f", THAT scoe HAS THE WROl'lG PERSON' I At4 ELIJAH BARTON AND DOUIT YA'LL FORGET IT
~/
• 11M REPORTS THESE PEOPLE IN MY ROOK ARE REALLY GET TO ME I CAN'T TAKE THE
SE VOICES IN MY HEAD TELLING ME TO DO CRAZY THINGS. 11M ~EPORTS TAKEN HIS
. MEDICATION. I/M DENIED HIS THOUGHTS.
A: 11M APPEARED TO BE AIO R3J MOOD APPEARED TO BE NORMAL WITH GOOD EYE CONT
ACT. 11M SPOKE IN NORMAL TONE VOICE. 11M REPORTS COMPLIANT WITH HIS MEDICAT
ION. 11M REPORTS AIV HALLUCINATIONS.
P: WILL'FIU AS PRN.
TANYA MCCANTs.ecc
SIGNED OFF ON 03/26/07 @ 15;54 BY TANYA FELICIA MCCANTS. HUMAN SERVICES COORD

** ENCOUNTER:

P}
P>

6'23 r(EloTTAL HEALTH CLINIC OZ/13/07
Ut3.Z LIEBER
MEDICATION RENEWAL.
SEROQUEL 300 QUS
1M REQUIRES APPOINTMENT WITHIN ONE MONTH.
CHRISTOPHER MYERS, M.D.
SEROQUEL 300MG
SIG:ONE TAB PO Qas
S IG:
START DATE: OZ/13/07 TOTAL DAYS: 90
MD:MYERS,CHRISTOPHE SIGNED OFF ON 02/13/07 @ 12:33 Bi CHRISTOPHE
HYERS. PHYSICIAN II
SIGNED OFF ON OZ/1S/07 @ 8:30 BY DEBRA
AUSTIN, REGISTERED NURSE I

** ENCOUNTER:

COMP

622 MENTAL HEALTH CLINIC 01/31/07 11:32 LIEBER
COMP
LATE ENTRY FOR l/Z5/07,
D= 11M SEEN FOR HIS MENTAL HEALTH F/U. l/M SEEN ALONG WITH DR. COBB. I/M RE
PORTS HE WANTS TO GO THE YARD, lCS OR GPH HE IS TIRED OF BRING ON LOCK AND
. HAVING THE FEELINGS OF SOMETHING CRAWLING ALL OVER HIM AND FEEL LIKE FIRE I
6875·DD-Oll

CONFIDENTIAL

P130-010

MDCP881D
OMINMDCA
(

iCDCD 181186

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCDe HEALTH SERVICES: MEDICAL SUMMARY

05/13/08

C029511
PAGE

BARTON.EDWARD E.

NSIDE OF HIM. I NEED TO GO TO GPH TO SEE A COUNSLEOR EVRRDAl AND BE IN GROU
P. 11M DENIED AIV HALLUCIANTIONS AS WELL AS HIS THOUGHTS. 11M REPORTS TAKEN
HI S MEDI CATION.
A: 11M AFPFEARED TO BE AID X3~ MOOD APPEARED TO BE ANGRY, lIM GOT SO UPSET
BECAUSE HE WANT TO BE SENT .OUT TO CPR. HE WAS BEING AGGRESSIVE THE SESSION
KAD TO BE TERMINATED.
P: WILL FlU AS FRN.
TANYA MCCANTS,CCC
SIGNED OFF ON 01/11/07 @ 11:44 BY TANYA FELICIA MCCANTS, HUMAN SERVICES COORD
CaMP
** ENCOUNTER:
621 DENTAL CLINIC
Ol/lZ/O? lZ:Z6 LIEBER
A) DENTAL CARIES
liM SEEN FOR #32 AMALGAM FILLING. 1PA TAKE!~
SIGNED OFF ON 01/1Z/07 @ lZIZS BY CANDACE A WIGFALL. MEDICAL ASSISTANT TECH I
COMP
~ ~ ENCOUNTER:
620 DOCTOR'S CLINIC
01/05/07
14: 56 LIEBER
P} DIPHENHYDRAMINE
JONG
P> SIG:ITAB AT NOON AND 2TABS HI (EPS)
P) SIG:
F) START DATE: 01/05/07 TOTAL DAYS: 90
P) MD:CUSAK,JOHN J.R. CUSACK, D.O.
SIGNED OFF OM 01/05/07 @ 11:57 BY JOHN
CUSACK. PHYSICIAN I
ORDER WRITTEN ON MAR.
SIGNED OFF ON 01/06/Q7 @ 18:55 BY HALCtEON A NOWACK-PANIAGUA. REGISTERED NURS

r ", '

~* ENCOUNTER:

619 ~ENTAL HEALTH CLINIC 1Z/1Z/06 10100 LIEBER
COMP
LATE ENTRY FOR 12/4106.
11M SEEN FOR HIS 90 DAY SEC DET EVAL. I/H SEEN AT HIS CELL DOOR ALOHG WITH
DR. CUSACK AND OC. SHITH. 11M STATED I AM TAKEN MY MEDICATION. 11M STATED I
AM STILL REARING VOICES AND SEEING THINGS. 11M STATED I CAN SMELL THINGS C
OMING OUT OF ME. 11M DENIED HIS THOUGHTS.
A: 11M APPEARED TO BE AIO 13; MOOD APPEARED TO 9E PLEASANT WITH GOOD EYE. I
1M REPORis COMPLIANT WITH MEDICATION. 11M REPORTS AIV HALLUCINATIONS. 11M 0
ENIED HIS THOUGHTS.
P: 90 DAY SECURITY DET EVAL COMPLETED. WILL FlU WITH NEXT 90 DAY.
TX TEAM UPDATE TX PLAN AND ACCEPTED IT. PLEASE SEE HARD COpy IN MEDICAL REC
ODRS. NEXT TX PLAN UPDATE WILL BE 3/4/07. '
TANYA MCCANTs.cce
SIGNED OFF ON 12/12106 @ 10:13 BY TAN~A FELICIA MCCANTS, HUMAN SERVICES COORD

** ENCOUNTER:
618 DOCTOR'S CLINIC
lZ/04/06
15:31 LIEBER
P> SEROQUEL ZOOMG
Pi SIGel AND l/ZTABS HS
P) SIG:
P) START DATEt 12/0./06 TOTAL DAYS: 90
Fi MD:CUSAK.JOHN DISCONTINUE: SEROQUEL 200MG. HS.
J.R. CUSACK, D.O.
~IGNED OFF ON 12104/06 @ 15:32 BY JOHN
CUSACK. PHYSICIAN I

(
\.

"
,

P130-011

687S·DD·0I2

CONFIDENTIAL

COMP

MDCP881D
OMINMDCA

,.'"

( / CDCt 181186

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCDe HEALTH SERVlCES: MEDICAL SUMMARY

05/13/08

COZ9511
PAGE

BARTON,EDWARD E.

NEW ORDER PLACED ON HARS
MEDS D/C'D PER MD ORDER
SIGNED OFr ON 12105/06 @ 10:55 BY RUTH A SkLTZER. LICENSED PRACTICAL NURSE
** ENCOUNTER:
617 MENTAL HEALTH CLINIC lZ/O+/06 15:27 LIEBER
COMP
D. THIS IS A 37 YEAR OLD. MARRIED. BLACK MALE. HE IS IN LOCKUP.
HE MAINTAINED. ~I'M HEARING VOICES AND HEARXNG S.... I CAN'T SEE IT, I
SMELL IT. n
MENTAL STATUS EVALUATI.ON RBVEALED A TALL, BUCK f4ALE. HE WAS
INTERVIEWED AT HIS CELL DOOR. HE WAS IN NO PHYSICAL DISTRESS. NO S/H.
NO DEMONSTRATIVE NEUROVEGATIVE SIGNS OF DEPRESSION. NO OBJECTIVE
EVIDENCE OF PSYCHOSIS. HE ENDORSED HALLUCINATIONS, SPEECH WAS CLEAR AND
LINEAR. HIS BEHAVIOR WAS ORGANIZED.
A. AS PREVIOUSLY LISTED.
P. SUGGESTED RECHECK IN 1-2MONTH5.
J.R. CUSACK. D.O.
SIGNED OFF ON 12104/06 @ 15:30 BY JOHN
CUSACK. PHYSICIAN I
~*

r~
" ./

ENCOUNTER:
616 MENTAL HEALTH CLINIC 11/30/06 15149 LIEBER
COMP
LATE ENTRY FOR 11/23/.06;
0: I/M SEEN FOR HIS MENTAL HEALTH F/U. 11M SEEN AT HIS CELL DOOR. 11M STATE
D HE ISDOING INE. I/M STATED I AM TRYING TO REMAIN DISCIPLINARY FREE SO THA
T I CAN GO TO THE YARD. 11M DENIED A/V HALLUCINATIONS AS WELL AS HIS THOUGH
IS. 11M WRtTES A REQUEST 10 STAFF WITH CONCERNS OF THE Ies PROGRAM AND IT C
HITERIA IS OR I/M WITH KIV AND SEXUAL PREDATORS. 11M STATED HE IS NOT A SEX
UAL PREDATOR AND HE DIDN'T RAPE NOBODY, HE SHOULDN'T HAVE BEEN PLACED THERE
OR THOS E R:Ii!ASONS.
A: 11M APPEARED TO BE AID X3, MOOD AND AFFECT APPEARED TO BE GOOD~ SPEECH
CLEAR. I/M REPORTS TAKEN HIS MEDICATION WITH NO PROBLEMS.
P: WILL FlU IN 30 DAYS OR PRN.
TANYA MCCANTS,eec
SIGnED OFF ON 11130/06 @ 15~ 5'9 BY V.NYA FELICIA MCCANTS, HUMAN SERVICES· COORD

*~ ENCOUNTER:
615 SICK CALL
11/15/06
0:57 LIEBER
COMP
S;. I/M REQUEST HIG VEG. FIBER FOR CONST IPATION HAS. USED MOM WITHOUT GOOD RESULT
S) S TAKES PSYCHOTROPIC MEDS ALREADY INCREASED FLD INTAKE AND EXERCISES
0) TEMP=091.9
PULSE: 60 - HESp:20
BP" 1121 48
WEIGHT=174:' PPD= 0
0> DOING ALL RECOMMENDED PROCEDURES ABO WITH·TENDERNESS AND HYPOACTIVE BOWEL S
O} OUNDS
A) CONSTIPATION
P > 1. 5KE S. 0 • *:.t 5 •
P) Z. GIVE MILK OF MAGNESIA 30 CC
P)
PO AS A ONE TIME DOSE.
P) 3. INCREASE FLUID INTAKE TO 6-8 GLASSES OF WATER PER DAY.
P> 4. ENCOURAGE A REGULAR HABIT.
P) 5. ENCOURAGE MORE EXERCISE.
SIGNED OFF ON 11/15/06 @ 1:05 BY CARLITA F JENKINS, REGISTERED NURSE I
SEE MDIF SX'5 PERSIST.
SIGNED OFF OlI 11117/66 @ 16tOl BY ROBERT E BABB. UNCLASSIFIED
SIGNED OFr ON l1/Z0/06 @ 10:51 BY RUTH A SELTZER. LICENSED PRACTICAL NURSE

6815·DD·013
CONFIDENTIAL

P130-012

MDcpa81D
OMINMDCA
("SCOCH 181186
&*

P)
P)

p>
p>
p>
P)

05/13/08

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
seDe HEALTH SERVICES: MEDICAL SUMMARY

COl9511

PAGE

BARTON, Em-lARD E.

ENCOUNTER:
614 NARRATIVE
ll/0~/06
zz:oo LIEBER
COMP
CLIENT REFUSED TO TAKE HIS SEROQUEL lOOMG PO @ THE ABOVE DATE & TINE. HE
REFUSED TO SIGN A REFUSAL FORM.
SIGNED orF OM 11/05/06 @
:11 BY DWIGHT D HOWARD, REGISTERED NURSE I
REVIEWED. J.R. CUSACK, D.O.
SIGNED OFF OM 11/06/06 @ 13:35 BY JOHN
CUSACK. PHYSICIAN I
E.NCOUNTER:
613 MENTAL HEALTH CLINIC 10/18/06
MEDICATION RENEWAL.
SEROQUEL, ZOO MG PO QHS
DIPHENHYDRAMINE, 50 QNOON, 100 QKS
CHRISTOPHER MYERS, M.D.
SEROQUEL ZOOHG
SIG:ONE TAB PO QHS
SIG:
START DATEf 10/18/06 TOTAL DAYS: 90
MD:MYERS,CHRISTOPHE
DIPHENHYDRAMINE
SOMG
SIG:ONE TAB PO QNOON, TWO TABS PO QAS (EPS)

9:55

LIEBER

COMP

srG:

P} START DATE: 10/18/0& TOTAL DAYS: 90
p> MD:MYERS.CHRISTQPHE
SIGNED OFF ON 10/18/06 @ 9:57 BY CHRISTOPHE
MYERS, PHYSICIAN II
SIGNED
OFF
ON
10/18/06 @ 10:15 BY PATRICK C LABBE. REGISTERED NURSE I
('"'
\,

** ENCOUNTER:

612 ~ENTAL HEALTH CLINIC 09/28/06 14:12 LIEBER
CaMP
0: 11M SEEN OR HIS MENTAL HEALTH FlU. 11M STATED HE HAS BEEN DISCIPLINARY F
REE AND WANTS TO KNOW WHAT ARE WE GOING TO DO WITH HIM. 11M DENIED HIS THOU
CHTS. 11M REPORTS AIV HALLUCINATIONS. 11M REPORTS TAKEN HIS MEDICATION AS P
RE'SCRIBED WITH NO SIDE EFFECTS.
A: OX: PSYCHOSIS NOS
GAF-li5;
liM APPEARED TO BE AID X3; MOOD APPEARED TO BE PLEASANT WITH GOOD EYE CONTA
CT. 11M DENIED HIS THOUGHTS. 11M REPORTS AIV HALLUCINATIONS. 11M APPEARED
TO BE MEDICATION COMPLIANT.
P: WILL FlU IN 30 DAYS OR PRN.
TANYA MCCANTS,ecc
SIGNED OFF ON 09/28/06 @ 14:16 BY TANYA FELICIA MCCANTS, HUMAN SERVICES COORD

** ENCOUNTER;

P>
P)

P>
P>

611 DOCTOR'S CLINIC
09/Z7/06
13:53
37 YO SHU INMATE MAOXUT 201+
BACK PAIN X Z YEARS
GAIT FINE
PLAN COURSE OF NAPROXEN
NAPROXEN
Z50MG
SIG:l TAB ZX/DAY WITH FOOD X 10 DAYS FOR BACK PAIN
SIG:
START DATE: 09/27/06 TOTAL DAYSt 10
MD:BYRNE.THOMAS 6875-DD·014
CONFIDENTIAL

P130~013

LIEBER

COMP

MDCP881D

OMHTMDCA

("scneff

181186

05/13/08

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCDe HEALTH SERVICES: MEDICAL SUMMARY

COZ9511

PAGE

BARTOl}, ED'IlARD E.

THOMAS E BYRNE MD
SIGNED OFF ON 09/Z7/06 @ 13:5+ BY THOMAS E BYRNE. PHYSICIAN II
SIGNED OFF ON 09/27/06 @ 14:+9 BY PATRICK C LABBE. REGISTERED NURSE I

*- ENCOUNTER:
610 SICK CALL
09/25/06
1:~2
S) INMATE PRESENTS WITH COMPLAINTS OF A RASH ON SIDE

LIEBER

COMP

0> TEMP=097.5
PU~SE= 82
RESP=18
BP=1181 88
WEIGHT=1+7
PPD: 0
0) INMATE PRESENTS WITH RAISED RED AREAS ON SIDE OF ABDOMEN.
INMATE STATES IT

0> ITCHES. NO DRAINAGE NOTED.
A) FUNGAL RASH (TINEA)
P) 1. SEE S.O. IZO.
P> 2. WASH AREA WITH SOAP AND WATER, RINSE WELL, AND DRY THOROUGHLY,
P)
FOLLOWED BY A THIN TOPICAL APPLICATION OF LOTRIMIN
P}
CREAM BID X 4 WEEKS.
CREAM GIVEN WITH INSTRUCTIONS. INMATE VOICED UNDERSTANDING OF INSTRUCTIONS
SIGNED OFF ON 09/25/06 @ 1:47 BY CAROLYN
MOORER. LICENSED PRACTICAL NURSE
NOTED. D.HOWARD.RN.
SIGNED OFF ON 091Z5/06 @ 7:20 BY DEMPSEY C HOWARD, UNCLASSIFIED
~* ENCOUNTERl
609 SICK CALL
09/19/06
2314% LIEBER
COMP
S) HI NEED TO SEE A DOCTOR BOUT MY BACK ••• SEE I BEEN HAVING THIS BACK PAIN ON
S) AND orr FOR 1-3 YEARS. THE PAIN IS MOSTLY BY MY HIP ARKA".
0) TEMP~097.7
PULSE- 56
RESP=ZO
BP=11~1 58
WEIGHT=155
PPD= 9
0) 37 YO MALE CLIENT WHO CONFIRMS HIP PAIN ESPECIALLY ON THE RIGHT HIP AREA.
, 0) HE DENIES ANY RECENT OR REMOTE TRAUNA AND HE HAS TAKEN MOTRIN IN THE PAST.
'0) BUT NO RELIEF. HE DENIES ANY RADIATION or THE PAIN DOWN HIS LEGS: HOWEVER,
·0) DURING EXAM· HE WAS ONLY ABLE TO RAISE EACH LEG APPROX. ·ZQ-DEGREES WHILE suO) PINE. INDENDENTLY. EACH LEG WAS ONLY ABLE TO OBTAIN 20-30 DEGREES.
A) A~TERATION IN COMFORT
P> REFER PT. TO THE HD FOR EVALUATION OF HIS BACK PAIN.
SIGNED OFF ON 09/20/06 @ 2;21 BY DWIGHT 0 HOWARD~ REGISTERED NURSE I
REFER TO HD CLINIC
SIGNED OFr ON 09/20/06 @ 15:12 BY ROBERT E BABB. UNCLASSIFIED
SIGNED OFF ON O~/ZO/06 @ 15:Z4 BY PATRICK C LABBE, .REGISTERED ·NURSE I
ft.:!\:

**
P>
P>
P}
P}
P>
P>
P>
p>
P}

ENCOUNTER:
608 SECURITY INIT
09/06/06
1:00 LIEBER·
CaMP
CLIENT WASNOT BROUGHT TO NURSE SICK CALL @ THIS TIME DUE TO SECURITY ISSUES
PT. WILL BE RESCHEDULE.D @ THE NEXT NURSE SICK CALL.
SIGNED OFF ON 09/06/06 @ 6:55 BY DWIGHT D HOWARD. REGISTERED NURSE I
E~COUNTERI

607 DOCTOR'S CLINIC
08129/06 14149
SEROQUEL IOOMG
SIG:I/ZTAB PO HS X3DAYS THEN INCREASE TO ITAS HS
SIG:
START DATE: 08/Z9/06 TOTAL DAYS: 90
MD:CUSAK.JOHN DIPHENHYDRAMINE
SOMG
SIG:1TAB PO AT NOON AND ZTABS HS (EPS)
SIG:
START DATE: '08/29/06 TOTAL DAYS: 90

681S-DD-OIS
CONFIDENTIAL

P130-014

LIEBER

CDHP

MDCP881D
OMINMDCA
('"

"CDC# 181186

05/13/08

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCOC HEALTH SERVICES: MEDICAL SUMMARY

C029511
PAGE

BARTON .ED~lARD E.

P} MD:CUSAK,JOHN DISCONTINUE: RISPERDAL.
J.P.. CUSACK. D.O.
SIGNED orr ON 08/29/06 @ 14151 BY JOHN
CUSACK. PHYSICIAN I
SIGNED OFF ON 08/39/06 @ 16:28 BY PATRICK C LABBE. REGISTERED NURSE I
u

COMP
ENCOUNTER,
606 MENTAL HEALTH CLINIC D8/.Z9/0S 140:42 LIEBER
D. THIS IS A 37 YEAR OLD t MARRIED, BLACK MALE. HE IS IN LOCKUP. HE
REQUESTEO RISPERDAL TO BE DISCONTINUED, AND SUBSTITUTED WITH ANOTHER
NEUROLEPTIC.
MENTAL STATUS EVALUATION REVEALED A PLESANT. BLACK MALE. HE WAS
INTERVIEWED AT HIS CELL DOOR IN LOCKUP. HE WAS IN NO PH~SICAL DISTRESS.
HE WAS LEAN. NO S/H. HO DELUSIONS OR HALLUCINATIONS. NO CLINICAL
PARANOIA. HE IS ACCOUNTABLE FOR HIS ACTIONS. SPEECH WAS CLEAR AND LINEAR .
. A. ALCOHOL DEPENDENCE
ANTISOCIAL PERSONALITY DISORDER WITH BORDERLINE FEATURES
INTERMITTENT EXPLOSIVE DISORDER
EXHIBITIONISM
P. SUGGESTED RECHECK IN 3-4MONTH5
J.R. CUSACK. D.O.
SIGNED orF ON 08/29/06 @ 14~48 BY JOHN
CUSACK. PHYSICIAN I

08/09/06
3~15
LIEBER
COMP
** ENCOUNTER: . 605 mSIDE, APPOINTMENT
CLIENT REFU.ED TO COME TO NURSE SICK CALL @ THE ABOVE DATE AND TIME. HE RErUSED TO SIGN A REFUSAL FORM.
('-'"
SIGNED OFF ON 08/09/06 ~ 7153 By'DWIGHT D HOWARD. REGISTERED NURSE I
\

604 DOCTOR'S CLINIC
ENCOUNTER:
07/21106
13:15 LIEBER
3HG
RISPERDAL
SIG: lTAii PO BID X90DAYS,
SIG:
P) START DATE: 07/21/06 TOTAL DAYS;
90
P) MD:CUSAK.JOHN J.R. CUSACK. D.O.
SIGNED OFF ON 07/21/06 @ 13:16 BY JOHN
CUSACK. PHYSICIAN r
SIGNED OFF ON 07/21/Q6 @ 15:38 BY PATRICK C LABBE. REGISTERED NURSE I

**
p>
p>
p>

COMP

** ENCOUNTER I

603 INSIDE APPOINTMENT
07/10/06 22;12 LIEBER
tOMP
INMATE NEEDS RENEWAL ON RISPERDAL. THANK YOU
SIGNED orF ON 07/20/06 @ ZI:12 BY ANGELA
BROWN, LICENSED PRACTICAL NURSE
COMPLETED. J.R. CUSACK. D.O.
SIGNED orF ON 07/21/06 @ 1+;39 BY JOHN
CUSACK. PHYSICIAN I

** ENCOUNTER:

€OZ MENTAL HEALTH CLINIC 07/20/06 11:za LIEBER
COMP
INC .t-fOTEI
TX TEAM DISCUSSED INMATE BARTON MENTAL HEALTH TX IN ITS ENTIRETY AND TX TEA
M HAS AGREED THAT liN BARTON IS NOT STABLE ENOUGH TO BE IN GENERAL POPULATI
ON AND THAT HE REMAINS ON LOCK UP. 11M CAN'T RETURN TO THE ICS PROGRAM DUE
TO A THREAT OF A STAFF MEMBER. THERE HAS BEEN A SEPERATION FROM Kef ON 5/05
6875·DD.016

CONFIDENTIAL

P130-015

MOCPS81D
OMINl4DCA
("CDCIt 181186

SOUTH CAROLINA DEPARTMENT. OF CORRECTIONS
scoe HEALTH BERVICESJ MEDICAL SUMMARY

05/13/08
COZ9511

PAGE

BARTOH • EDl,lARD E.

TEAM MEMBERS------------------T. MCCANTS.CCC C. BYNES,CCC S. COMPTON~CCC
DR. CUSACK.PSYCH AND D. HARRISON. HCA
TANYA MCCANTS,cec
SIGNED OFF ON 07/20/06 @ 1Z:17 BY TANYA FELICIA MCCANTS, KUMAN SERVICES COORD
~*

ENCOUNTERt
601 MENTAL HEALTH CLINIC Q7/1g/06 15:45 LIEBER
CaMP
D: 11M SEEN FOR HIS MENTALHEALTK FlU. 11M SEEN AT HIS CELL DOOR ALONG WITH
OFC. LLOYD. liM HAS COMPLAINED THAT HIS TIME IS UP FOR LOCK AND HE WANTS T
o RETURN TO THE ICS PROGRAM. 11M WAS ADVISED THAT HE WAS BANNED FROM THE I
CS PRdcRAM. 11M STATED IF HE DOESN'T GET UP FROM LOCK HE IS GOING TO START
SMEARING FECES AND THEN YALL WILL HAVE TO GET ME FROM BACK HERE. 11M DENIED
AIV HALLUCINATIONS AS WELL AS HIS THOUGHTS. 11M COMPLAINS OF THINGS CRAWLI
NG OVER HIS BODY. 11M REPORTS HE HAS GOTTEN A CHARGE FROM MEDICAL aUT I WIL
L BEAT BECAUSE I AM MENTALLY ILL.
A: P'lSCHOSIS NOS
11M APPEARED TO BE AIO X3; MOOD APPEARED TO BE ANGRY. 11M DENIED AIV HALLUC
INATIONS AS WELL HIS THOUGHTS. lIM APPEARED TO BE MEDICATION COMPLIANT.
P: WILL MAKE REFERRAL TO SEE THE PYSeRIATRIST. WILL FlU IN 30 DAYS OR PRN.
TANYA MCCANTS,GCC
SIGNED OFF ON 07/19/06 @ 16;06 BY TANYA FELICIA MCCANTS, HUMAN SERVICES COORD

~ft

ENCOUNTER:
600· MENTAL HEALTH CLINIC 06/2Z/06
11:01 LIEBER
eOMP
0: I/M·SEEN FOR HIS gO DAY SECURITY DETENTION EVAL. liN STATED HE HAS BEEN
COMPLIANT WITH HIS MEDICATION. 11M REPORTS HE'S BEEN DISCIPLINARY FREE FOR
1 MTHS AND HIS DISCIPLINARY DETENTION TIME IS UP. CCC EXPLAINED TO 11M THAT
SHE WILL SPEAK WITH MS. BOYD (CLASSIFICATION) ABOUT 11M LOCK UP TINE. MR. B
OYD STATED 11M HAS COMPLTED HIS DISCIPLINARY DETENTION TIME AND WILL BE BOA
RD TO MIE CUSTODY. eec SPOKE WITH A/W. THOMPSOli ABOUT 11M BA·RTON BEING RELEA
SE TO MEDIUM CUSTODY, A/W THOMPSON STATED I/M WILL BE WEARING A PINK JUMPSU
I.T WilEN HE GO ON THE YARD. 11M DENIED AIV HALLUCIANTIONS AS WELL AS HIS THO
UGHTS. 11M REPORTS HE IS READY TO GO TO THE YARD.
A: DX: PYSCHOSIS NOS, ASPD
11M APPEARED TO BE AIO X3: MOOD APPEARED TO BE PLEASANT WITH GOOD EYE CONTA
CT. 11M DENIED AIV HALLUCINATIONS AS WELL AS HIS THOUGHTS. WE DISCUSSED .COP
ING SKILLS HE CAN USE TO HELP HIM MANAE HIS DAILY STRESSORS.
PI 90 DAY SECURITY DETENTION EVAL COMPLETED. WILL FlU WITH 90 DAY SEC DET E
VAL 9/22/06 IF STILL IN .SMU.
TANYA MCCANTS,eec
SIGNED OFF ON 05122/06 @ 11135 BY TANYA FELICIA MCCANTS. KUMAN SERVICES COORD

** ENCOUNTER:
599 DENTAL CLINIC
06/22/06
10:14 LIEBER
A> OTHER DENTAL DISORDER*
DIFL COMP #10
SIGNED OFF ON 05122/06 @ 10:16 BY JOHN S TIMMERMAN. DENTIST

COMP

** ENCOUNTER:
5~8 DOCTOR'S CLINIC
06/19/06· 8:55 LIEBER
S) REORDER MEDS PER VIO DR. CUSAK
S> DIPHENHYDRAMINE SOMG
0> TEMP=OOO.O
PULSE= 0
RESP: 0
BP= 01 0
WEIGHT: 0
PPD= 0
P> DIPHENHYDRAMINE
SOMG

COMP

6875-DD-017

CONFIDENTIAL

P130-016

MDCPBBID
OMIN[~DCA

C-' CDC#
P>
P)
P>
P)

1B1186

05/13/08

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
seDC HEALTH SERVICES: MEDICAL SUMMARY

COZ9511
PAGE

BARTON EmlARD E.
I

SIG;TAKE 1 CAPSULE TWICE DAILY EACH HORNING AND AT NOO
SIG:N FOR EPS
START DATE: 06/19/06 TOTAL DAYS: 180
MD:CUSAK.JOHN SIGNED OFF ON 0&/19/0& @ 8:57 BY DEBRA
AUSTIN, REGISTERED NURSE I
P: 1. BENADRYL 50 MG 1 PO BID FOR EPS X 90 DAYS.
SIGNED OFF ON 0&/19/06 @ 13:49 BY RICHARD C BEARDEN. JR, PHYSICIAN II
MEDS COPIED AND GIVEN TO PHARMACY. D.HOWARD.RN.
SIGNED OFF ON 06/19/06 @ 13:58 BY DEMPSEY C HOWARD., UNCLASSIFIED

** ENCOUNTER,

597 FOLLOW-UP DENTAL
06/15/06 15156 LIEBER
CaMP
RESCHEDULED PER SECURITY-PT ADVISED OF RESCHEDULING AND IN NO DISCOMFORT
SIGNED OFF ON 06/15/06 @ 15;56 BY JOHN S TIMMERMAN, DENTIST

** ENCOUNTER:

596 NARRATIVE
OS/20/06
9155
LIEBER
COMP
11M BROUTHY BY SECURITY TO MEDICAL EXAM ROOM TO REVIEW CHART. 11M STATED TM
AT HE1I1ANTED TO REVIEW CHART FROM WHICH HE STARTED HIS SENTENCI AROUND 1991.
11M WAS TOLD TO WRITE HEADQUATER MEDCIAL RECORDS PERSONNEL.
SIGNED OFF ON 05/20/06 @ 11:33 BY EVELYN
GADSON. MEDICAL ASSISTANT TECH I
SIGNED OFF ON 051Z4/06 @ 15:37 BY SALLY V BLAKE, NURSE PRACTITIONER III

** ENCOUNTER:
595 LAB CLINIC
05/18/06
6;34 LIEBER
COMP
I/M REFUSED LABWORK THIS AM. SCHEDULED DRAW AMYLASE.
SIGNED OFF ON 05/18/06 @ 6:34 BY SANDI
ZURLO. LICENSED PRACTICAL NURSE
SIGNED OFF ON 05/19/06 @ 8:47 BY RICHARD C BEARDEN, JR. PHYSICIAN II
\

~* ENCOUNTER:

594 MENTAL HEALTH CLINIC 05/09/06 10:25 LIEBER
CaMP
LATE ENTRY FROM 5/Z. 36 T/O INMATE WELL KNOWN TO THIS EXAMINER. SEEN ON LO
CK-UP. REPORTED SAME COMPLAINTS (ATYPICAL) OF "THINGS CRAWLING ON HIS SKIN
, BURNING HIS BUTTOCKS. REPORTED HE ONLY HAD 14 DAYS LEFT ON LOCK-UP NAD I
NMFORMED ME THAT "YOU NEED TO GET STARTED ON THE Ies PAPERWORK). HAS HISTO
RY OF ATYPICAL PSYCHOSIS VS MALINGERUfG AND ASPD. NO SI/HI. ' COGNITION INT
ACT. ,CURRENTLY MAIITAINTED ON RISPERDAL AND BEIAORYL FOR IMPULSE CONTROL.
A. AS ABOVE
'
P. CONTutUE CURRENT MED REGIMEN. WHEN INMATE DIC' 0 FROM HAX, TREATMENT TEA
M TO DISCUSS ICS. FlU IN l-Z MONTHS.
TGCOBBHD
SIGNED OFF ON 05/09/06 • 10:29 BY THOMAS
COBB, PHYSICIAN II

ENCOUNTER:
5~3 MENTAL HEALTH CLINIC OS/OB/06 ,11:13LIiBER
COMP
INC NOTE;
TX PLAN UPDATE MENTAL HEALTH STATUS WILL REMAIN MENTALY ILL WITH A DX; MALI
NGERING PYSCHOSIS AND ASPD. PLEASE SEE HARD COpy OF TX PLAN IN MEDICAL ~ECO
RDS. NEXT TX PLAN UPDATE WILL BE 8/8/06.
TEAM MEMBERS~---~--T. KCCANTS,CCC
S. COMPTON.GCC
C. BYNES.GeG
M. RANDSOM.HSCII
TANYA MCCANTS,eec
687s.nn'OlB
CONFlDENT.ctu.

P130-017

MDCPS81D
OMINMDCA
\, .,DCtt 1 B11 Bfi

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS.
scne HEALTH SERVICES, MEDICAL SUMMARY

05/13/08
COZ9511

PAGE

BARTON,KDIIlARD E.

SIGNED OFF ON 05/0S/06 @ 11:16 BY TANYA FELICIA MCCANTS. HUMAN SERVICES COORD

** ENCOUNTER:

592 MENTAL HEALTH CLINIC 05/08/06 10:43 LIEBER
COMP
LATE ENTRY FOR 5/3/06, '
D: l/M SEEN FOR HIS MENTAL HEATH F/U. I/M HAS WRITTEN A REQUEST TO STAFF 8T
ATING THAT WE (SCDC) HAVE BEEN PASSING OTHER PEOPLE orF BY BHING HIM. EVERY
ONE ELSE HAS LIED ~BOUT BEING HIM EDWARD BARTON OR ELIJAH BARTON. I /M BART
ON STATED HE IS GIVEN SCDC 7Z HRS TO PAY HIM BACK WHAT IS OWED TO HIM. 11M
SEENED AT HIS CELL POOR HE STATED HE IS EXPECTED TO GO TO THE ICS PROGRAM B
ECAUS!' HE FINISHED WITH HIS LOCK UP TIME AND I (CCC) IS HOLDING HIM BACK HE
RE ON LOCK UP AGAINST HIS OWN WILL. 11M COMPLAINS OF SEEING PEOPLE AND HEAR
ING VOICES IN HIS ROOM.
A: DX: MALINGERING PYSCHOSIS ASPD
I/M APPEARED TO BE A/O X3~ MOOD APPEARED TO BE ANGRY AND AGGRESSIVE. GOOD E
YE CONTACT. 11M REPORTS A/V HALLUCINATIONS, 11M DENIED H/S THOUGHTS. 11M HA
S 240 DAYS OF DISCIPLINARY DETENTION SINCE 9/27/05. 11M APPEARES TO BE cp
MPLIANT WITH MEDICATION.
P: WILL F/U IN 30 DAYS OR PRN.
TANYA MCCANTS,cce
SIGNED orF ON 05/0B/06 @ 11:13 BY TANYA FELICIA MCCANTS. HUMAN SERVICES COORD

** ENCOUNTER:

05/05/06
11:Z6 LIE~ER
COMP
591 NARRATIVE
LIM REFUSED AM DOSES OF RISPERDAL AND BENADRYL TODAY.
SIGN'ED OFF ON 05/05/06 f!! 11:27 BY SANDI
ZURLO, LICENSED PRACTICAL NURSE
J.R. CUSACK. D.O.
SICN~D OFF ON 05/05/0~ @ 14:53 BY JOHN
CUSACK. PHYSICIAN I

** ENCOUNTER,
S}

0)
0>

590 DOCTOR'S CLINIC
05/03/06 1+:38 LIEBER
COMP
31,YO SfW INAMTE KAKOUT lOU
BOTH SIDES BAK PAIN X Z YEARS
ALSO RASH IN SHIN ITCHES
TEMP:09S.9
PULSE: 68
RESP=ZO
BP=lZ11 83
WEIGHT=170
PPD:: 0
RECENT AMYLASE 131 H PYLORI 4.5
PLEASANT KALE IN NAD
RASH HPYLORIMPOSITIVH AND ELEVATED AMYALSE
I WILL ORDER ABX
HC ORDERED FOR RASH
NEEDS REPEAT AMYLASE LEVEL THIS MONTH
THOMAS E BYRNl MD
SIGNED OFF ON OS/03/06 @ ItltS BY THOMAS E BYRNE, PHYSICIAN II
NEW MEDICATION ORDERED PLACED ON 11M'S MAR. LAB ORDER PLACED ON LAB LOG
AT THIS TIME TO BE DRAWN OIl THE 9TH OF THIS MONTH.-T . .rOY,LPN.
SIGNED OFF ON 05/03/0& @ 15:36 BY TANEKA
JOY. LICENSED PRACTICAL NURSE
ORDERED H PYLORI MEDICINE THIS AM
THOAMS E BYRNE DM
SIGNED OFF ON 05/04/06 @ 8:+2 BY THOMAS E BYRN&. PHYSICIAN II
SIGNED OFF ON 05/04/06. 8:57 BY SANDI
ZURLO. LICENSED PRACTICAL NURSE.
ENCOUNTER~

5B9

DOCTOR'S CLINIC'

04/20/06

AMYLASE-13l (25-125)
6875-D1)..019

CONFIDENTIAL

P130-018

14:14

LIEBER

COMP

MDCP881D
OMINMDCA
("";DCij 181186

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
seDe HEALTH SERVICES: MEDICAL SUMMARY

BARTO~LEmlARD E.

05/13/08
COZ9511

PAGE

REP KAT AMYLASE.
SCHEDULE TO BE SEEN BY NP/MD NEXT AVAIALBLE APPT.
SIGNED OFF ON 04/Z0/06 @ 14:15 BY SALLY V BLAKE. NURSE PRACTITIONER III
LAB SCHEDULED
SIGNED OFF ON 04/20/06 @ 36:53 BY SANDI
ZURLO. LICENSED PRACTICAL NURSE

** ENCOUNTER:

588 DOCTOR'S CLINIC
O~/1BI06
14J5B LIEBER
NSG STAFF: ON 4/14/06. I WAS CALLED ABOUT THIS PT. H!V[MG INTERMITTENT
CHEST PAIN. BESIDES THE MOTRIN, I ORDERED IHAT THIS PT. BE
SCHEDULED TO SEE YOURND/NP FOR FIUP KVAL THIS WEEK. PLEASE
SCHED. APPNT THIS WEEK FOR FIUP KVAL. THANKS.
SIGNED orF ON 04/18106 @ 15:01 BY DONALD R SAMPSON, PHYSICIAN II
SIGNED orF ON 04/18/06 @ 15;13 BY DEMPSEY C HOWARD. UNCLASSIFIED

COMP

** ENCOUNTER:

r-'

(

587 NARRATIVE.
04/14/06
3:58 LIEBER
CO"F
1M REPORTS TO SICK CALL FOR CIO INTERMITTENT CREST PAIN GOING ON SINCE YEST
ERDAY AFTERNOON. IM DENIES ANY SOB DURING EPISODES. 1M STATES THAT HE FEL
T NAUSE ONLY TWICE DURING EPISODES. IN STATES HE HASHT DON~ ANYTHING PHYSI
CAL TODAY. 1M HAS HIGH CHOLOSTEROL. BUT NO CARDIAC HISTORY IN THE FAMILY.
IN SP 108/82, PULSE 54. TEMP 97.&, RR 14, 02 SATS 95%. 1M ASSESSED. BRE
ATH SOUNDS CLEAR TO AUSCULTATION. NQRMAL HEART SOUNDS HEARS. NO RUBS OR IRR
EGLUAR HEART BEATS DETECTED. PAIN IS SUBSTERNAL RADIATING TO BACK. PAIN IS
NOT REPRODUCABLE DURING ASSESSMENT. 1M DENIES ANY CHEST PAIN AT THIS TIME
• 1M TRANSFERRED TO INFIRMARY FOR EKG WHICH SHOWED A NSR, BRADYCARDIA WIT
H NORMAL PH INTERVALS AND QRS COMPLEXES.
NO 5T ELEVATION OR DEPRESSION NOT
ED. SPOKE WITH DR SAMSPSON ASOUT fINDINGS, 1M GIVEN MorRIN 600 MG WITH IN
STRUCTIONS TO TAKE TAKE TID PRN PAIN AND TO FOLLOW UP WITH SICK CALL IF P~I
l~ RETURns.
SIGNED OFr ON 04/14/06 @ 4,05 BY MICHAEL
SAWIN~ REGISTERED NURSE I
SIGNED OFr ON 04/17/06 @ 13:40 BY RICHARD C BEARDEN. JR, PHYSICIAN II

** ENCOUNTER:

586 LAB CLINIC
04/11/06
6:58 LIEBER
COMP
BLD DRAWN FOR CDC, FASTING CHEM 18, LIPASE, HPYLORI TITER. AMLASE AND URINE
OBTAINED FOR UtA AND e.s AS ORDERED PER GATHERS.RN.
SIGNED orr ON 04/11/06 @ 6:59 BY SANDI
ZURLO. LICENSED PRACTICAL NURSE

~* ENCOUNTER:
585 DOCTOR'S CLINIC
oa/29/06
14:05 LIEBER
S) INMATE SEEN FOR COMPLAINT OF KIDNEY PAIN
S) STATES HE HAS HAD THIS PAIN SINCE 1999
5) MULTIPLE UA SHOW NO CLEAR PATTERN OF INFECTION
S) PAIN CAN PREVENT USUSAL ACTIVITIES
a} TEMP=097.7
PULSE= 85
RESP=ZO
BP=1241 78
WEIGHT=17Z
PPD= 0
0) HEENT NO SCLERAL ICTERUS
0) HEART RRR
0> LUNGS CLEAR
0) ABO DIFFUSE MILD TENDERNESS
O} MILD BILAT eVA TENDERNESS
A> BACK AND ABO PAIN CHRONIC
P) -} LABS CBe, CHEM 18. AMYLASE, LIPASE, H PYLORI TITER
-} QRINE FOR UA AND e.s

687S.DD"()20

CONFmENnAr..

P130-019

COMP

MDCFBB1D
(QJ:lINMDCA
\ .... ~DC# 181186

SOUTH CAROLINA DEPARTMENT OE CORRECTIONS
SCOC HEALTH SERVICESt MEDICAL SUMMARY

05/13108

COZ9511

PAGE

BARTON ,EmIARD E.

-) PLEASE SCHEDULE FOR FlU VISIT IN 1 MONTH
WILL DEFER TREATMENT UNTIL SOME DIAGNOSIS CAN BE MADE
SIGNED OFF ON 03/29/06 @ 14,17 BY WALTER
SMITH, PHYSICIAN I
NOTED LABS IN LAB BOOK PENDING COLLECTON TIME
AFPT MAD a IN NP ~OOK X1MON
SIGNED OFF ON 04/04/06 @ 1:18 BY WYLENE
BROWN-DAVIS, REGISTERED NURSE II

.* ENCOUNTER:

584 MENTAL HEALTH CLINIC 03/29/06 12:22 LIEBER
COMP
36 YIO INMATE WITH A HISTORY OF PSYCHOSIS va MALINGERING OF PSYCHOSIS. roc
USED ON GETTING TO lCS PROGRAM. STAnD HE HAD 50 DAYS LEFT AND THEN WE HAD
TO SEND HIM TO ICS. I INFORMED HIM tHAT WE COULD APPLY FOR HIM TO GO IF T
HE TREATHENT TEAM FELT IT WAS NEEDED, BUT WE DID NOT HAVE THE FINAL SAY. H
E CONTINUES TO DESCRIBE ATYPICAL HALLUCINATIONS. IS ABLE TO RECONSTITUTE W
HEN ASKED PARTICULAR QUESTIONS OR IS CONFRONTED.
A. MALINGERING OF PSYCHOSIS MOST LIKELY
ASPD
P. CONTINUE TO MONITOR AND CONTINUE ON CURRENT MEDICATION REGIMEN FOR IMPUL
SE CONTROL. FlU IN 5 WEEKS
TGCOBBHD
SIGNED OFr ON 03/29/06 • 11:25 BY THOMAS
COBB. PHYSICIAN II

** ENCOUNTER:
583 MENTAL HEALTH CLINIC 03/17/06
15:39 LIEBER
COMP
D: 11M SEEN FOR HIS MENTAL HEALTH FlU. liM STATED. HIS LOCK UP TIME IS UP AN
HE WISHES TO GO BACK TO TliE ICS PROGRAM. ecc CONTACTED MS, BOYD (CLASSIFICA
r' TION) S~E STATED 11M BARTON HAS 60 DAYS TO COMPLETE HIS DISCIPLINARY DETENT
\ / ION PROVIDING HE DOESN'T GET ANY MORE CHARGES. 11M DENIED HIS THOUGHTS. 11M
REPORTS AIV HALLUCINATIONS. HE STATED PEOPLE ARE IN HIS ROOM TELLING TO SN
EAR SHIT AND THROW URINE. I/M STATED I TRY NOT ACTED OUT ON THIS.
A: DX, PYSCHOSIS NOS VB MALINGERING~ATSP
11M SEEN IN SMU MEDICAL ROOM ALONG WITH CPL. PERKINS AND OFC. ALSTON. 11M
APPEARED TO BE AID X3; MOOD APPEARED TO BE ANGRY. 11M WAS VERY AGGRESSIVE A
NO ARGUMENTIVE ABOUt GOING BACK TO ICS PROGRAM, DEMANDING TO GO. 11M COMPLI
ANT WITH MEDICATION. 11M SPEECH CLEAR. HYGINE IS POOR.
PI WILL FlU IN 30 DAYS OR PRN.
TANYA MCCANTS,ecc
SIGNED OFF ON 03/17/06 @ 15:54 BY TANYA FELICIA MCCANTI. HUMAN SERVICES COORD

** ENCOUNTER:
58Z DOCTOR'S CLINIC
P> RISPERDAL
3HG
P} SIG:ITAB PO BID X180DAYS.
p>

01/30/06

14:50

LIEBER

COMP

SIG~

P} START DATE: 01/30/06 TOTAL DAYS: 180
P) MD:CUSAK,JOHN J.R. CUSACK. D.O.
SIGNED OFF ON 01/30/06 @ 14:51 BY JOHN
CUSACK. PHYSICIAN I
NOTED TO PHARMACY,
SIGNED OFF ON 01/31/06 • 12:44 BY SUSAN CHEN ROSARIO, RBGISTERED NURSE I
U

ENCQUNTER:
581 DOCTOR' 5 CLINIC
01/18/06 16: 01
-) PLEASE SCHEDULE ROUTINE APPT TO REVIEW MED CLASS
687S·DD·021
CONFIDENTIAL

P130-020

LIEBER

COMP

MDCP881D
OMINMDCA
f'
\..._.'::OC# 181166

05/13/08

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
scoe HEALTH SERVICES: MEDICAL SUMMARY

C029511

PAGE

BARTOH.EDWARD E.

SIGNED OFF ON 01/18/06@ 16:01 Bf WALTER
ROUTINE APPT. SCHEDULED U. FRAZIER LPN.
SIGNED OFF ON 01/18/06 @ 16:07 Bf UKEISHA

SMITH. PHYSICIAN I
FRAZIER. LICENSED PRACTICAL NURSE

ENCOUNTER,
580 MENTAL HEALTH CLINIC 01/17/06 14:46 LIEBER
COMP
36 YEAR OLD INMATE WITH A HISTORY OF PSYCHOSIS NOS VS MALINGERING AND ASPD.
ON RISPERDAL AND BEMADRYL. HAD SHORT INTERACTION. STATED THAT IF HE HAD TOO
MUCH TIME ON LOCK-UP THAT HE WANTED TO GO TO GPR. HE WAS DIRECTED TO MS.
BARTON TO DETERMINE HOW MUCH TIME HE HAD. STATED HE IS HOLDING OUT UNTIL T
HEN. NO SIIHI REPORTED VICERAL HALLUCINATIONS (ATYPICAL).
A. AS ABOVE.
P. CONTINUE MEDS. FlU AFTER LOCK-UP TIME DETERMINED TO HELP MANAGE. BEHAVI
ORA L PROBLEMS.
TGCOBBHD
SIGNED OFF ON 01/17/06 @ 14:49 BY THOMAS
COBB, PHYSICIAN II

ENCOUNTER:
579 NARRATIVE
01/04/06
3:05
LIEBER
COMP
CLIENT REFUSED TO COME TO NURSE SICK-CALL ON 4 JANUARY Z006 @ oaOSHRS, THIS
IS A DELAYED ENTRY.
DWIGHT D. HOWARD.RN.
SIGNED OFF ON 01/07/06 @ 5:45 BY DWIGHT D HOWARD~ REGISTERED NURSE I

_. ENCOUNTER:
578 NARRATIVE
12131/05
4:40 LIEBER
COMP
CLIENT REFUSED TO COME TO NURSE SICK-CALL @ THE ABOVE DATE AND TIME AND
THIS IS A DELAYED ENTRY.
DWIGHT D. HOWARD,RN
('" SIGNED OFF OH 01/06/06 @ Z3: 54 BY DWIGHT D HOWARD, REGISTERED NURSE I

".{

ENCOUNTER:
577 INSIDE APPOINTMENT
01/06/06
5:00 LIEBER
CLIENT REFUSED TO COME TO NURSE SICK~CALL ON 6 JAN. 06 @ 0500HRS.
DWIGHT D. HOWARD;RN
SIGNED OFF ON 01/06/06 @ 8:41 BY DWIGHT 0 HOWARD~ REGISTERED NURSE I

COMP

ENCOUNTER:
576 NARRATIVE
01/05/06 &Z:30 LIEBER
COMP
RES ULTS OF URINE DIPSTICK. LUECOCTYE5-NEG. NITRATE-NEG. UROBILINGEN~O"Z mo
RMAL. PROTEIN-TRACE. PH-S.D. BLOOD-NEG, SPECIFIC GRAVITY-1.030, KETONE-NEG;
BILIRUBIN~NEG, GLUCOSE-NEG. THESE ARE THE RESULTS FOR THE ABOVE MD. ORDER.
D. COLLINS, LPN
.
SIGNED OFF ON 01/05/06 @
:S4 BY DEBBIE .COLLINS, LICENSED PRACTICAL NURSE
SIGNED OFF ON 01/05/06 @ 10:18 BY WALTER
SMITH. PHYSICIAN I
ENCOUNTER:

575 SICK CALL

1Z/31/05

3:45

LIEBER

COMP

S) "SIR I N*ED SOMETHING THIS RASH ••• ITS BEEN THERE FOR A MONTH. I SCRATCH IT

S) CAUSE IT ITCHES"."ITS ON MY BACK AND MY ARMPITS TOO~ IT .HURTS WHEN I PEE.
S) IT DOESN"T REALLY BURN. BUT IT JUST HURTS ••• MI URINE WAS LOOKING LIKE SOME
S> OLD TEA".
0) TEMP=097.7
PULSE; 70
RESP=2Z
BP:l1~/ 6Z
WEIGHT=178
PPD= 0
0> 31 YO AlA MALE CLIENT WITH A DRIED CIRCULAR ON HIS POSTERIOR BACK. THAT IS
0> SLIGHTLY RAISED. NO REDNESS, NO SWELLING. AND NO DISCHARGE OBSERVED @ THE
O} SITE. BOTH ARMPITS WERE ASSESSED WITH A BRIGHT SPOT LIGHT AND NO RASH FOUND
O} CLIENT HAS BILATERAL eVA TENDERNESS WITH GUARDING MORE PRONoueED ON THE
O} LEFT SIDE COMPARED TO THE RIGHT. HE DENIES ANY HX OF KIDNEY STONES, DENIES
6875-DD-022
CONFIDENTIAL

P130-021

MDCP8S1D
OMUTMDCA

r'
,,_.. CDC ..

181186

05/13/08
COZ9511

SOUTH CAROLINA DEPARTHENT OF CORRECTIONS
sene HEALTH SERVICES: MEDICAL SUMMARY

PAGE

BARTON. EmlARD E.

& BENADRYL ONLY. HIS URINE HAS
A) UP NOW BUT IT HURTS WHEN I PEEu. HE DENIES ANY PENILE DISCHARGE.
P) ASSESSMENT: ALTERATION iN COMFORT DUE TO PAIN DURING VOIDING.
PLAN: 1. CLIENT REFERRED TO HD FOR EVALUATION OF (A} eVA TENDERNESS
PAIN ON URINATION.
SIGNED OFF ON 12/31/05 @ 7:06 BY DWIGHT D HOWARD. REGISTERED NURSE
-> PLEASE OBTAIN A URINE FOR DIP IN MEDICAL AND PALCE RESULTS ON MY
SIGNED OFF ON 01/02/06 @ 19:59 BY WALTER
SMITH. PHYSICIAN I
OBTAINED 1-4-06 U.FRAZIER LPN
SIGNED OFF ON 01/04/06 @ 12:00 BY SANDI
ZURLO. LICENSED PRACTICAL

0) BLUNT TRAUMA AND HE TAKES RISPERADOL

57t FOLLOW-UP DENTAL
** ENCOUNTER:
A) TOOTH POSITION ANOMALY
4-00MG
P> IBUPROFEN

12/19/05

** ENCOUNTER:

12/13105

g: 51

LIEBER

"CLEARE
(8)

r
DESK
NURSE
COMP

P) SIG:TAKE 1 TABLET PO Q6H PRN PAIN X 3D (HEDS GIVEN)
P} SIGI
p> START DATE: 121IIJ/OS TOTAL DAYS:
3
P) MD:TIMMERMAN,JOHN S.
EXT ~1-HEDS/POI GIVEN
SIGNED OFF ON 12/19/05 @ 9:5Z BY JOHN S TIMNERMA~r, DENTIST

573 DOCTOR'S CLINIC

13 I 56

LIEJ:lER

C01~P

REttEW BENADRYL

DIPHENHYDRAMINE
SONG
SIG:TAKE ONE TAB IN AM AND ONE TAB AT NOON FOR EPS (50
SIG:MG QAM AND SOMG QNOON)
START DATE: 12/13/05 TOTAL DAiSe IBO
MD:SIMPSON,BRIAN SIGNED OFF ON 12/13/05 @ 13t57 BY BRIAN RUSH SIMPSON. PHYSICJAN II
SIGNED OFF ON lZ/1+/05 @ 18:Z3 BY SUSAN E HADLEY, LICENSED PRACTICAL NURSE

** ENCOUNTER:l72 SICK CALL

S>
0>

O}
0)
0)

A)
P>

c:
P130-022

lZ/09/05
14t56 LIEBER
COMP
rIM INTO MAX SICK-CALL ASKING THAT ZANTAC BE RE-ORDERED AND THAT RASH TO UN
DEH RT ARM REMAINS. STS THAT AREA WILL DRAIN AND BE WORSE AT TIME THAN OTHE
R TIMES. STS THAT HE HAS HAD ULCERS SINCE TEENAGER EO YEARS.
TEMP=O~8.0
PULSE: 72
RESP=16
BP=1101 82
WEIGHT=176
PPD= 0
NO APPAREIU ABD DI SCONFORT AT PRESE~lT. RASH TO UNDER ARM NOTED TO NOT BE RA
ISED HAVE BUMPS OR DRAINAGE. ONLY NOTED DIFFERENCE IN SURROUNDING SKIN IS T
HAT AREA IS DARKER IN COLOR.
..
ABO DISCOMFORT/RASH
INSTRUCTED I/M TO NOT LIE FLAT AFTER EATING AND TO INCREASE H20 INTAKE. VOl
CED UNDERSTANDING. ALSO TO NOT SCRATCH AREA WITH FINGERNAILS ANFD TO USE PA
LM OF HAND. VOICED UNDERSTANDING. WOULD LIKE ZANTAC REORDERED.
SIGNED OFF ON 12109/05 @ 15:01 BY MICHELLE 5 INFINGER. LICENSED PRACTICAL NUR
NOTED D.BASINGER RN
SIGNED OFF ON 12/11/05 @ 5:&3 BY DARRELL A BASU{GER. UltCLASSIFIED

El.fCOU)JTER:
571 14ENTAL HEALTH CLINIC lllZ9/05
UISO LIEBER
. COMP
36 YEAR OLD INMATE. WITH A HISTORY OF PSYCHOSIS NOS V5 MALINGERING AND ASPD.
STATED HE CONTINUES TO HEAR THE WARDEN'S VOICE COMING THROGH HIS FLOOR ANDH
687,S·DD·023

CONFIDENTIAL

MDCPBBID
OMINMDCA

I""

\. -",CDCtt 181186

SOUTH CAROLIHA DEPARTMENT OF CORRECTIONS
seDe HEALTH SERVICES~ MEDICAL SUMMARY

05/13/08

COZ9511

PAGE

BARTON, EDylARD E.

E FEELS THINGS CRAWLING ON HIM. HAS A HISTORY OF MALINGER. DISCUSSED ACIU
ALLY DECREASING HIS MEDICATION AS HE IS ON TWO ATYPICAL ANTIPSYHCOTICS. IN
MATE A~REED. NO ACUTE PSYHOSIS EVIDENT ON PRESENTATION OTHER THAN HIS REPO
RTS. NO SI/HI.
.
A. PSCHOSIS NOS VS MALINGERING
ASPD
P. DIC GEODON, CONTINUE RISPERDAL AND BENDRTL. FlU IN l-Z MONTHS OR SOONE
R AS NEEDED.
TGCOBBMD
BIGNED OFF ON 11/29/05 • 14:53 BY THOMAS
COB~, PHYSICIAN II

** ENCOUNTER:

ole GIODON

570 DOCTOR'S CLINIC

ll/Z9/05

14:40

LIEBER

COMP

COBB, PHYSICIAN II
SIGNED. OFF ON 11/29/05 • 14:41 BY THOMAS
NOTED IN MAR
SIGNED OFF mJ 11/Z9/05 @ 15:56 BY SUSAN E HADLEY. LICENSED PRACTICAL NURSE
COMP
11/1+/05
9:09 LIEBER
3MG
P) SIG:ITAB PO BID xaODAIS, ZREFILLS.
P) SIG:
P} START DATE: 11/1~/05 TOTAL DAYS: 90
P> MD: CUSAK .JOHlt J.R. CUSACK. D.O.
CUSACK, PHYSICIAN I
SIGNED OFF ON 11/14/05 @ 9~09 BY JOHN
NOTED TO PHARMACY.
SIGNED OFF ON 11/14/05 @ 11:04 BY SUSAN CHEN ROSARIO. REGISTERED NURSE I
"" ENCOUNTER:

p> RISPERDAL

569 DOCTOR'S CLINIC

.. ENCOUNTER1
568 SICK CALL
11/07/05, 16: 13
LIEBER
COMP
S) 11M INTO MAX SICK-CALL CIO RASH TO UNDERARM A~D ON KNEES. ALSO STS THAt KI
S} DNEY PAIN RAS REOCCURED. (ENC 549) STS IF HE MOVE~ TOO FAST OR URINATING MA
S> KES SHARP PAIN COMES. STARTED JUST TODAY. STS SOME DRAINAGE FROM RASH.
0) TEMP=09S.7
PULSE= 68
RESP=16
BP=lZ~1 88
WEIGHT=179
PPO= 0
0) RAISED DARK DISCOLORED ARES NOTED TO UNDER BOTH ARMS. NO DRG AT PRESENT. II
0) M NOTED TO SCRATCHING AT RASH. ALSO PAIN NOTED TO BOTH SIDES WITH PALPATION
0) OF FROIn AND BACK.
.
A) RASH AND KIDNEY PAIN
P) INSTRUCTED 11M TO KEEP AREA CLEAN AND DRY AND NOT SCRATCH WITH FINGER MAILS
3 PACK OF HYDROCORTIZONE CREAM GIVEN TO 11M. NO VOICED ALLERGIES. WILL REFE
R TO DR. SMITH CONCERNING RASH AND KIDNEY PAIN.
SIGNED OFF ON 11/07/05 @ 16:21 BY MICHELLE
INFINGER. LICENSED PRACTICAL NUR
WILL HAVE 11M REASSESSED.
SIGNED OFF ON 11/10/05 @. 6:30 BY SUSAN E HADLEY, LICENSED PRACTICAL NURSE

** ENCOUHTER;

567 MENTAL HEALTH CLINIC 11/02/05 10:50 LIEBER
COM~
D: 11M SEEN FOR HIS 90 DAY SECURITY DETENTION EVAL. 11M COMPLAINS OF ELECTR
ICITY RUNNING THROUGH HIS BODY AND BUGS CRAWLnG OVER HIM. 11M REPORTS TAKE
N HIS MEDICATIQN WITH NO SIDE EFFECTS. liN INQUIRED ABOUT THE ICS PROGRAM,
HE WAS ADVISED THAT A REFERRAL COULDN'T BE 14ADE \I1HILE ON SD STAUS« 11M STAT "
ED HE VERBALLY UNDERSTOOD.
6875-00-024

CONFIDENTIAL

P130-023

MDCP881D
OMINMDCA

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCDe HEALTH SERVICES: MEDICAL SUMMARY

05/13/08
COZ9511

("".

t, ....

.JC#

181186

BARIOH,EDII/ARD E •

PAGE

A:DX; ANTISOCAIL PERSONALITY 0/0
MALINGERING OF PYSCHOSIS VS PSYCHOSIS NOS
11M APPEARED TO BE A/O X3; MOOD APPEARED TO BE PLEASANT WITH GOOD EYE CONTA
CT. l/M DENIE A/V HALLUCINATIONS AS WELL AS HIS THOUGHTS. WE DISCUSSED HIS
CONCERNS AS WELL AS SOME COPING SKILLS TO DEAL WITH HIS DAILY STRESSORS.
P: 90 DAY SECURITY DETENTION COMPLETED. NEXT 90 DAY SECURITY DETENTION WILL
BE 212/06.
TREATMENT TEAM UPDATED TXPLAN WITH THE FOLLOWING RECOMMENDATIONS MENTAL HE
AtTN STATUS WILL REMAIN MENTALLY ILL WITH A OX OF AMTISOCAIL PERSONALITY
0/0 MALINGERING OF'PYSCHOSIS VS PSYCHOSIS NOS. PLEASE SEE HARD COpy OF TX P
LAN IN MEDICAL RECORDS. NEXT TX PLAN UPDATE WILL BE Z/Z/06.
TANYA MCCANTS,ecc
SIGNED OFF ON 11/0Z/05 '. 11:12 BY TANYA FELICIA MCCANTS. HUMAN SERVICES COORD

** ENCOUNTERs

566 MENTAL HEALTH CLINIC 11/01/05 14,+a LIEBER
COMP
ADDENDUM. INMATE ALSO ON RIPSERDAL AND BENADRYL. , CONSIDER DIC OF RISPERDA
, L. TGCOBBMD
SIGNED OFF ON 11/01/05 @ 1+:48 BY THOMAS
COBB. PHYSICIAN II

** ENCOUNTER:

565 MENTAL HEALTH CLINIC 11/01/05
14:+4 LIEBER
COMP
36 YEAR OLD AFRICAN AMERICAN MALE WITH A HISTORY OF ASPD AND MALINGERING OF
PSYCHOSIS. REPORTS FEELINGS OF "ELECTRICITY" AND "BUGS CRAWLING ON MY SKI
N", HOWEVER, STATED IT IS NOT BAD AT THIS TIME. HAPPY WITH MEOS. REQUEST!
MG ICS PRDGRAM AFTER HIS TIME IN LOCK-UP. NO ACTIVE SI/HI. REPORTS AIH TE,
LLING HIM TO HURT HIMSELF, BUT HE JUST "CUSSES THEM OUT," COGNITIDN INTACT.
A. ASPD
MALINGERING OF PSYCHOSIS VS PSYCHOSIS NOS
P. CDNTINUE CURRENT MEDICATION OF GEODON BOMG BID.
F/U IN ONE MONTH OR SOONER AS .1'EEDED.
TGCOBBMD
COBB, PHYSICIAN II
SIGNED OFF ON 11/01/05 @ 14:47 BY THOMAS

CaMP

ENCOUNTER:
56+ FOLLOW-UP DENTAL
10/Z4/05
7:11 LIEBER
RESCHEDULED-SECURITY COULD NOT BRING PT TO CLINIC
SIGNED OFF ON 10/Z4/05 @ 7:13 BY JOHN S TIMMERMAN. DENTIST

ENCOUNTERz
563 INSIDE APPOINTMENT
10/18/05 10;56 LIEBERCOMP
CHANGE NOON MEDS TO AM MEDS PER ~O DR COBB.
SIGNED OFF DN 10/18/05 @ 10158 BY SUSAN E HADLEY. LICENSED PRACTICAL NURSE
J.R. CUSACK. D.O.
SIGNED OFF ON 10/18/05 @ 15~05 BY JOHN
CUSACK, PHYSICIAN I
NOTHO HI MARS
SIGRED OFF ON 10/18/05 @ 16:11 BY SUSAN E HADLEY. LICENSED PRAtTICAL NURSE

ENCOUNTER I
562 FOLLOW-UP DENTAL
10/17/05
9:58 LIEBER
RESCHEDULED-SECURITY UNABLE TO BRING PT TO CLINIC
SIGNED OFF ON 10/17/05 @ 9:58 BY JOHN S TIMMERMAN, DENTIST

** ENCOUNTER:

561 DOCTOR'S CLINIC

09/30/05

CHANGE MED DOSE
6875·DD·025

CONFIDENTIAL

P130-024

15;35

LIEBER

COMP

MDCPS91D
OMHfMDCA

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
seDC HEALTH SERVICESI MEDICAL SUMMARY

r ....

p> GEODON
P) SIG:TAKE
P) SIG:

PAGE

BARTm1 , ED"TA~D E.

\.. -",Dett 181186
OI~E

TABLET AT NOON

05/13/08
COZ9511
Z5

aOMG
AND AT IIrIGHT

p> START DATE: 09/30/05 TOTAL DAYS: 90
p> MD:COB8.THOMAS p> DIPHEtfHYDRAMINE
SOMG
p> SIG: TAKE ONE TABLET AT HOON AIW ONE BEFORE BEDTIME

p> SIG~
p> START DATE: 09/30/05 TOTAL DAYS:

MD~COBB.THOKAS

SIGNED OFF ON 09/30/05
tWTED IN MAR
SIGNED OFF ON O~/30/05

15:38 BY THOMAS

COBB, PHYSICIAN II

16:36 BY SUSAN E HADLEY. LICElfSED PRACTICAL NURSE

** ENCOUNTER:

S60 MENTAL HEALTH CLINIC 09/30/05
15:Z7 LIEBER
caMP
YEAR OLD BLACK HALE WITH WITH A HISTORY OF ASPD. MALINGERING OF PSYCHOSI
S. HAS MADE MANY TRIPS TO GILLIAM DUE TO SMEARING FECES.
REPORTS HE IS H
ANGING ON AND DOES NOT NEED TO GO TO GPH RIGHT. REPORTED DOING WELL OTHER
THAN NOT GETTING HIS MEDICATION AT THE RIGHT TIME. REQUESTED MEDS AT NOONT
IKE. NO SI/HI. NO A/VH COGNITION.
A. AS ABOVE
P. WILL CHANGE GEODON TO aOMG BID AND BENADRYL AT NOONTIME.
FlU IN ONE MONTH OR SOONER IF NEEDED.
TGCOBBMD
SIGNED orF ON 09/30/03 @ 15:34 BY THOMAS
COBB. PHYSICIAN II
NOTED IN HAR
SIGNED OFF ON 09/3U/05 @ 16;38 BY SUSAN
HADLEY, LICENSED PRACTICAL NURSE
36

ENCOUNTER:
559 INSIDE APPOINTMENT
09/Z9/05 10:17 LIEBER
COMP
11M SEEN IN MAX SICK CALL STS HIS BACK IS NOW O.K. HE DOESN'T WANT TO
SPEND Z DOLLARS AT THIS TIME FOR JUST TYLENOL OR MOTRIN AT THIS TIME. AND
INSTRUCTED THAT HE DOESN'T HAVE A NOON MED SCHEDULED AT THIS TIME.
SIGNED OFr ON 09/29/05 @ lO:Zl BY CARLA
FELDER-GASTON. LICENSED PRACTICAL N
NOTED. M. ALLEN IN
SIGNED OFF ON 10/02105 @ 10~56 BY MARGARET W ALLEN. NURSE ADMINISTRATOR/HGR I

** ENCOUNTER:
558 MENTAL HEALTH CLINIC 09/Z9/05
8:31 LIEBER
COMP
LATE ENTRY FOR 9/26105:
0: 11M SEEN AT HIS CELL DOOR ALONG WITH SGT. WILSON. 11M BARTON STATED HE N
EED TO SEE THE DOCTOR ABOUT HIS MEDICATION BECAUSE IT'S NOT WORKING. tIM WA
S ADVISED THAT HE WILL SEE THE DR. COBB ON 9/30/05. l/M STARTED CURSING AND
SAY YOU ARE THE ONE WHO'S KEEPING ME FROM THE ICS PROGRAM.
A: DX, INTERKITTEN EXPLOSIVE
ANTISOCIAL PERSONALITY DID
EXHIBITIONISM
I/M APPEARED TO BE AID X3J MOOD APPEARED TO BE VERY ANGRY. EYE CONTACT WAS
GOOD. SPEECH CLEAR. SESSION WAS ENDED DUE TO 11M BEING VERY AGGRESSIVE.
P: WILL FlU IN 30 OR PHN.
.
T. MCCANTS.CCC
SIGNED OFF ON 09/29/05 @ 8:51 BI TANYA FELICIA MCCAlfTS, HUMAN SERVICES COORD

('.
\.../

P130~025

6875-DD-026

CONFIDENTIAL

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
seDe HEALTH SERVICES: MEDICAL SUMMARY
scnCff 181166

05/13/08
C0Z9511

PACE

BARTON,BDWARD E.

** ENCOUNTER:
557 FOLLOW-UP DENTAL
09/15/05 11:24 LIEBER
A} DENTAL EXAMINATION
POE, CHARTING AND OHr
SIGHED OFF ON 09/15/05 @ 11:Z+ BY JOHN S TIMMERMAN, DENTIST

COMP

** ENCOUNTER:
556 INSIDE APPOINTMENT
08/31/05
P} DIPHENHYDRAMINE
sOMG
p> SIG:TAKE 1 PO BID (EPS) X 30 DAYSJ Z REFILLS.

COMP

14: Zl

LIEBER

src:

P> START
P)

P}
P>
P)

P}
P>
P>
P}
P>
P>
P)

DATE~ 08/31/05 TOTAL DAYS:
90
MD:CUSAK.JOHN RISPERDAL
3MC
SIG:TAKE 1 PO BID X 30 DAYS ~ Z REFILLS.
SIG:
START DATE: 08/31/05 TOTAL DAYS: 90
MDICUSAK.JOHN GEODON
BONG
SIG:TAKE 1 PO aHS X 30 DAYS: Z REFILLS,
5 IG:
START DATE: OBI31/05 TOTAL DAYS: 90
MD:CUSAK.JOHN SIGNED OFF ON 08/31/05 @ 14:Z+ B7 SUSAN E HADLEY, LICENSED PRACTICAL NURSE
j.R. CUSACK, D.O.
SIGNED OFF ON 06/31/05 @ 15:06 BY JOHN
CUSACK, PHYSICIAN I
NOTED IN MAR
SIGNED OFF ON 08/31/05 @ 16:0+ BY SUSAN E HADLEY, LICENSED PRACTICAL NURSE

_. ENCOUNTER:
555 NARRATIVE
08/Z6/05
"8:~Z
LIEBER
COMP
A COPY OF THE 11M'S MOST RECENT KIV ANTIBODY LAB RESULTS WAS HAND CARRIED!
o THE ABOVE NAMED I/M.6126/05 BY COOPER.
SIGNED OFF ON 08/Z5/05 @ 8:+~ BY NED
COOPER, LICENSED PRACTICAL NURSE
NOTED
SIGNED OFF ON 08/27/05 @ 7:50 BY SUSAN E HADLEY, LICENSED PRACTICAL NURSE

** ENCOUNTER:

554 MENTAL HEALTH CLINIC 08/Z4/05 14115 LIEBER
COMP
SEEN BY NURSE AT WINDOW FOR SECURITY.
REFUSING TO SIGN NEUROLEPTIC CONSENT.
aD % COMPLIANT WITH MEDS GEODON , RISPERDAt AND DPH.
CIO "TREMORS IN BOTH HANDS,"
NO OTHER ADVERSE REACTIONS.
RTC 11/05
WILL DEFER TO MCCANTS FOR NO APPT.
SIGNED OFF ON 08/24/05 @ 14:18 BY SUSAN E HADLEY. LICENSED PRACTICAL NURSE
SCHEDULED TO BE SEEN BY DR. COBB OU9/30/05.
STEVE COMPTON.eec
SIGNED OFF ON 08/Z4/05 @ 17;05 BY STEPHEN F COMPTOM,·HUMAN SERVICES COORD I

** ENCOUNTER:
/",
\

'-"

HfC

553 MENTAL HEALTH CLINIC 08/23/05

~IOTE l

11:36

LIEBER

COMP.

TX TEAM UPDATED TX PLAN TO CONTINUE WITH PLAN. NEXT UPDATE WILL BE 11/05.

687S~DD..()21

CONFlDE'NTIAL

HDeFaB10
OMINMDCA
("CDC# lB1186

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCDe HEALTH SERVICES: MEDICAL SUMMARY

05/13/08

C029511
PAGE

BARTON .EDT.4ARD E.

PLEASE SEE HARD COPY OF TX IN MEDICAL RECORDS.
TEAM HEI1BERS:
T. MCCANTS,ece
S. COMPTON.CCC
M. RANSOM ,.HBC
TANYA MCCANTs.cec
SIGNED OFF ON 08/23/05 @ 11:39 BY TANYA FELICI~ MCCANTS, HUMAN SERVICES tOORD
•• ENCOUNTER:
552 SECURITY INIT
08/19/05
7106 LIEBER
COMP
flIT'S HARD TO BREATHE IN HERE"
36Y/0 BIM IN CELL WAS GASSED THIS AM. 02 SAT 97% ON ROOM AIR. NO ACUTE
DISTRESS NOTED. NO DIFFICULTY BREATHING SEEN. DENIES ANY INJURY.
NO TREATMENT REQUIRED AT THIS TIME.
SIGNED OFF ON 08119/05 @ 7r10 87 SANDI
IURLO, LICENSED PRACTICAL NURSE
NOTED D.BASINGER RN
SIGNED OFF ON 08/Z0/05 • 21:24 BY DARRELL A BASINGER. UNCLASSIFIED
&&

ENCOUNTER:
551 INSIDE APPOINTMENT
08/15/05 15133 LIEBER
COMP
11M WAS PULL TO REVIEW HIS MEDICAL RECORDS IN MAX TODAY. B. GADSON CNA.
SIGNED OFF ON 08/15/05 @ 15:37 BY EVELYN
GADSON. MEDICAL ASSISTANT TECH I
SIGNED OFF ON 08/15/05 • 15155 BY WALTER
SMITR. PHYSICIAN I

** ENCOUNTER:

550 MENTAL HEALTH CLINIC 08/1S/05
9:5~ .LIEBER
COMP
0: 11M SEEN FOR HIS MENTAL HEALTH FlU. 11M REPORT HE IS SUPPOSED TO HOUSED

AT KIRKLAND ICS PROGRAM LIEBER IS NOT EQUIPED TO DEAL WITH HIS SCHIZOPHRENI
A. rIM STATED HIS NED CLASS HAS CHANGED TO AREA MENTAL .HEALTH PERMANTLE2
NAD THAT HAS CLASSIFIED HIM TO BE AT THE les PROGRAM. 11M REPORT AIV HALLUC
INAT!ONS, DENIED HIS THOUGHTS.
A: DX, INTERMITTEN EXPLOSIVE
ANTISOCIAL PERSONALITY
GAF-&51
11M SEEN IN cec OFFICE ALONG WITH CPT. WHITTEN.
11M APPEARED TO BE A/O X3; MOOD APPEARED TO' BE PLEASANT WITH GOOD EYE CONTA
CT. 11M WAS ADVISED THAT HIS MED CLASS WAS CHANGED TO AREA MENTAL HEALTH
6/14/05 BY TIE PSYCHIATRIST AT GPH TO HOUSED AT LIEBER. TO BE HOUSED AT THE
ICS PROGRAM AT KIRKLAND HIS MED CLASS WOULD HAVE BE CHANGED TO INTERMEDIAT
E CARE SERVICES. 11M WAS ADVISED THAT HE CAU'T GO TO THE ICS PROGRAM ON DIC
IPLINARY DETENTION. 11M STATED HIS LOCK TIME IS UP HE IS JUST WAITING ON KS
• BOYD (C_LASSIFICATION) TO SEND HIM TO THE YARD. cec CONTACT I!fS.BOYD SHE S
TATED THAT 11M BARTON HAS TWO CHARGES FOR DESTROYING PROfERTY AND THROWING
A SUBSTANCE ON AN OFFICER HE WAS GIVING 390 DAYS DISCIPLINARY DETENTION TIK
CONT----.
E AND ALSO HAVE SEXUAL MISCONDUCT CHARGE AGAINST HIM. HIS CHARGES WON'T BE
DROPPED UNTIL MARCH' Z006. I/f4 GOT REALLY UPSET Al{Q HAD TO BE TAKEtl BACK TO
HIS CELL BY CPT. WHITTEN.
Pr FlU WILL BE MADE 9/13/05 OR PRN. WILL DISCUSSED WITH TX TEAM.
TANYA MCCANTS.CCC
SIGNED OFF ON 08/15/05 @ 101+0 BY TANYA FELICIA MCCANTS. HUMAN SERVICES COORD

** ENCOUNTER:

5+13 SICK CALL

07/28/05
6875-DD·028

CONFIDENTIAL

19:46

LIEBER

CaMP

MDCPS81D
OMUrNDCA

C·.~C'

181186

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCDC HEALTH SERVICES: MEDICAL SUMMARY

O!i/13/0a

COZ9511

PAGE

BARTON.EDWARD E.

I'M HAVING KIDNEY PAIN AND PAIN IN MY LOWER BACK ON THE SIDES. THIS HAS BEE
N GOING ON FOR 10 MONTHS NOW. I HAVE PAIN WHEN I URINATE IF I HAVE ANY FORC
E BEHIND MY URINE SO I HAVE TO SLOW DOWN THE SPEED. WHEN I'M URINATING THE
PAIN IS IN MY GROIN AND IN MY SIDES.
0) TEMP=098.1
PULSE= 70
RESP=ZO
BP=122/ 60
WEIGHT=179
PPD: 0
0> NO PALPABLE ENLARGEMENTS NOTED TO THE BACK OR SIDES. liM IS NOT TENDER TO
0) THE TOUCH, NO REBOUND PAIN NOTED.
P} DEFERED TO THE MD.
SIGNED OFF ON 07/2B/05 @ 19:49 BY CHRISTINE
MCFADDEN, LICENSED PRACTICAL NU
-) PLEASE OBTAI» A ROUTINE UAJ THANKS
SIGNED OFF ON 07/31/05 @ 17;03 BI WALTER
SMITH. PHYSICIAN I
NOTED LABS ORDERED.
SIGNED OFF ON 08/01/05 @ 9:04 BY SUSAN E HADLEY, LICENSED PRACTICAL NURSE
S)
S)
S>
S}

** ENCOUNTER:

548 MENTAL HEALTH CLINIC 07/2Z/05
14:09 LIEBER
CaMP
36 TWAN OLD BLACK MALE WITH A HISTORY OF ASPD. INTERMITTENT EXPLOSIVE DISOR
DER AND EXHIBITINISM. PRESENTS TODAY FOR FlU. ALSO HAS HISTORY, OF POSSISL
E MALINGERING OF PSYCHOSIS. JUST RETURNED FROM GPH. H/O SMEARING FECES ON
SELF AND URINATING ON SELF. WANTS TO GET BACK TO GP. ON LOCK-UP FOR THRE
ATENING WARDEN IN LETTER. HAS TWO MONTHS LEFT. WANTS TO BE IN ICS PROGRAM
STATES HE WAS IN Ies FROM 98-04. REPORTED NO SI/HI. STATED HE SEE'S BU
GS COMING OUT OF HIS HEAD AND FEELS THINGS CRAWLING ON SIIN.
A. ASPD
INTEMITTENT EXPLOXIVE DISORDER
('
RIO MALINGERING OF PSYCHOSIS va PSYCHOSIS NOS
\ ."
ALCOHOL DEPENDENCE
CURRENTLY ON GEODON. RISPERDAL, BENADRYL AND RANITIDINE. CONISDER DIC ONE
OF ANTIPgYCHOTICS
P. DISCUSS NEED FOR res WITH TREATMENT TEAM AND START PAPERWORK AS NEEDED.
CONSIDER ole ONE ATYPICAL ANTIPSYCHOTIC. F/U 1-2 MONTHS OR AS NEEDED.
TGCOBBHD
SIGNED OFF ON 011ZZ/05 @ 14:15 BY THOMAS
COBB. PHYSICIAN II
AGREE. DISCONTINUE AS ~ou SEE FIT.
J.R. CUSACK. D.O.
SIGNED OFF ON 011ZS/05 @ 10:00 BY JOHN
CUSACK. PHYSICIAN I
NOTED MEDS DC'D IN MAR
SIGNED OFF ON OB/Ol/05 @ 9:03 BY SUSAN E HADLEl. LICENSED PRACTICAL NURSE

** ENCOUNTER:

547 MENTAL HEALTH CLINIC 06/30/05 11:23 LIEBER
COMP
D: 11M SEEN FOR HIS MENTAL HEALTH FlU. I/M STATED HE IS DOING FINE. 11M STA
tED THE COUNSELOR AT GPR STATED THE THE PYSCHIATRIST FROM LIEBER WOULD HAVE
TO RECOMMEND HE GOES BACK TO THE ICS PROGRAM IN ORDER FOR HIM TO ACCEPTED
BACK INTO THE PROGRAM. I/M STATED THE DOCTOR PRESCRIBED HIM GEODON SO MG
At-rD ORDERED DOUBLE PORTION OF FOOD BECAUSE IT HAS CAUSBD HIl4 TO LOOSE \I/EIGH
t. 11M STATED HE HAVEN'T BEEN GETTING HIS DOUBLE HEALS. I/M STATED HE IS'DO
ING BETTER SINCE HE'S BEEN BACK BUT HE NEEDS TO GET BACK INTO THE PROGRAM A
T KIRKLAND. 11M DENIED A/V HALLUCINATIONS AS WELL AS HIS THOUGHTS.
A: OX: ANTISOCIAL PERSONALITY DID
.
INTERMITTE~ EXPLOSIVE 0/0
ALCOHOL DEP
EXHIBITIONISM
687S-DD·029

CONFIDENTIAL

P130-028

MDCP881D
OMINMDCA

r"
\. ...-.ieDe*,

lB1186

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
scoe HKALTH SERVICES, MEDICAL SUMMARY

05.113/08
COZ9511

PAGE

BARTml,EDWARD E.

11M APPEARED TO BE A/O X3; MOOD APPEARED TO BE PLEASANT WITH COOD EYE CONTA
CT. 11M SPEECH WAS CLEAR. lIM FACE AND HAIR NEED SHAVED. 11M DENIED AIV HAL
LUCINATIONS AS WELLL AS HIS THOUGHTS. 11M REQUEST TO BE SENT TO THE ICS PRO
GRAM FOR HORE STRUCTURED TRE~. THENT. WE DIS"CUSSED CO.JCERNS AND SOME COP ING S
KILLS HE COULLD USE TO HELP HIM MANAGE HISDAILY STRESSORS.
Pr CCC WILL SCHEDULE 11M TO SEE DR. CUSACK. WILL FlU IN 30 DAYS OR PRN.
TANYA MCCANTS~CCC
SIGNED OFF ON 06/30/05 @ 11138 BY TANYA FELICIA MCCANTS, HUMAN SERVICES COORD
SIGNED OFF ON 07/01/05 @ 10~51 BY SANDI
ZURLO, LICENSED PRACTICAL NURSE,
SCHEDULED TO SEE PSYCHIATRIST 7-6-05. IT APPEARS DOUBTFUL TO ME THAT BARTON
MEETS CRITERIA FOR INTERMEDIATE CARE DUE TO HIS DIAGNOSIS AND AGGRESSIVE
BEHAVIOR. THIS SHOULD BE DISCUSSED AGAIN BY TREATMENT TEAM AND THE TEAM SHO
ULD MAlE THE FINAL DECISION ABOUT THE REFERRAL.
STEVE COMPTON,ece
SICNED OFF ON 07/01/05 @ 11:33 BY STEPHEN F COMPTON. HUMAN SERVICES COORD r

.* ENCOUNTER: 546 SICK CALL
06/Z9/05 15:33 LIEBER
COMP
S) 11M CIO LUMP ON RT. HIP; STATES INTERMITTENT, THROBBING PAIN WHEN WALKING a
S) R LYING ON RT. SIDE. DENIES DRAINAGE FROM AREA, OR TRAUMA~ SAYS LUMP HAS BE
S) EN THERE "AWHILE".
"
0) TEMP=097.1
PULSE= 80
RESP=18
BP=1101 70
WEIGHT=174
PPD: 0
0) 36 Y/O B/M IN NAD. TENNIS BALL-SIZED SOFT SPONGY HASS PALPATED NEAR HIP SOC
O} lET ON RIGHT. NO REDNESS OR EXUDATE NOTED. NOR PAIN ON PALPATION. NO GAIT D
0) IFFICULTIES SEENJ FULL ROM WI INTACT 5ENSORIUH,CIRCULATION AND MOTOR PRESEN
rOO} T DISTALLY.
~ /) SOFT TISSUE MASS
P> 11M ADVISED TO LIE IN POSITION or COMFORT~ AND TO RETURN to SICK CALL IF AN
Y CHANGES ARE SEEN IN AREA. "
CLOSED ENC
SIGNED OFF ON 07/08/05 @ 7:56 BY CHARLETTE
BOWDEN, LICENSED PRACTICAL NURS
SIGNED OFF ON 07/09/05 @ 7:31" BY MARGARET W ALLEN, NURSE ADMINISTRATOR/MGR I
LIKELY HAS A" LIPOMA~ WIL~ SEE IF CONDITION WORESENS
SIGNED OFF ON 07/09/05 @ ZO:49 BY WALTER
SMITH~ PHYSICIAN I
** ENCOUNTER:

545 PHYSIcAL EXAM
061Z9/05
15:25 LIEBER
SCDCt: 00181186
BARTON,EDWARD E.
POB: OUT-OF-STATE. IL
UNITED STATES
DOB: 12/15/68.
AGE136
RACE: BLACK
SEXI M MARITAL STATUS: M
COMMITING COUNTY: LEXINGTON
KAXPUTI 08/14/15
DORM: MA0211A
55#: 64B-25-5618 "

IN EMERGENCY NOTIFY: MITZI BROOKS
MOTRER
RELATIONSHtP:
Z02 CHERRY ST.
ADDRESS:
ABBEVILLE, SC

ABBEVILLE

(S03)H9 Z755
A

FAMILY PHYSICIAN:

687s·nn'{)30
CONFIDENTIAL

P130-029

COMP

MDCPS81D
OMUIMDCA

(?"
I,.

05113/08

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
seDC HEALTH SERVICES: MEDICAL SUMMARY

-,CDCtt 181186

COZ9511

PAGE

BARTON,EDWARD E.

FAMILY HISTORY OF THE FOLLOWING
PATIENT ALLERGY
NKA

ALIMENTS:-~---------------------------------

HISTORy------------------------------~-----------------------

ADDEO ON

06/02/98

PATIENT MEDICAL HISTORy-----------------------------------------------------eH ILDHDOD 01 SKASES: ••••••..•• , .•.••• " ••

•••••••••

'.••

••

••••••

DENIES
SURGERYt

•••••••••

III

....................................

••

GUNS HOT WOUl{DS 1 ••••

•••••••

••••••

DENIES
FRACTURES e •• "

111

•••

...

.......

••

...

•••••

......

.....

•

......

......................

DENIES

•••••

•••

••••

•••

' ••

DENIES
STAB

WOUl~DS:

................

.......................

DENIBS
PATIENT HAS A HISTORY OF-----------------------------------------------------

CURR HBO/DEr-rTAL/MENTAL HX:-------.,------------------------------------------DENIES
CURRENT
DEIHES

MEDICATIONS~---------------------------------------------------------

GENERAL

APPEARANCE:------------------------------------~---~~------.,------~-,

BEHAVIOR:-------------------------------------------------------------------COMMENTS:--------------------------~~----------------------------------------

DENIKS
VI TAL S : - - - ": - - - - - - ., ., - - - - - - - - - - - - - - - - - - - - - - - - - .;;."- - - - - - - - - - - - - - - - - - - - - ., - - - - - ., - - - -

HEIGHTI 6 FT 1 IN
WEIGHT:
0 TEMP: 000.0 PULSE:
.01 0 RESP:
0,.
VISION SCREEN WITHOUT CLASSES: R:ZO/ 0 L:IO/ 0
WITH GLASSES: R:lOI 0 L:201 0

EP:

VACC!NES:------------------------------------

J
-------------------------------

--------.-------~----------------------------------.-- ------------._---------

SIGNED OFF ON 07/09/Q5 AT 10:14 BY REBECCA S STRAWMAN, LICENSED PRACTICAL NU
INDICATED NO NEED FOR DOCTORS REVIEW
687S·DD"()31
CONFIDENTIAL

P130-030

MDCP881D
OMINMDCA
('"
\ .... DC# 181186

SOUTH CAROLINA DEPARTMENT OF COR~ECTIONS
seoe HEALTH SERVICES: MEDICAL SUNMARY

05/13/08
C02'3511

PAGE

BARTON.EDWARD E,

PHYSICAL ABNORMALITIES:-------------------~---------------------~-----------CURRENT MEDICAL CONDITIONS:-------------------------------------------------PHYSICANS COMMENTS:---------------------------------------------------------PHYSICANS ORDERS:------------------------------------------------------------

NURSES

RESPONSE:~------------------------------------------------------------

** ENCOUNTER:
INC

cec

54+ MENTAL HEALTH CLINIC 06/18/05

14:47

LIEEER

COMP

~lOTE:

RECEIVED A REQUEST TO STAFF FROM I/M BARTON REQUESTING TO EE TRANSFEREO
TO LEE C.I. FOR MORE INTENSE COUNSELING. 11M WAS ADVISED THAT THE ICS PROGR
AM WAS HOUSED AT KIRKLAND AND MOT AT LEE.
TANYA MCCANTs.cec
SIGNED OFF OM 06/28/05 @ 14:52 BY TANYA FELICIA MCCANTS, HUMAN SERVICES COORD

r'
\

ENCOUNTER:
5+3 INSIDE APPOINTMENT
06/27/05
11:31 LIEBER
COMP
LATE ENTRl: WAS BROUGHT TO MAX SICK CALL ROOM ON 6/17/5 TO HAVE A MEDICAL 5
CREEN ASSESSMENT RELATED TO RETURNING FROM CPR. ADMITED TO HAVING A PAST HI
STORY OF MENTAL HEALTH PROBLEMS (PARANOIn SCHIZOPHRENIA), Axn TWO BLEEDING
ULCERS. DENIES ANY CURRENT PROBLEMS WITH DENTAL. DENIES ANY KNOWN ALLERGIES
CURRENT MEns ARE: GEODON. RISPERDOL, BENADRYL & ZANTAC. ADMITS TO ATTEMPT
ING SUICIDB IN JUNE OF ZOOO+ ON AN OVERDOSE OF STELAZINE. DENIES CURRENTLY
THINKING ABOUT SUICIDE. STATES THAT HE WOULD LIKE TO SEE MENTAL HEALTH, INS
ISTING ON THAT HE HAVE LEGAL RIGHTS TO A DOUBLE TRAY, I/M LAST fB SCREENING
WAS 4/28/5 AND WAS NEGATIVE. WAS VERBALLY ORIENTATED TO MEDICAL AND J/M VER
BALIZED UNDERSTANDING. NED COOPER,LPN.
SIGHED OFF ON 06/37/05 @ 11:56 BY NED
COOPER, LICENSED PRACTICAL NURSE
SIGNED OFF OM 01101/05 @ 10:17 BY SUSAN C ROSARIO. REGISTERED NURSE II

*--~NCOUNTER:
542 DOCTOR'S CLINIC
06/16/05
P} GEODOH
BONG
P) SIG:1TAB PO HS X30DAYS; ZREFILLS.
P> SIG:
I=!.> START DATE: 06/16/05 TOTAL DAYS:' 90
p> MD~CUSAK,JOHN P) RISPERDAL
3MG
P) SIG.1TAB PO BID X30DAYS, ZREFILLS.
P> SIG:
P) START DATE: 06/,16/05 TOTAL DAYS: 90
P) MD:CU5AK.JOHN
P) DIPHENHYDRAMINE
SOMG
P) SIG:ITAB PO BID X30DAYS: 2REFILLS. (EPS)
P> s IG:
P} START nATE: 06/16/05 TOTAL DAYS: 90
P> MD:CUSAK.JOHN P> RANITIDINE
150MG
P> SIG:1TAB PO BID X30DAYS; ZREFILLS.
w

687S-DD-032
CONFIDENTIAL

P130-031

lb:26

LIEBBR

CaMP

MDcpaB1D
OM IlUfDC A

" ... CDCtf: 1811B6

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCOC HEALTH SERVICES: MEDICAL SUMMARY

05/13/08
COZ9511

PAGE

BARTON .EDlJ1ARD E.

P) SIGI
P) START DATEt 06/16/05 TOTAL DAYS: 90
P> MD:CUSAK.JOHN •
DISCO~TINUEI
5TELAZINE.
NOTE: PATIENT RETURNED FROM GILLIAM ON ABOVE MEDICATIONS.
J.R. CUSACK. D.O.
SIGNED OFF ON 06/16/05 @ 10:31 BY JOHN
CUSACK. PHYSICIAN I
ALL CHANGES NOTED IN MAR.
SIGNED OFF ON 06/16/05 @ 10:45 BY SUSAN PALMER HADLEY, LICENSED PRACTICAL NUR
~*

ENCOUNTER:
541 MENTAL HEALTH CLINIC 05/16/05 l+:tZ LIEBER
COMP
O-INMATE SEEN ALONG WITH DR. CUSACK, SIGNED VOLUNTARY ADMISSION TO GILLIAM.
PHONED JIM PAGE AT GILLIAM WHO APPROVED ADMISSION FOR EARLY AM, SERGEANT
PERRY IN LIEBER TRANSPORTATION VERIFIED AVAILABILITY OF TRANSPORTATION
TOMMORROW MORNING.
A-ANTISOCIAL PERSONA~ITY DISORDER WITH BORDERLINE FEATURES.
P-TRANSPORT TO GILLIAM TOMHORROW.
STEVE COMPTON,CCC
SIGNED OFF OM 05/16/05 @ 14:45 B7 STEPHEN F COMPTON. HUMAN SERVICES COORD I

** ENCOUNTER:
r~,
~/

540 MENTAL HEALTH CLINIC 05/16/05 13:42 LIEBER
COMP
D. THIS IS A 36 YEAR OLD. MARRIED, BLACK MALE. FOR THE PAST SEVERAL
DAYS. HE HAD BEEN URINATING ON HIMSELF AND THE FLOOR. HE HAS COLLECTED
HIS FECES AND ALSO FILLED THE TOILET WITH FECES AND PAPER. HE HAD
CEASED TAKING 'HIS PRESCRIBED MEDICATIONS. HE WAS PLACED IN A RESTRAINT
CHAIR, MAX-OUT IS 2014. HE STATES. "I GOT SOMETHING IN THAT ROOM THAT
IS RINGING MY Boor OUT, INSIDE OUT. I HEAR THE VOICES TOO! I FEEL A
STICKING PAIN IN MY STOMACH LIKE SOMEONE IS STICKING A KNIFE IN THERE.
I WANT TO GO TO GILLIAM." HE HAD SMEARED FECES ON HIMSELF.
MENTAL STATUS EVALUATION REVEALED A FAST TALKING. BLACK MALE. NO S/H.
HE IS LEAN AND BATHED. HE COMPLAINED OF, SOMATIC AND AUDITORY HALLUCINATION
YET ON' EXAMInATION HE DID NOT APPEAR PSYCHOTIC OR IN ACTUAL PHYSICAL
DISTRESS.
.
A. ANTlSOCIAL PERSONALITY DISORDER WITH BOROERLIRI!: FEATURES
INTERMITTENT EXPLOSIVE DISORDER
ALCOHOL DEPENDENCE
EXHIBITIONISM
P. SUGGESTED RECHECK AS NEEDED.
RECOMMEND: TRANSFER TO GILLIAM.
J.R. CUSACK. D.O.
SIGNED OFF ON 05/16/05 @ 13:54 BY JOHN
CUSACK. PHYSICIAN I

05/06/05
539 DOCTOR'S CLINIC
12:5+ LIEBER
** ENCOUNTER~
SHC
P) TRIFLUOPERAZ INE
P> SIG:3TABS PO BID X30DAY!;: ZREFILLS.
P} SIG:
90
P) START DATEt 05/06/05 TOTAL DAYS;
P} MD:CUSAX •.TOHN .T.R. CUSACK, D.O •
SIGNED OFF ON 05/06/05 @ 12:55 BY 'JOHN
CUSACK. PHYSICIAN I

6875-DD-033
CONFIDENTIAL

P130·032

COl4P

MDCP8810
OIHNNDCA

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCDC HEALTH SERVICES: MEDICAL SUMMARY

('~~DC~ 1B118 6
oeD.

05/13/08

COZ9511
PAGE

SIGNED OFF ON 05/08/05 @ 18:09 BY SUSAN C ROSARI0 1 REGISTERED NURSE II

CaMP
a~ ENCOUNTER:
538 P~D
04/28/05
11: 31 LIEBER
A) SCREENING-PULMONARY TB
PPD GIVEN 00 MM READING.
SIGNED OFF ON 04/28/05 @ 11:31 BY CHRISTINE
MCFADDEN, LICENSED PRACTICAL NU

ENCOUNTER~
537 MENTAL HEALTH CLINIC-04/Z7/05 13:54 LIEBER
COMP
OPEN BY ACCIDENT
TANYA MCCANTS,cec
SIGNED OFF ON 04/27/0~ @ 14:14 BY TANYA FELICIA MCCANTS. HUMAN SERVICES COORD

** ENCOUNTER:

COMP
536 MENTAL HEALTH CLINIC 04/17/05 13~31 LIEBER
LATE ENTRY FOR 4/26105.
0: I/M SEEN FOR MENTAL HEALTH FlU. I AM DOING OK. I DON'T NEED TO SEE DR. C
USACK I JUST NEED FOR HIM TO CHANGE MY STELAZINE TO TAKE ALL 3 PILLS IN THE
AFTERNOON AND TA~E 2 BENEDRILS IN THE A.M. AND P.M. I MEED TO BEABLE TO RES
T TO AVOID THE VOICES IN MY ROOM. I AM NOT HAVING ANY HIS THOUGHTS.
A: OX: ANTISOCIAL PERSONALITY 0/0
INTERMITT!N EXPLOSIVE
ALCOHOL DIP:
GAF-70 I
,
11M SEEN AT HIS CELL ALONG WITH LT. KING. 11M APPEARED TO BE AID X3: MOOD A
PPEARED TO BE PLEASAl-IT WITH GOOD EYE CONTACT. IIl~ ATTITUDE WAS PLEASAnT HE
DIDN'T HAKE ANY THREATS. riM DENIED HIS THOUGHTS., 11M REPOR! AIV HALLUCINAT
IONS. WE DISCUSSED HIS CONCENRS AND SOME COPING SKILLS HE CAN USE TO HELP H
1M MANAGE HIS DAILY STRESSORS.
P: WILL MAKE REFERRAL TO DR. CUSACK. WILL SEE IN 30 DAYS.
TANYA MCCANTs.cce
SIGNED OFF ON 041Z7/05 @ 14:l4 BY TANYA FEL[CIA MCCANTS. HUMAN SERVICES COORD
DR. CUSACK, PLEASE LET ME KNOW IF YOU CAN MAKE REQUESTED CHANGE IN MEDS
WITHOUT SEEING INMATE. I WILL SCHEDULE HIM FOR YOU PRN.
STEVE COHPTON,CCC
SIGl{ED OFF ON 041ZS/05 @ 1.(.;05 BY STEPHEN F COMPTON. HUMA'N'S'ERV'IC'E'S COORD I
REVIEWED. J.R. CUSACK. D.O.
SIGNED OFF ON 04129/05 @ 14:12 BI JOHN
CUSACK, PHYSICIAN I
ENCOUNTER:
535 MENTAL HEALTH CLINIC 04/25/05 15:08 ~IRBER
COMP
INC 1>rOTE:
ecc UNABLE 10 CONDUCT IIC SESSION WITH I/M TODAY DUE TO INSTITUTIONAL ON LO
CK DOWN FOR TB READING. WILL FlU MAY·Z005.
TANYA MCCANTS,ece
SIGNED orr ON 04/25/05 @ 15:09 BY TANYA FELICIA MCCANTS. HUMAN SERVICES COORD

** ENCOUNTER:

534 MENTAL HEALTH CLINIC 0+/04/05 15:11 LIEBER
CaMP
D. THIS IS A 36 YEAR OLD. MARRIED, BLACK MALE. HE IS IN LOCKUP.
HE IS PERVASIVELY ANGRY REGARDING SCOC, SECURITY AND MEDICAL CARE.
HE INSISTS HIS MEDICATIONS DO NOT RELIEVE HIS SYMPTOMS OF »SMELLING FIRE
AND FEELIN' STUFF CRAWLIN ON MY BODY."
f

/"
\,

"-,

P130-033

6815.DD-034

CONFID.BN'.rIA.L

MDCP881D
OMINMDCA

r--'

\-, .. CDCij 161186

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
seDC HEALTH SERVICES: MEDICAL SUMMARY

05/13/08

COZ9511
PAGE

BARTON,EDWARD E.

MENTAL STATUS EVALUATION REVEALED A TALL, LANKY. BLACK MALE WHO WAS
ANGRY AND THREATENING. HE WAS VERBALLY LOUD AND HOSTILE. AFFECT WAS
ANGR! AND DISRUPTIVE. NO S/H. NO OBJECTIVE EVIDENCE OF PSYCHOSIS.
SPEECH WAS CLEAR AND LINEAR. BEHAVIORS WERE METHODICAL. ALL PSYCHOTIC
SYMPTOMS WERE SUBJECTIVELY REPORTED. AND. IN ACTUALITY, HE DID NOT APPEAR
TO BE PSYCHOTICALLY TROUBLED. INSTEAD, HE APPEARED TO BE IMPRESSED WITH
HIS OWN ANGER. HE IS ORIENTED IN ALL SPHERES.
A. ANTISOCIAL PERSONALITY DISORDER
INTERMITTENT EXPLOSIVE DISORDER
ALCOHOL DEPENDENCE
EXHIBITIONISM
P. SUGGESTED RECHECK IN 3-4MONTH5.
J.R. CUSACK, D.O.
SIGNED OFF ON 04/04/05 @ 15:10 BY JOHN
CUSACK, PHYSICIAN I

** ENCOUNTER:
533 DENTAL CLINIC
04/04/05 11:09 LIEBER
A} OTHER DENTAL DISORDER·
PT REFUSED EXT i l (CROWN FX)-REFUSAL SIGNED
SIGNED OFF ON 04/04/05 • 11:09 BY JOHN S TIMMERMAN, DENTIST

Cot1P

** ENCOUNTER:

532 MENTAL HEALTH CLINIC 03/31/05 14:49 LIEBER
COMP
0: 11M SEEN FOR MENTAL HEALTH F/U. 11M STATED IF IALL DON'T GET ME SOME HEL-

P I AM GOING TO SHIT rNTO MY OWN HANDS.I WILL SMEAR FEeIES ALL OVER THE eEL
LAND MISELF. I NEED TO SEE DR. CUSACK TO CHANGE MY MEDICATION TO HELP WITH
THE VOICES AND THEIS SHIT THAT'S CRAWLING OVER ME. I DON'T CARE ABOUT GETTI
NG NO CHARGES. I AM PARANOID SCHIZOPHRENIA AND YALL KNOW IT. "DON'T COME TO
MY DOOR IF IA'LL AINT GONNA DO SHIT",
A: DX: SCHIZOPHRENIA PARANOID rYPE:
GAF-40:
I/M SEEN AT HIS CELL DOOR ALONG OFF PALMER. 11M APPEARED TO BE 1.10 X3; MOOD
APPEARED TO VERY ANGRY AND HOSTILE. 11M DENIED AIV HALLUCINATIONS AS WELL A
S HIS THOUGHTS. WE DISCUSSED Krs CONCERNS AND SOME COPING SKILLS HE CAN USE
TO HELP HIM MANAGE HIM MANAGE HIS DAILY STREsaORS.
PI 11M SCHEDULE TO SEE DR. CUSACK ON 4/4/05, NEXT I/C SESSION WILL BE APRIL
• 05.
TANYA MCCANTs.ecc
SIGNED OFF ON 03/31/05 @ 15:03 BY TANIA FELICIA MCCANTS, HUMAN SERVICES COORD,

531 DOCTOR'S CLINIC
03/17105 11:Z7 LIEBER
COMP
*'* ENCOUNTER:
50MG
P} DIPHENHYDRAMINE
(EPS)
p> SIG:1TAB PO TID X30DAYS~ 2REFILLS.
p> BIG:
p> START D".TE: 03/17/05 TOTAL DAYS: 90
P> MD:CUSAK.JOHN ~
J.R. CUSACK, D.O.
CUSACK. PHYSICIAN I
SIGNED OFF ON 03/17/05 @ 11128 BY JOHN
NOTED.
SIGNED OFF ON 03/17/05 @ 14-:36 BY LOIS K GRAHAM. LICENSED PRACTICAL NURSE
U

ENCOUNTER,

530 FOLLOW-UP DENTAL

03/14/05

6875-DD·03S
CONFIDENTIAL

P130-034

'3:29

LIEBER

COMP

MDCPBB1D
OMINMDCA

r--'

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
seDe HEALTH SERVICES~ MEDICAL SUMMARY

C029511
PAGE

BARTQN.Em'JARD E.

lCDC# 181186

05/13/08

A) OTHtH DENTAL DISORDER w
MIFDL COMP 125*-5% SOD. FL VARNISH APPLIED TO #10, #l~t #25
SIGNED OFF ON 03/14/05 @ 9:29 BY JOHN S TIMMERMAN, DENTIST

** ENCOUNTER:

529 FOLLOW-UP DENTAL

A> DENTAL EXAMINATION

03/14/05

91Z5

LIEBER

COMP

POE, CHARTING AND OHI
SIGNED OFF ON 03/14/05 @ 9125 BY JOHN S TIMMERMAN. DENTIST

** ENCOUNTER,
P>
P)

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S)
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COMP
528 NARRATIVE
9:06 LIEBER
03/PZ/05
INMATE WITH CHIPPED TEETH
HISTORY OF STOMACH PROBLEMS REQUIRING HZ BLOCKER
WILL USE PHENYLGESIC INSTEAD OF IBUPROFEN
PHENYLGESIC
SIG:1 OR 2 TABS FOUR TIMES A DAY AS NEEDED FOR DENTAL
SIG;PAIN
(PLEASE GIVE STARTER PACK)
'
START DATEI 03/02/05 TOTAL DAYS: 15
MDeSMITH,WALTER SIGNED OFF ON 03/02/05 @ 9:09 BY WALTER
SMITH. PHYSICIAN I
lmTED.
SIGNED OFF ON 03/02/05 @ 11:11 BY LOIS K GRAHAM# LICENSED PRACTICAL NURSE

ENCOUNTER:
5%7 SICK CALL
OZ/22/05
lal!! LIEBER
COMP
I BELEIVE THAT MY GAS ULCER ARE FLRING UP. I'M HAVING STOMACH~ PAIN AFTER I
EAT. I CONTINUE TO BELCH HRS AFTER I EAT. MY STOMACH HURTS. I HAVE BLEEDING
ULCERS BUT 1M NOT LOSING BLOOD SO I KNOW THAT IT ISN'T THEM. IN EED SOME P
UHPLE PILLS •.. PRILOSEC SOMETHING FOR MY STOMACH.
'
TEMP=097.3
PULSE= az
RESP=18
BP=lZ81 82
WEIGHT=170
11M PRESENTS HIMSELF TO MEDICAL WI THE ABOVE C/O. UPON ASSESSMENT ABLE TO C
OME TO UNDER5TA1>rD THAT liM MEAnT GASTRIC ULCERS. 11M CONTUfUED TO BELCH DUR
ING ASSESSMENT. STOMACH DISTENDED BUT SOFT. DENIES BLOOD IN STOOLS. DOES CO
NFIRM KX OF ACID REFLUX/ULCERS.
SYMPTOMATIC GERD
1. SEE S.D. #29.
Z. INSTRUCT LIFESTYLE CHANGES AS FOLLOWS: AVOID ALCOHOL. ElEV~JE HEAD AT
NIGHT. DECREASE FATTY FOOD INTAKE, STOP SMOKING, LOSE WEIGHT (IF OVER
WEIGHT) AVOID LYING DOWN FOR AT LEAST 3 HOURS AFTER EATING.AVOID LARGE
MEALS AND CERTAIN FOODS SUCH AS CHOCOLATE,PEPPKRMINT. COFFEE. ONIONS.
GARLIC,rOMATO-BASBD SAUCES,CITRUS#FRIED OR FATr( FOODS.' -3. ZANTAC 150 MG. PO BID X Z WEEKS.
4. EXPLAIN THE DIFFERENCE BETWEEN THERAPY FOR PREVENTION OF SYMPTOMS AND
THERAPY OF IMMEDIATE RELIEF.' (SEE NURSING NOTES).
5. FOR ATYPICAL SYMPTOMS OF GERD SUCH AS COUGH.HOARSENESS,WHEEZING. ASTHMA
WEIGHT LOSS. DYSPHAGIA. AND NON CARDIA CHEST PAIN. REFER TO MD/NP.
I/M ISSUED 1 PACK OF ZANTAC. WILL ASK MD TO RENEW ORDER FOR DAILY USE. 11M
INSTRUCTED ON ABOVE. 11M UNDERSTANDS ABOVE.
SIGNED OFF ON 02/ZZ/OS @ 18:27 BY ASTERIO
BASOBAS, LICENSED PRACTICAL NURSE
P: 1. ZANTAC 150 MG 1 PO BID X 90 DAYS,
SIGNED OFF ON 021Z+/05 @ lO~07 BY RICHARD C BEARDEN. JR. PHYSICIAN II
oeD. M. ALLEN RN
#

6875-DD-036

CONFIDENTIAL

P130-035

MDCPB81D
rMHJMDCA
\./

SCDe» 181186

O:illJl08
COZ9511

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
senc HEALTH SERVICES: MEDICAL SUMMARY
BARTON,EDWARD E.

PAGE

SIGNED OFF ON 01/24/05 @ 10:36 BY MARGARET W ALLEN, NURSE ADMINISTRATOR/MeR I
a* ENCOUNTER:
516 NARRATIVE
02/16/05 15:40 LIEBER
P} TRIFLUOPERAZINE
SHG
P) SIG:TKREE TABS PO BID X 30 DAYS. 2 REFILLS
P) SIG:
P) START DATE: 01/16/05 TOTAL DAYS:
90
P) MDcCOBB.THOMAS .
V/O RENEEW TRIFULOPERAZINE PER DR. COBB/J. SOVACOOL. RN.
SIGNED OFF ON OZ/16/05 @ 15:42 BY JILL P SOVACOOL. REGISTERED NURSE I
SIGNED OFF ON 02/1B/05 • 13:29 BY RICHARD C BEARDEN. JR, PHYSICIAN II

CaMP

** ENCOUNTER:

525 INSIDE APPOINTMENT
02/14/05
10:13 LIEBER
COMP
RX EX?
o REFILLS
TRIFLUOPERAZINE
SIGNED OFF ON 02/14/05 @ 10:14 BY SUSAN PALMER HADLEY: LICENSED PRACTICAL HUR
SEE ENCOUNTER # 5Z6,
SIGNED OFF ON 01)16/05 @ 15:42 BY JILL P 50VACOOL, REGISTERED NURSE I

** ENCOUNTER:

~
~

524 SECURITY INrT
OZ/13/05 15:4Q LIEBER
COMP
VEST, RN OVER AT MAX TO EVA~UATE INAMTE. "INMATE WAS CALK. CIO HANDS AND
FINGERS TINGLING. HANDS COLD T9 TOUCH. HE ALSO COMPLAINS OF PAIN IN THE
RIGHT SHOULDER. NOTED INDENTATIONS IN THE SKIN. RADIAL, AND BRACHIAL PULSE
PALPABLE. IN GOOD HEALTH. N9TED CHANGE IN THE TEMP OF HIS LEFT AND RIGHT
ARM/COLD. INMATE RELEASED FOM RESTRAINTS. HE WAS ALERT CALM AND COOPERATIVE
AT THE TIME." VEST STS THAT OFFICER NOTED THAT INDENTATIONS WERE FROM THE
INMATE MOVING WHILE WITHIN THE RESTRAINTS/ IN rHE CHAIR.
STATMENT PER RN VEST.
A. FARRINGTON
.
SIGNED OFF ON OZ/13/05 @ 15:58 BY ALEXIS
FARRINGTON, LICENSED PRACTICAL NUR
SIGNED OFF ON 02/14/05 @ 1:06 BY ~USAN C ROSARIO. REGISTERED NURSE II

** ENCOUNTER:

523 INSIDE APPOINTMENT
OZ/13/05 10:45 LIEBER
COMP
OFFICER KING CALLED FROM HAX. REQUESTS MEDICAL CLEAlANCE TO PLACE INMATE IN
RESTRAINT CHAIR. INFORMED TO OFFICER THAT INMATE IS CURRENTLY RECEIVING
BENADRYL AND STERLAZINE IN DAILY DOSES. CQNFERRED WITH NURSE SANDERS AT
THIS TIME. INAMTE IS PLACED TO REST. CHAIR. WILL GO OVER TO MAX AS OFFICER
REQUESTS IN 30 MIN-l HR TO ASSESS.
NOTED. FARRINGTON
SIGNED OFF ON OZ/13/05 @ 10:+9 BY ALEXIS
FARRINGTON, LICENSED'PRACTICAL NUR
INMATE OBSERVED IN CHAIR WITH ALL POINTS RESTRAINED, UPPER CHEST RESTRAINT
LOOSENED. PULSES PALPABLE AT ALL polNTS. INMAT~ IS IN NO DISTRESS.
SIGNED OFF ON 02/13/05 @ 13~10 BI ALEXIS
FARRINGTON. LICENSED PRACTICAL NUR

** ENCOUNTER:

522 MENTAL HEALTH CLINIC 02/03/05 13:19 LIEBER
COMP
35 YEAR OLD BLACK HALE IN LOCK-UP. SEEN TODAY DUE TO THREATENING"REQUEST T
o TALK TO STAFF", HISTORY OF POSSIBLE PSYCHOSIS. TODAY BROUGHT UP IN CHAI
NS. ANGRY~ DEMANDING "THE APPROPRIATE PSYCHIATRIC CARE. I NEED TO TALK TO A
COUNSELOR", WHEN INFORMED I WAS A PSYCHIATRIST WHO WAS ,HERE TO TALK TO HIM
687S.DD·031

CONFIDENTI A J

P130-036

MDCP881D
OMINMDCA

(:DC~

181186

SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
SCDC HEALTH SERVICES. MEDICAL SUMMARY
BARTOlt IEDWARD

OS/13/0B

COZ9511
37

PAGE

E•

• HE INSISTED ON GOING TO GPH OR ELSE HE WAS GOING TO nCO OFF ON SOMEONE"

HOWEVER, HE COULD NOT POINT OUT A SPECIFIC REASON FOR NEEDING GPH OTHER IRA
N »OTHE INMATES GET TO GO." REPORTED FEELING THINGS ON HIS SKIN AND HEARIN
G VOICES FOR EIGHT YEARS. HE REPORTED NO SI/HI CURRENTLY. BUT LATER BECAKE
THREATENING. HIS REPORTED SYMPTOMS DID NOT MATCH HIS PRESENTATION AND HE
APPEARED TO BE EXAGGERATING HIS SYMPTOMS ALONG WITH THREATS TO GET WHAT HE
WANTED.
A. PSYCHOSIS VS MALINGERING
ANTISOCIAL PERSONALITY DISORDER
ALCOHOL 'DEPENDENCE
P. COllTUfUE TO MONITOR INMATE. NO CHANGES AT THIS TIME. TOLD INMATE I WO
ULD BE GLAD TO SEE HIM ON A MORE FREQUENT BASIS, BUT HE DECLINED STATING,;"
DON'T CALL HE UP HERE IF ALL YOU WANT TO DO IS TALK." F/U 1-2 MONTHS.
TGCOBB HD
SIGN_D OFF ON 02/03/05 , 13:28 BY THOMAS
COBB, PHYSICIAN II
U

ENCOUNTER:
COMP
5Z1 MENTAL HEALTH CLINIC 01/18/05
10:50 LIEBER
nrc J.IOTE:
IX TEAM UPDATED IP WITH THE FOLLOWING RECOMMENDATIONS: MENTAL HEALTH STATUS
WILL REMAIN MENTALLY ILL WITH THE A ox: SCHIZOPHRENIA PARANIOD TYPE BY HX,
ax ETOH DEP. CCC--MCCANTS. PLEASE SEE HARD COpy OF TX PLAN IN MENDrCAL REeo
RDS FOR HaRE DETAILS. NEXT TP REVIEW WILL BE 3/05.
.
TEAM MEMBERS
S. COMPTOJ.Lecc

T MCCANTS.CCC

J. SHEALLY,CCC
TANYA MCCANTS,CCC
SIGNED OFF ON 01/16/05 @ 10:55 BY TANYA FELICIA MCCANTS# HUMAN SERVICES COORD

ENCOUNTER:
5Z0 NARRATIVE
01/03/05
Zlla LIEBER
CaMP
DIPHENHYDRAMINE
SOMG
P> SIG:TAKE ONE CAPSULE TID FOR EPS
P> BIG:
P> START DATE: 01/03/05 TOTAL DAYS. 90
p> MD:CUSAK.JOHN ~
SIGNED OFF ON 01/03/05 @ 2:20 BY LOIS K GRAHAM. LICENSED PRACTICAL NURSE
ORDERED
SIGNED OFF ON 01/05/05 @ Zlt16 BY EILEEN B PALMER, NURSE PRACTITIONER III
SIGNED OFF ON 01/06/05 @
:43 BY BRENDA K KEAY, LICENSED PRACTICAL NURSE
~*
P)

a* ENCOUNTER:
519 DOCTOR'S CLINIC
12/15/04 14~43; LIEBER
S) INMATE COMPLAINS OF PAINFUL LUMP NEAR RIGHT HIP
0> TEMP=OOO.O
PULSE: 0
RESP= 0
SP= 01 0
WEIGHT: 0
0) FATTY LIPOMA NOTED NEAR RIGHT GREATER TROCHANTER
A> FATTY LIPOMA
.
P> WILL SCHEDULE FOR MINOR SURG IN HOUSE WHEN HE IS OUT OF SNU
SIGNED OFF ON 12/15/04 , 14t4S BY WALTER
SMITH. PHYSICIAN I

COMP

LIEBER

COMP

A* ENCOUNTER:
518 SICK CALL
S} I/M CIO KNOT ON MY RIGHT HIP.

P130-037

12/14/04

687s-nn·038

CONFIDENTIAL

11:27

1'-../

CURRENT MEDICAL CONDITIONS:------------------------------------------------PHYSICANS COMMENTS: - -- --- ----- --------- ---.---------------------------------CAME FROM DJJ ON KLONOPIN AMBIENS AND PROZAC, LAST DOSE THURS PM
WAS FOLLOWED BY DR MORGAN
;PRIOR SUICIDE ATTEMPT AT DJJ,DENIES INTENT TOD
PHYSlCANS ORDERS:----------------------------------------------------------VISTARIL 25MG PO TID X3D WITH 50 MG PO QHS
PROZAC 20MG POQ AM X30D
RECORDS FROM DJJ
PHASE III EVALUATION ASAP AND PLEASE GET BACK TOME TODAY TO ADJUST MEDS
S.WILLIAMS PAC
SIGNED OFF ON 02/0B/99 AT 10:IB BY SARA 0 WILLIAMS, UNCLASSIFIED
NURSES RESPONSE:-----------------------------------------------------------OCO. RICHARD JOHNSON NOTIFIED RE PHASE 3 AND WILL SEE TODAY.
SIGNED OFF ON 02/09/99 AT 05:40 BY NELL F ADAMS, REGISTERED NURSE II
00181186 EDWARD

BARTON

LOC:

LIEBE~

CORR INS

** ENCOUNTER 00797 INSIDE APPOINTMEN 09/08/11 07:59 LIEBER CORR INST

. C~

COMP
I/M REPORTS GOOD RESULTS WITH CHLORZOXAZONE 500 MG TABLETS AND WOULD LIKE
TO HAVE AN ACTIVE RX FOR THIS MEDICATION (SEE ENC # 795).
SIGNED OFF ON 09/08/11 @ 8:00 BY JENNIFER L SCOTT, REGISTERED NURSE I
ORDERED
SIGNED OFF ON 09/08/11 @ 9:10 BY ELIZABETH A HOLCOMB, NURSE PRACTITIONER II
MEDICATION TRANSMITTED TO KIRKLAND PHARMACY. LIEBER MARS UPDATED
SIGNED OFF ON 09/08/11 @ 16:17 BY SHARON
TISON~ REGISTERED NURSE I
** ENCOUNTER 00796 MENTAL HEALTH CLI 09/06/11 09:42 LIEBER CORR INST
COMP
D-MET WITH I/M 0 N09/02/11 FOR MONTHLY F/U; I/M REMAINS ON SMU. I/M RPTD D
OING WELL. HOWEVER, CONTINUES TO RPT A/VH WHICH ARE MANAGABLE W/MEDICATIONS
I/M DOESN'TeENGAGE I N REC; HE STATES PREFERS TO STAY IN AND WRITE HIS NOV
EL. I/M RPTD EATING AND SLEEPING WNL. I/M DENIED DEPRESSED MOOD, MANIA, S
/HI AND MEDICATION SIDE EFFECTS. I/M IS HOUSED ALONE. I/M IS MEDICATION CO
MPLIANT~

**
S>
S>
S>
0>
0>

A>
P>
P>
P>
P>

A-PRESENTED WITH NORMAL At:FECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS, ORIENTED X3, GOOD HGYIENE AND MOOD.
P-CONTINUETO MONITOR.
LORETTA AIKEN, HSCI
SIGNED OFF ON 09/06/11 @ 9:49 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00795 SICK CALL
09/04/11 06:46 LIEBER CORR INST
COMP
"I AM HAVING SERIOUS PAINS IN THE LOWER PARTS OF MY BACK AND MY SPINE HURTS
AS WELL. PLEASE BRING ME A CUP OF THAT GREEN SOAP THE STATE SOAP HAS
STARTED TO MAKE ME ITCH AGAIN."
TEMP=096.4
PULSE= 84
RESP=18
BP~132/ 72
WEIGHT= 50
PPD= 0
WT IS NOT ACCURATE. CA&OX4, MAE AMBULATORY INTO TX ROOM. PERRLA, SKIN
~lARM/DRY-FLAKY.
MID TO LOWER BACK-PARASPINOUS MUSCLES POSITIVE FOR
SPASMS, PAIN AND TENDERNESS ON PALPATION. INCREASED LOWER BACK PAIN WITH
LEG LIFTS BIL AT APPROX 45 DEGREES. NO CVA TENDERNESS, NO REPORTED URINARY
ISSUES.
MUSCULOSKELETAL DISCOMFORT
1. SEE S.O. #27.
2. ACETAMINOPHEN 325 MG. TABS 2 PO QID X 3 DAYS OR IBUPROFEN 400 MG.TABLETS
2 P.O.TID PRN X 3 DAYS. DOCUMENT MEDS GIVEN IN AMR.
3. IF PALPABLE MUSCLE SPASMS PRESENT, CHLORZOXAZONE 500MG.TABS PO QID X

CONFIDENTIAL

P130-038

6875-EEEE-132

,'"
\..,,/

P>
P>
P>
P>
P>
P>

3 DAYS.
FOR LOWER BACK DISCOMFORT, USE A ROLLED TOWEL UNDER LOW BACK X 5 DAYS.
I'HLLIAM FLEXION EXERCISE(SCDC FORM 24-1461 FOR CHRONIC LOVI BACK PAIN.
RESTRICT STRENUOUS ACTIYITES OR REST THE INVOLVED AREA.
HEAT (BY SHOWER, MOIST COMPRESSES OR HOT WATER SOAKS) TO THE INVOLVED
AREA QID X 3 DAYS.
I/M WAS INSTRUCTED ON LOWER BACK EXERCISES AND GIVEN SCDC 24-146 AND INSTRU
CTIONS AS PER STANDING ORDER. I/M WILL BE STARTED ON CHLORZOXAZONE 500 MG
PO 4 TIMES DAILY X 3 DAYS. I/M WAS INSTRUCTED TO DRINK ADEQUATE AMOUNTS OF
WATER (AT LEAST SIX 8 02 GLASSES DAILY) IN ORDER TO REMAIN HYDRATED, TAKE
REC WHEN IT IS OFFERED, PLAN FREQUENT REST BREAKS DURING THE DAY, AND
INFORM MEDICAL DEPARTMENT SHOULD HE DEVELOP ANY N/T TO HIS EXTREMITIES,
PAIN THAT RADIATES INTO HIS THIGHS, SHOULD HE DEVELOP ANY CHANGES IN HIS
URINARY HABITS OR IF HE HAS ANY QUESTIONS OR CONCERNS. I/M WAS INFORMED
THAT THE MEDICAL DEPARTMENT DOES NOT ISSUE ANY "SPECIAL" TYPES OF SOAP AT
THIS PRESENT TIME. I/M INSTRUCTED TO PAT HIS SKIN DRY AFTER SHOWERS AND
WATCH FOR ANY OPEN AREAS AND REPORT THEM TO THE MEDICAL DEPT. I/M WAS ABLE
TO VERBALIZE COMPLETE AND APPROPRIATE UNDERSTANDING OF ALL INSTRUCTIONS AS
PROVIDED BY RN. WILL FOLLOt'1 PRN.
SIGNED OFF ON 09/04/11 @ 22:49 BY JENNIFER L SCOTT, REGISTERED NURSE I
ENCOUNTER 00794 SECURITY INIT
08/05/11 19:28 LIEBER CORR INST
COMP
INMATE SEEN CELL FRONT AT APPROX. 4:00PM 'S/P tHEMlCAL EXPOSURE. NO RESPlRAT
ORY DISTRESS NOTED. NO COMPLAINTS VOICED.
SIGNED OFF ON 08/05/11 @ 19:29 BY SHARON
TISON, REGISTERED NURSE I
ENCOUNTER 00793 MENTAL HEALTH CLI 08/02/11 14:56 LIEBER CORR INST
COMP
D-MET WITH I/M FOR MONTHLY F/U; I/M CONTINUES TO RESIDE ON LOCK-UP. I/M RP
TD BEING STRESSED REGARDING RECEIVING CHARGE{HE CLAIMS) WERE ERRONEOUS. 1/,
M CONTINUES BE ISOLATIVE (DOES NOT ENGAGE IN REC). I/M RPTD DOING "OK". I/M
STATED HE CONTINUES TO DEAL WITH A/V/H. I/M RPTD NO IMPROVEMENT. I/M IS M
EDlCATIOIN COMPLIANT. I/M RPTD EATING AND SLEEPING WNL. I/M DENIED S/RI, M
EDlCATION SIDE EFFECTS AND DEPRESSED MOOD. WHILE I/M DOES NOT VERBALLY END
ORSE DELUSIONAL IDEATION, HIS REQUESTS TO STAFF INDICATES SUCH.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS, ORIENTED X3, GOOD HYGIENE AND MOOD.
P-CONTINUE TO MONITOR.
LORETTA AIKEN, HSCI
SIGNED OFF ON 08/02/11 @ 15:14 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00792 MENTAL HEALTH CLI 07/26/11 10:17 LIEBER CORR INST
COMP
S: SAYS MEDICINES DON'T STOP VOICES. HEARS THEM ALL DAY, TELLING HIM HE I
S BEING SET UP FOR THINGS HE IS NOT DOING. VOICES TELL HIM HE IS AT ALL IN
TITUTIONS AT THE SAME TIME. SEES SHADOWS.
0: SAYS HIS CELL IS TOO HOT. SLEEPS 4 TO 5 HOURS PER 24 HOUR PERIOD. CAN
'T FOCUS ON A BOOK TO READ. SAYS HE HAS BEEN READING SAME BOOK FOR COUPLE
MONTHS. TOOK HIM 3 WKS TO FINISH A LETTER TO HIS FAMILY. FEELS DOWN, ROWDY
, MAD, UPSET. SAYS HE WOULDN'T TELL ME IF HE WANTED TO HURT SELF. HAS TRI
ED IN THE PAST. SAYS HE DOESN'T SAY ANYTHING BECAUSE HE DOESN'T WANT TO GE
T STRIPPED OUT.
DOESN'T WANT TO SAY IF HE WANTS TO HURT OTHERS EITHER. D
ENIES SIDE EFFECTS OF MEDS. LABS WNL. HE IS NOT INTERESTED IN TRYING OTHER
MEDS. STAFF REPORT HE IS BETTER ON THESE MEDS THAN HE HAS BEEN IN THE PAS
T.
A; SCHIZOPHRENIA
P: CONTINUE CURRENT MEDS.
SIGNED OFF ON 07/26/11 @ 10:25 BY BEVERLY A WOOD, PSYCHIATRIST
ENCOUNTER 00791 MENTAL HEALTH CLI 07/25/11 12:16 LIEBER CORR INST
COMP
INC NOT: I/M IS SCHEDULED FOR A PSYCH APPT ON 07/27/11.
LORETTA AIKEN, HSCI
SIGNED OFF ON 07/25/11 @ 12:16 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
4.
5.
6.
7.

CONFIDENTIAL

P130-039

6875-EEEE-133

** ENCOUNTER 00790 MENTAL HEALTH CM 07/25/11 09:37 LIEBER CORR INST

**
**

**
P>
P>
P>
P>
P>
P>
P>
P>
P>
P>

COMP
MED RENEWAL.
LABS OK.
N~ COMPLETED FOR SEROQUEL XR 400 MG PO BTD FOR 180 DAYS.
WILL TRY TO CONSO
LIDATE '1'0 HS DOSE NEXT TIME HE IS SEEN. BWOODMD
SIGNED OFF ON 07/25/11 @ 9:38 BY BEVERLY A WOOD, PSYCHIATRIST
NON-FORMULARY SHEET HAS I'lOT ARRIVED HERE YET (APPROVAL) MEDS HERE
SIGNED OFF ON 07/25/11 @ 18:10 BY LINDA E JONES, REGISTERED NURSE I
ENCOUNTER 00789 DOCTOR'S CLINIC
07/18/11 16:12 LIEBER CORR INST
COMP
CMP AND LIPID PANEL ORDERED BY PSYCH ARE WNL'S.
SIGNED OFF ON 07/18/11 @ 16:12 BY ROBERT E BABB, UNCLASSIFIED
ENCOUNTER 00788 LAB CLINIC
07/14/11 04:13 LIEBER CORR INST
COMP
LAB RESULTS REC'EIVED FOR A CMP, AND A LIPID PANEL. PLACE ON CHART FOR M. D.
SIGNATURE.
SIGNED OfF ON 07/14/11 @ 4:15 BY PAULETTE L SEABROOK, LICENSED PRACTICAL NU
ENCOUNTER 00787 LAB CLINIC
07/13/11 03:25 LIEBER CORR INST
COMP
BLOOD WORK DRAWN FOR A CMP, LIVER PANEL, FASTING GLUCOSE LEVEL, AND A
LIPID PANEL. FASTING. NO PROBLEMS.
SIGNED OFF ON 07/13/11 @ 3:28 BY PAULETTE L SEABROOK, LICENSED PRACTICAL NU
ENCOUNTER 00786 MENTAL HEALTH CLI 07/08/11 13:00 LIEBER CORR INST
COMP
D-MET WITH I/M ON 07/06/11 FOR MONTHLY F/U. I/M RPTD DOING WELL. CONFRONT
ED I/M REGARDING SENDING INAPPROPRIATE STAFF REQUESTS WHEN HE'S UPSET. I/M
APOLOGIZED FOR BEHAVIOR AND AGREED TO CONSIDER CONSEQUENCES OF HIS BEHAVIO
R. I/M RPTD EATING AND SLEEPING vINL. I/M DENIED A/VH, S/HI, MEDICATION SI
DE EFFECTS AND DELUSIONS OF ANY KIND. I/M CONTINUES TO BE HOUSED IN AN ONE
-MAN CELL ON LOCK.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS, ORIENTED X3, GOOD MOOD AND HYGIENE.
P-CONTINUE TO MONITOR.
LORETTA AIKEN, HSCI
SIGNED OFF, ON 07/08/11 @ 13:05 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00785 MENTAL HEALTH CLI 07/08/11 08:03 LIEBER CORR INST
COMP
INC NOTE: STAFFED UPDATED TREATMENT PLAN W/TREATMENT TEAM ON 07/06/11.
LORETTA AIKEN, HSCI
SIGNED OFF ON 07/08/11 @ 8:03 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00784 MENTAL HEALTH CLI 07/07/11 11:14 LIEBER CORR INST
COMP
WILL RENEW STELAZINE AND COGENTIN. WILL D/C SEROQUEL IF HE DOESN'T ALLOW L
ABWORK.
TRIFLUOPERAZINE
2MG
SIG:TAKE FOUR PO QHS
SIG:
START DATE: 07/07/11 TOTAL DAYS: 90
MD:WOOD,BEVERLY
BENZ TROPINE
1MG
SIG:TAKE ONE PO QAM AND TWO PO QHS
SIG:
START DATE: 07/07/11 TOTAL DAYS: 90
MDIWOOD,BEVERLY
LABS: FASTING CMP, LIPID PANEL. BWOODMD
SIGNED OFF ON 07/07/11 @ 11:16 BY BEVERLY A WOOD, PSYCHIATRIST
MED DIRECT TRANSMIT TO KCI PHARMACY. LIEBER MAR UPDATED. LAB SLIP FILLED
OU'1' AND APPT ENTERED IN LAB BOOK.
SIGNED OFF ON 07/08/11 @ 9:53 BY LUANNE W MAUNEY, REGISTERED NURSE II
ENCOUNTER 00763 MENTAL HEALTH CLI 06/30/11 13:18 LIEBER CORR INST
COMP
INC NOTE: UPDATED TREATMENT PLAN-DIAGNOSIS: SCHIZOPHRENIA, UNDIFF. MEDIC
ATIONS: SEROQUEL, COGENTIN, AND STALAZINE. MED CLASS: L3. NEXT UPDATE: 09/
30/11.

CONFIDENTIAL

P130-040

6875-EEEE-134

c:·

LORETTA AIKEN, HSCI
'SIGNED OFr ON 06/30/11 @ 13;19 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
** ENCOUNTER 00782 INSIDE APPOINTMEN 06/19/11 11:29 LIEBER CORR INST
COMP
I/M WAS GIVEN THE TOENAIL CLIPPERS AND AFFORDED THE OPPORTUNITY TO CLIP HIS
FINGER/TOENAILS UNDER CLOSE SUPERVISION OF OFFICER HARTMAN. THIS TASK WAS
COMPLETED WITHOUT ANY INCIDENT OR INJURY.
SIGNED OFF ON 06/19/11 @ 11:32 BY JENNIFER L SCOTT, REGISTERED NURSE I
** ENCOUNTER 00781 EMERGENCY INHOUSE 06/11/11 20:31 LIEBER CORR INST
COMP
S> I/M COMPLAINED OF "HEART PAIN' '. I/M WAS TAKEN TO TREATMENT ROOM AND VITA
S> LS TAKEN. I/M STATED THAT PAIN WAS IN STOMACH AND RADIATING UP,
0> TEMP=098.8
PULSE= 80
RESP=20
BP=118/ 82
WEIGHT= 0
PPD= 0
0> I/M'S LUNGS CLEAR BILATERALLY. I/M HAS NO SIS OF SOB. I/M RATED A PAIN LE
0> VEL OF 10/10 ON PAIN SCALE. I/M APPEARS TO BE IN NO CURRENT RESPIRATORY DI
0> STRESS. I/M INSTRUCTED TO FILL OUT A FORM FOR SICK HALL TO SEE MD.
SIGNED OFF ON 06/11/11 @ 20;34 BY LAUREN L WISHMAN, LICENSED PRACTICAL NURSE
** ENCOUNTER 00760 MENTAL HEALTH CLI 06/09/11 13:56 LIEBER CORR INST
COMP
D-MET WITH I/M ON 06/06/11 FOR MONTHLY F/U. I/M REMAINS ON LOCK-UP. r/M R
PTD DOING "OK". r/M CONTINUES TO RPT A/VH. AGAIN DISCUSSED GOING TO REC
, WHICH HE ASSURED CC HE WOULD DO. I/M RPTD EATING AND SLEEPING WNL. I/M D
NIED S/HI, MEDICATION SIDE EFFECTS AND DELUSIONS OF ANY KIND. r/M IS HOUSE
o ALONE. GAVE I/M PUZZLES.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS, ORIENTED X3, GOOD HYGIENE AND MOOD.
P-CONTINUE TO MONITOR lAW POLICY.
LORETTA AIKEN, HSCI
SIGNED OFF ON 06/08/11 @ 14:00 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
** ENCOUNTER 00779 MENTAL HEALTH CLI 05/16/11 12:23 LIEBER CORR INST
COMP
S: 1M REFUSED TO COME TO CLINIC. I WENT TO CELL DOOR AND HE STARTED YELLIN
G TO "GET AWAY". HAD BEEN YELLING AT OFFICERS EARLIER. ASKED IF HE HAD AN
Y PROBLEMS AND HE SAID THAT I WAS HIS PROBLEM. I HAVE NEVER PROVIDED TREAT
MENT TO HIM. NOTE THAT HE REFUSED LABS FOR SIDE EFFECTS OF SEROQUEL.
P: CONTINUE MEDS FOR NOW.
LABS: FASTING GLUCOSE, LIPID PANEL. SEROQUEL WILL NOT BE CONTINUED IF
HE DOESN'T HAVE LABS TO CHECK FOR SIDE EFFECTS. BWOODMD
SIGNED OFF ON 05/16/11 @ 12:26 BY BEVERLY A WOOD, PSYCHIATRIST
LAB FORMS FILLED OUT. LABS ADD TO LAB BOOK AND RETURNED TO LAB.
SIGNED OFF ON 05/16/11 @ 15:52 BY SHARON
TISON, REGISTERED NURSE I
** ENCOUNTER 00778 MENTAL HEALTH eLI 05/11/11 15:00 LIEBER CORR INST
COMP
D-MET WITH I/M ON 05/06/11 FOR MONTHLY F/U. I/M CONTINUE TO RPT A/V/TH. I
/M RPTD SEEING SHADOWS, FEELINF SOMETHING CRAWL ON HIM AND VOICES. 11M RPT
D KEEPING HIS LIGHT ON HELP WITH THE SHADOWS. I/M RPTD EATING AND SLEEPING
WNL, AS WELL AS MEDICATION COMPLIANT. I/M STATED HE WOULD START GOING OUT
TO REC. 11M DOES NOT HAVE A CELLMATE. I/M DENIED MEDICATION SIDE EFFECTS
AND S/HL
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS, ORIENTED X3, GOOD HYGIENE AND MOOD.
P-CONTINUE TO MONITOR.
LORETTA AIKEN, HSCI
SIGNED OFF ON 05/11/11 @ 15:06 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
** ENCOUNTER 00777 MENTAL HEALTH CLI 05/10/11 09:36 LIEBER CORR INST
COMP.
INC NOTE;
I/M SCHEDULED TO BE SEEN IN PSYCH CLINIC 5/13/11.
SIGNED OFF ON 05/10/11 @ 9:37 BY TANYA F MCCANTS, HUMAN SERVICES COORD I
** ENCOUNTER 00776 MENTAL HEALTH CLI 04/11/11 12:18 LIEBER CORR INST
COMP
D-ME'l' WITH I/M FOR MONTHLY F'/U ON 04/07/11. I/M RPTD EATING AND SLEEPING W
NL. I/M CONTINUE TO RPTS TACTILE AND AUDITORY HALLUCINATIONS. I/M RPTD NO
T GOING OUT TO REC(FEELS COMFORTABLE IN CELL). I/M Dru~IED V/H, MEDICATION

CONFIDENTIAL

6875-EEEE-135

SIDE EFFECTS AND DELUSIONS. I/M FEELS COMFORTABLE THAT HE CAN MANAGE HIS M
ASTURBATION.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS, ORIENTED X3, GOOD HYGIENE AND MOOD.
P-CONTINUE TO MONITOR.
LORETTA AIKEN, HSCI
SIGNED OFF ON 04/11/11 @ 12:22 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00775 MENTAL HEALTH CLI 03/30/11 13:26 LIEBER CORR INST
COMP
INC NOTE: STAFFED TREATMENT PL UPDATE WITH TREATMENT TEAM. NEXT UPDATE: 06/
30/11. DX: SCHIZOPHRENIA, UNDIFF. MEDS: STALAZINE SEROQUEL AND COGENTIN.
MED CLASS: L3. TACTILEiVISUAL HALLUCINATIONS.
LORETTA AIKEN, HSCI
SIGNED OFF ON 03/30/11 @ 13:28 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00774 MENTAL HEALTH CLI 03/29/11 15:09 LIEBER CORR INST
COMP
INC NOTE: UPDATED· TREATMENT PLAN. DIAGNOSIS: SCHZIPHRENIA, UNDIFF. MEDICA
TIONS: SEROQUEL 400MG BID, COGENTIN IMG QAM AND 2MG QHS, STALAZINE 8MG QHS.
MED CLASS: L3. NEXT UPDATE: 06/30/11. I/M EXPERIENCES TACTILE AND VISUAL
HALLUCINATIONS.
LORETTA AIKEN, HSCI
SIGNED OFF ON 03/29/11 @ 15:11 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
NARRATIVE 00773 NARRATIVE
03/22/11 01:40 LIEBER CORR INST
COMP
SIGNS UP FOR SICK CALL THEN REFUSES TO BE SEEN, WILL CONT. TO TRY TO SEE HI
M AS OFTEN AS HE PUTS IN SICK CALL REQUEST.
SIGNED OFF ON 03/22/11 @ 1:41 BY BRENDA K KEAY, LICENSED PRACTICAL NURSE
ENCOUNTER 00772 MENTAL HEALTH CLI 03/14/11 14:57 LIEBER CORR INST
COMP
D-MET WITH I/M FOR I/C ON 03/10/11. 11M REMAINS OF LOCK-UP. I/M RPTD EATI
NG AND SLEEP~NG WNL. I/M RPTD A/V/TH(SHOWDOW AND FEELING AS IF SKINS ON FI
RE). I/M DENIED S/HI AND MEDICATION SIDE EFFECTS. I/M RECIEVED A MASTURBA
TION CHARGE WHICH HE FELT THAT HE SHOULD NOT HAVE GOTTEN BECAUSE HE WAS LYI
NG IN HIS BED AWAY FROM THE DOOR. DISCUSSED POLICY REGARDING MASTURBATION.
I/M RPTD ENGAGING IN RECREATION OCASSIONALLY.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS, ORIENTED X3, GOOD HYGIENE AND MOOD.
P-CONTINUE TO'MONITOR.
LORETTA AIKEN, HSCI
SIGNED OFF ON 03/14/11 @ 15:05 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00771 LAB CLINIC
02/17/11 09:29 LIEBER CORR INST
COMP
I/M REFUSED LABWORK. EXPLAINED TO 11M THAT THE DOCTOR MAY HAVE ORDERED THIS
SO THAT MEDICATION CAN CONTINUE. I/M STATES THAT COMMISSARY HAS LOST CLOTHE
S AND HE HAS NO UNDERWEAR. STATES "I'M NOT DOING ANYTHING." EXPLAINED THAT
I WOULD BRING A REFUSAL FOR HIM TO SIGN. I/M STATED, "SIGN THE F--ING
THING YOURSELF. I AIN'T SIGNING IT." REFUSED TO SIGN OR HAVE LABS DRAWN.
SIGNED OFF ON 02/17/11 @ 9:33 BY LUANNE W MAUNEY, REGISTERED NURSE I
SIGNED OFF ON 02/22/11 @ 1Q:43 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00770 MENTAL HEALTH CLI 02/14/11 13:31 LIEBER CORR INST
COMP
D-MET WITH ,I/M FOR I/C ON 02/11/11. I/M RPTD DOING WELL; I/M DENIED A/VH,
S/HI, MEDICATION SIDE AFFECTS AND DELUSIONS OF ANY KIND. I/M C/O NOT RECEI
VING SNAKES WHICH HAD BEEN ORDER BY THE DOCTOR.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS, GOOD HYGIENE AND MOOD, ORIENTED X3. ,
P-CONTINUE TO MONITOR.
LORETTA AIKEN, HSCI
SIGNED OFF ON 02/14/11 @ 13:33 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
NARRATIVE 00769 NARRATIVE
02/09/11 02:45 LIEBER CORR INST
COMP
I/M REFUSED SICK CALL.
SIGNED OFF ON 02/08/11 @ 2:46 BY JENNIFER L SCOTT, REGISTERED NURSE I
NARRATIVE 00768 NARRATIVE
01/26/11 18:52 LIEBER CORR INST
COMP

CONFIDENTIAL

P130-042

6875-EEEE-136

(;

p>
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DR. BABB, THIS 1M STATES THAT HE WAS ALLOWED TO HAVE SNACKS BID WITH MEDICA
ITONS-- HOWEVER, (STATES THE 1M) THE KITCHEN HAS NOT SENT THE SNACKS TO HIS
CELL (PERHAPS THE 1M IS MISTAKEN AND IT WAS DR. MULBERRY WHO HAS AUTHORIZE
D SNACKS) IF YOU HAVE NOT ALLOWED SNACKS, COULD YOU FORWARD THIS Nor TO DR.
MULBERRY PLEASE SO THAT HE COULD SAY TAKE THE NESS. STEPS TO NOTIFY THE KI
THCHEN TO DELIEVER SNACKS TO MAX. THANK YOU.
SIGNED OFF ON 01/26/11 @ 18:57 BY TOBY
MARKOWITZ, REGISTERED NURSE I
I HAVE SEEN THIS I/M ONLY ONCE IN LAST 2 YRS. AND HE IS NOT DIABETIC. I DID
NOT AUTHORIZE SNACKS. WILL SEND TO PSYCH.
SIGNED OFF ON 01/28/11 @ 8:58 BY ROBERT E BABB, UNCLASSIFIED
SIGNED OFF ON 02/01/11 @ 16:40 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
NARRATIVE 00767 NARRATIVE
01/26/11 18:44 LIEBER CORR INST
COMP
DR. BABB, THIS 1M STATES THAT HE WAS OK'ED FOR SNACKS 2 BID WITH HIS MEDICA
TION, HOWEVER HE STATES THAT THE KITCHEN HAS NOT (FOR WHATEVER REASON) DELI
VERED HIS SNACKS. IF YOU ARE UNAWARE OF THIS 1M GIVING SNACKS (IF HE IS IND
EED FACTUAL) THEN PERHAPS ITS DR. MULBERRY WHO OK'ED THE SNACKS (COULD YOU
FORWARD THE THIS NOTE TO DR. MULBERRY) SO HE CAN SAY YES OR NO. THANK YOU.
SIGNED OFF ON 01/26/11 @ 18:52 BY TOBY
MARKOWITZ, REGISTERED NURSE I
ENCOUNTER 00766 MENTAL HEALTH CLI 01/14/11 09:56 LIEBER CORR INST
COMP
D~MET WITH I/M FOR IHD COUNSELING ON 01/12/11; I/M C/O OF HUNGER. I/M RPTD
MEDICATION MADE HIM HUNGRY AND THAT THE TREATING PSYCHIATRIST ORDER SNACKS
WHICH HE HAD NOT BEEN GETTING. I/M RPTD A/H, HOWEVER STD THEY WERE MANAGEAB
LE. I/M DENIED V/H, T/H, S/HI, MEDICATION SIDE AFFECTS AND DELUSIONS OF ANY
KIND.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS, ORIENTED X3, GOOD HYGIENE AND MOOD.
LORETTA AIKEN, HSCI
SIGNED OFF ON 01/14/11 @ 10:08 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00765 MENTAL HEALTH CLI 01/11/11 12:11 LIEBER CORR INST
COMP
39 YO AAM SEEN FOR FOLLOWUP, HE SAYS THAT HE IS DOING PRETTY WELL, MOODS
GOOD AND STABLE, NOT SAD OR DEPRESSED, NO SI HI, STILL SOME VOICES BUT NOT
TO MUCH A BOTHER, NO TACTILE, NO VH, NOT STIFF NOT ABN MVTS, NOT FEARFUL.
NO SIDE EFFECTS, NOT TO IRRITABLE NOT ANGRY NO ABN MVTS NOT STIFF
o
CALM AND COOPERATIVE, SPEECH NL R/V/P, TP LINEAR AND GD, TC NO SI HI A
AVH, MEM AND CONC GOOD NOT STIFF NO TD
A
SCHIZOPHRENIA
BETTER ON STELLAZINE 8
P
WILL CONTINUE STELAZINE 8, COGENTIN 1 AM AND 2 HS,
NEW NF FOR SEROQUEL 400 BID
LAST LABS NOT DONE
PLEASE DRAW FBS, LIPIDS
FOLLOWUP ABOU'l' 8 WEEKS
PLEASE ORDER EVENING SNACK, DISCUSSED METABOLIC WITH PT
TRIFLUOPERAZINE
2MG
SIG:FOUR TABLETS PO QHS
SIG:
START DATE: 01/11/11 TOTAL DAYS: 180
MD:MULBRY,L. WILLIAM
1MG
BENZTROPINE
SIG:ONE TABLET PO QAM AND TWO TABLETS PO QHS
SIG:
START DATE: 01/11/11 TOTAL DAYS: 180
MD:MULBRY,L. WILLIAM
SIGNED OFF ON 01/11/11 @ 12:20 BY LEONARD W MULBRY JR, UNCLASSIFIED
LAB ORDERS PLACED IN LAB BOOK
MEDICATION ORDERS TRANSMITTED TO PHARMACY AND MAR UPDATED
SIGNED OFF ON 01/11/11 @ 18:11 BY LINDA E JONES, REGISTERED NURSE I
NARRATIVE 00764 NARRATIVE
01/04/11 07:39 LIEBER CORR INST
COMP

CONFIDENTIAL

P130-043

6875-EEEE-137

**
0>

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**
**

r/M REQUESTED HIS AMMONIUM LACTATE 12% CREAM BE REORDERED. I/M C/O
REOCCURING RASH ON HANDS AND LEGS. I/M RE~ORTS POSITIVE RESULTS WITH THIS
CREAM IN THE PAST. INFORMATION PLACED ON EXPIRED MEDICATIONS FORWARDED TO
MD BOARD.
SIGNED OFF ON 01/04/11 @ 7:43 BY JENNIFER L SCOTT, REGISTERED NURSE I
ENCOUNTER 00763 MENTAL HEALTH CLI 12/15/10 10:53 LIEBER CORR INST
COMP
D-MET WITH I/M FOR IND. COUNSELING. I/M RPTD DOING WELL. I/M DENIED A/VH,
S/HI, MEDICATION SIDE AFFECTS AND DELUSIONS OF ANY KIND. I/M RPTED EATING
AND SLEEPING WNL.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS, GOOD HYGIENE, GOOD MOOD, ORIENTED X3.
P-CONTINUE TO MONITOR.
LORETTA AIKEN, HSCI
SIGNED OFF ON 12/15/10 @ 10:55 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00762 MENTAL HEALTH CLI 11/23/10 14:11 LIEBER CORR INST
COMP
D-MET WITH I/M FOR IND. COUNSELING; I/M RPTD DOING WELL. I/M C/O OF NOT RE
CEIVING MEDICTION FOR THE PAST THREE DAY, HOWEVER MAR INDICATES TO THE CONT
RARY. I/M RPTD EATING AND SLEEPING vlNL BUT CONTINUES TO RPT A/VH. I/M IS D
OIN WELL WITH NOT MASTURBATING. I/M DENIED, S/HI, MEDICATION SIDE AFFECTS
AND DELUSIONS OF ANY KIND.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED/
LOGICAL THOUGHTS, ENGAGED IN DISCUSSION AS A CONTRIBUTOR, GOOD HYGIENE, ORI
ENTED X3.
P- CONTINUE TO MONITOR.
LORETTA AIKEN, HSCI
SIGNED OFF ON 11/23/10 @ 14:18 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00761 SICK CALL
11/23/10 04:55 LIEBER CORR INST
COMP
BP= 0/ 0
WEIGHT=188
PPD= 0
TEMP=098.6
PULSE= 0
RESP= 0
KJSCULOSKELETAL DISCOMFORT
1. SEE S.O. #27.
2. ACETAMINOPHEN 325 MG. TABS 2 PO QID X 3 DAYS OR IBUPROFEN 400 MG. TABLETS
2 P.O.TID PRN X 3 DAYS. DOCUMENT MEDS GIVEN IN AHR.
3. IF PALPABLE MUSCLE SPASMS PRESENT, CHLORZOXAZONE 500MG.TABS PO QID X
3 DAYS.
4. FOR LOWER BACK DISCOMFORT, USE A ROLLED TOW~L ONDER LOW BACK X 5 DAYS.
5. WILLIAM FLEXION EXERCISE(SCDC FORM 24-146) FOR CHRONIC LOW BACK PAIN.
6. RESTRICT STRENUOUS ACTIVITES OR REST THE INVOLVED AREA.
7. HEAT (BY SHOWER, MorST COMPRESSES OR HOT t'l'ATER SOAKS) TO THE INVOLVED
AREA QID X 3 DAYS.
GIVEN STARTER PACK OF CHLORZOXAZONE INSTRUCTED I/M TO NOTIFY MED.IF INEFFE
CTIVE ALREADY R/O KIDNEY STONE AND XRAYS WERE NEG.
SIGNED OFF ON 11/23/10 @ 4:58 BY DENISE
ARGENTINO, LICENSED PRACTICAL NUR
ENCOUNTER 00760 FOLLOW-UP SICK CA 11/23/10 04:53 LIEBER CORR INST
COMP
OPENED IN ERROR
SIGNED OFF ON 11/23/10 @ 4:55 BY DENISE
ARGENTINO, LICENSED PRACTICAL NUR
ENCOUNTER 00759 MENTAL HEALTH CLI 11/10/10 16:09 LIEBER CORR INST
COMP
CORRECTION TO ENCOUNTER 759: DATE IS 11/05/10.
LORETTA AIKEN, HSCI
SIGNED OFF ON 11/10/10 @ 16:09 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00758 MENTAL HEALTH CLI 11/10/10 15:47 LIEBER CORR INST
COMP
INC NOTE: UNABLE TO SEE I/M ON 11/07/10 DUE TO SECURITY ISSUES.
LORETTA AIKEN
SIGNED OFF ON 11/10/10 @ 15:49 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
NARRATIVE 00757 NARRATIVE'
10/28/10 16:11 LIEBER CORR INST
COMP
I/M REQUESTS DIAL SOAP FOR VERY DRY, ITCHY SKIN. HE STATES HE HAS BEEN GETT
ING DIAL SOAP FOR QUITE A WHILE. NO EVIDENCE SEEN OF THIS. HE HAS, HOWEVER
f
BEEN TREATED FOR DRY, ITCH SKIN WITH AMMONIUM LhCTATE CREAM IN THE PAST.

CONFIDENTIAL

P130-044

6875-EEEE-138

HE STATES THE REGULAR ISSUED SOAP IN MAX IS REALLY BAD + DRIES OUT HIS SKIN
THANK YOU.
SIGNED OFF ON 10/28/10 @ 16:17 BY JAN MARIA
PITT~~, REGISTERED NURSE II
41 YO SMU INMATE
DIAL SOAP IS NOT MEDICALLY NECESSARY
THOMASE BYRNE MD
SIGNED OFF ON 10/29/10 @ 10:15 BY THOMAS E .BYRNE, PHYSICIAN II
** ENCOUNTER 00756 FOLLOW-UP SICK CA 10/13/10 14:27 LIEBER CORR INST
COMP
I/M INFORMED BY POLLARD, LPN THAT U/A WAS NEGATIVE. I/M VERBALIZED UNDERSTANDING.
SIGNED OFF ON 10/13/10 @ 14:28 BY LUANNE W MAUNEY, REGISTERED NURSE I
** ENCOUNTER 00755 BLOOD PRESSURE CL 10/12/10 17:34 LIEBER CORR INST
COMP
CALLED TO l1AX BY CO. I/M COMPLAINING THAT HE KNOWS HIS BP IS HIGH. BP
130/92. COMPLAINS OF CHEST HURTING WHEN HE TAKES A REALLY DEEP BREATH. NO
APPARENT DISTRESS NOTED. RESPIRATIONS 24 AND REGULAR. STATES HIS NOSE IS
STUFFY AND HIS THROAT IS VERY DRY FROM BREATHING THROUGH HIS MOUTH. I/M
INSTRUCTED TO SIGN UP FOR SICK CALL AND ASK FOR CTM; INCREASE FLUID INTAKE;
I/M VERBALIZED UNDERSTANDING.
SIGNED OFF ON 10/12/10 @ 17:39 BY LUANNE W MAUNEY, REGISTERED NURSE I
** ENCOUNTER 00754 MENTAL HEALTH CLI 10/11/10 17:04 LIEBER CORR INST
COMP
D-MET WITH I/M ON 10/07/10 FOR IND' COUNSELING; I/M RPTD DOING "OK". I/M C/O
OG A/A AND WANTING TO SEE HIS TREATING PSYCHIATRIST. lIM FEELS THAT HE NE
EDS MORE ,HEDICATION TO COPE WITH A/H. 1/1'1 DENIED V/H, S/HI, NEDICATION SID
E AFFECTS AND DELUSIONS OF ANY KIND. I/M RPTD TACTILE HALLUCINATION(BUGS C
RAWLING ON HIM). I/M RPTD EATING AND SLEEPING WNL.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS, GOOD HYGIENE, ORI~NTED X3.
P-CONTINUE TO MONITOR.
LORETTA AIKEN, HSCI
SIGNED OFF ON 10/11/10 @ 17:08 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
** ENCOUNTER 00753 MENTAL HEALTH CLI 10/05/10 08:38 LIEBER CORR INST
COMP
INC NOTE: DISCUSSED WITH TREATMENT TEAM ON 10/01/10 UPDATED TREATt1ENT PLAN

**
S:>
0>

A:>

LORETTA AIKEN, HSCI
SIGNED OFF ON 10/05/10 @ 8:40 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00752 DOCTOR'S CLINIC
09/27/10 15:08 LIEBER CORR INST
COMP
URINALYSIS IS NORMAL.
SIGNED OFF ON 09/27/10 @ 15:09 BY ROBERT E BABB, UNCLASSIFIED
ENCOUNTER 00751 LAB CLINIC
09/23/10 08:44 LIEBER CORR INST
COMP
URINE COLLECTED FOR DIP UA AS ORDERED.
FASTING. NO PROBLEMS
SIGNED OFF ON 09/23/10 @ 8:45 BY GWENDOLYN
TAYLOR-BISHOP, MEDICAL ASSISTA
ENCOUNTER 00750 SICK CALL
09/17/10 00:46 LIEBER CORR INST
COMP
"1M HAVING KIDNEY PAINS AGAIN AND I NEED MY TOENAILS CUT."
TEMP=098.1
PULSE= 0
RESP= 0
BP= 0/ 0
WEIGHT=223
PPD= 0
GIVEN TOENAIL CLIPPERS,INSTRUCTED I/~ TO INCREASE FLUID INTAKE AND
TAKE MOTRIN FOR PAIN I/M BELIEVES PAIN TO BE KIDNEY RELATED REQUESTING
F/U BY MD
SIGNED OFF ON 09/17/10 @ :52 BY DENISE
ARGENTINO, LICENSED PRACTICAL NUR
DIP UA
SIGNED OFF ON 09/21/10 @ 15:26 BY BENJAMIN F LEWIS JR, PHYSICIAN II
LAB WRITTEN IN LAB BOOK.
SIGNED OFF ON 09/21/10 @ 15:30 BY LUANNE 1il MAUNEY, REGISTERED NURSE I
ENCOUNTER 00749 MENTAL HEALTH CLI 09/10/10 08:30 LIEBER CORR INST
COMP
D-NET WITH I/M FOR IND. COUNSELING; I/M C/O CONSISTENTLY PACING. I/M RPTD
EATING AND SLEEPING WNL, AS vlELL AS MEDICATION COMPLIANCE. I/M DENIED S/H
I AND VIR.
1/1'1 ADMITS TO A/H, HOWEVER STATED HE WAS ABLE TO MANANGE THEM.

C~
CONFIDENTIAL

P130~045

6875-EEEE-139

('
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I/M INTERACTS APPROPRIATELY WITH STAFF AND PEERS.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED/
LOGICAL THOUGHTS: PACING WHICH MAYBE SIDE AFFECT
P-CONTINUE TO MONITOR.
LORETTA AIKEN, HSCI
SIGNED OFF ON 09/10/10 @ 8:37 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00748 MENTAL HEALTH CLI 09/08/10 15:49 LIEBER CORR INST
COMP
39 YO AAM SEEN FOR FOLLOW UP. PATIENT SAYS HE IS NOT DOING WELL, HE IS HEAR
ING MORE VOICES, AND COMPLAINS OF TACTILE HALLUCINATIONS- BUGS CRAt'lLING ON
ME. DEPRESSED ABOUT THESE HALLUCINATIONS, OTHERWISE OKAY, NO SI HI. DID NOT
DESCRIBE VH OR P. TACTIL HALLUCINATIONS CAUSE RESTLESSNESS AND ANGER AND I
RRITABILITY. NOT STIFF NO ABNORMAL MOVEMENTS. NO SIDE EFFECTS.
o
RESTLESS BUT COOPERATIVE, SPEECH A BIT LOUD AND A BIT FAST BUT NOT PRE
SSURED, TP LINEAR AND GO, TC NO SI HI, SOME AH, NO ~i OR P, MEMORY AND CONC
GOOD, NO TO, NOT STIFF
A
SCHIZOPHRENIA
P
PATIENT SAYS STELAZINE WORKS WELL, WANTS MORE, WILL GO TO 8
DISCUSSED MOTOR SIDE EFFECTS
INC COGENTIN 1 QAM AND 2 QHS
CONT SEROQUEL 400 BID, FILLED OUT NEvl NF
PLEASE DRAW LABS, FBS AND LIPIDS
ROUTINE FOLLOW UP
BBNZTROPINE
1MG
SIG:1 TAB PO QAM AND TWO TABS PO QHS
SIG:
START DATE: 09/08/10 TOTAL DAYS: lao
MD:MULBRY,L. WILLIAM
TRIFLUOPERAZINE
2MG
SIG:4 TAB PO QHS
SIG:
START DATE: 09/08/10 TOTAL DAYS: 180
MD:MULBRY,L. WILLIAM
SIGNED OFF ON 09/08/10 @ 16:04 BY LEONARD W ~ruLBRY JR, UNCLASSIFIED
LAB WRITTEN IN LAB BOOK. ORDER DIRECT TRANSMITTED TO PRARM. MAR MADE
AND GIVEN TO PHARM. NON FORM FAXED FOR SEROQUEL PENDING APPROVAL
COpy IN NONFORM BOOK ORIGINAL IN CHART.
SIGNED OFF ON 09/08/10 @ 20:05 BY KISHA
LINNEN, LICENSED PRACTICAL NURSE
ENCOUNTER 00747 MENTAL HEALTH CLI 09/03/10 15:53 LIEBER CORR INST
COMP
INC NOTE: CC WAS UNABLE TO SEE I/M TODAY DUE TO SECURITY SHORTAGE. CC WIL
L ATTEMPT AGAIN AT A LATER DATE.
LORETTA AIKEN, HSC
SIGNED OFF ON 09/03110 @ 15:55 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00746 EMERGENCY INHOUSE 08/27/10 19:20 LIEBER CORR INST
COMP
CALLED TO MAX. I/M COMPLAINS OF CHEST PAlN - MID CHEST. STARTED YESTERDAY.
APPEARS TO BE IN NO ACUTE DISTRESS. BP 142/96 P66 REG; OXYGEN SAT = 98%
I/M STATES HE HAS PM MEDS BUT HAS NOT TAKEN ANY YET. CO WILL GIVE ANTACID
AND IF SYMPTOMS CONTINUE, WILL CALL MEDIC1\L.
SIGNED OFF ON 08/27/10 @ 19:23 BY LUANNE W MAUNEY, REGISTERED N~RSE I
ENCOUNTER 00745 MENTAL HEALTH CLI 08/04/10 12:32 LIEBER CaRR INST
COMP
D-MET WITH I/M FOR INDIVIDUAL COUNSELING. I/M CONTINUES TO C/O A/V/H. I/M
REFUSED TO DISCUSS A/R WITH CC. HOWEVER DESCIBED V/R AS LIGHTS. I/M RPT
S EATING AND SLEEPING WNL. 1/1'4 RPTS NOT GOING TO REC, S'fATING HE PREFER TO
STAY IN. I/M DID RPT A DECREASE IN THE DESIRE TO MASTURBATE. I/M DENIES
S/R/I.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS:
P-CONTINUE ~O MONITOR.

CONFIDENTIAL

P130-046

6875-EEEE-140

SIGNED OFF ON 08/04/10 @ 12:39 BY LORF.TTA

AIKEN, HUMAN SERVICES COORD I
COMP

** ENCOUNTER 00744 MENTAL HEALTH CLI 08/03/10 10:14 LIEBER CORR INST

{',

\../

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LATE NOTE
D:MET WITH I/M FOR INDIVIDUAL COUNSELING ON 07/30/10. riM STATED HE WANTED
TO SEE DR. MULBRY BECAUSE HE WANTED TO TO COME OPF STELEZINE(FELT THE MEDI
CATIONS WAS NOT WORKING). I/M RPTS EATING "OK" AND NOT BEING ABLE TO SLEEP
DUE TO THE HEAT. I/M RPTS A/H(NON SPECIFIC). I/M DENIES MEDICATION SIDE A
FFECT, S/H/I AND V/H.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, COOPERATIVE, CALM, NORMAL
SPEECH, ORGANIZED THOUGHTS
P-CONTINUE TO MONITOR
LORETTA AIKEN, HSCI
SIGNED OFF ON 08/03/10 @ 10:19 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00743 MENTAL HEALTH CLI 07/26/10 10:26 LIEBER CORR INST
COMP
INC NOTE: STAFFED W/TREATMENT TEAM ON 07/23/10 REGARDING TP UPDATE
PRESENT: DR. RANSOM, MS. MCCANTS, MS. LEE AND MS BIRCH
LORETTA AIKEN, HSCI
SIGNED OFF ON 07/26/10 @ 10:27 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00742 MENTAL HEALTH CLI 07/08/10 10:24 LIEBER CORR INST
COMP
39 YO AAM SEEN FOR FOLLOWUP, HE SAYS HE IS DOING FINE, HE SAYS MOOD IS OK
NOT SAD OR DEPRESSED, NO SI HI, NOT TO IRRITABLE, OR ANXIOUS, MOOD STABLE,
NO AVH, NO SIDE EFFECTS, NO COMPLAINTS, NOT STIFF, NO ABN MVTS
o
CALM QUIET, SPEECH SPARSE NL R/V/P, TP APPROP, TC NO SI HI AVH, MEN AND
CONC FAIR, NOT STILL NOT TD
A
SCHIZOPHRENIA
P
CONTINUE STELAZINE 5, COGNETIN 1 BID, AND SEROQUEL 400BID
FILLED OUT NF.
PLEASE DRAW LABS, FBS AND LIPIDS
ROUTINE F/U
TRIFLUOPERAZINE
5MG
SIG:ONE TAB PO QHS
SIG:
START DATE: 07/08/10 TOTAL DAYS: 180
MD:MULBRY,L. WILLIAM
BENZTROPINE
1MG
SIG:ONE TAB PO BID
SIG:
,
START D~TE: 07/08/10 TOTAL DAYS: 160
MD:MULBRY,L. WILLIAM
SIGNED OfF ON 07/08/10 @ 10:31 BY LEONARD W MULBRY JR, UNCLASSIFIED
MEDICATION ORDERS TRANSMITTED DIRECTLY TO PHARMACY AND MAR COMPLETED.
SIGNED OFF ON 07/12/10 @ 7:40 BY LINDA E JONES, REGISTERED NURSE I
ENCOUNTER 00741 MENTAL HEALTH CLI 06/15/10 12:47 LIEBER CORR INST
COMP
D-MET WITH 1/1'1 FOR INDIVIDUAL COUNSELING. 1/1'1 CONTINUES TO RPT A/H AND NEE
D NEED TO MASTURBATE WHICH HE ATTRIBUTS TO THE A/H.
I/M RPTS EATING A
ND SLEEPING WNL. I/M DENIES S/H/I AND MEDICATION SIDE AFFECTS.
A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, NORMAL SPEECH, ORGANIZED
THOUGHTS
P-CONTINUE TO MONITOR.
LORETTA AIKEN, HSCI
SIGNED OFF ON 07/23/10 @ 9:36 BY MELVIN
RANSOM, HUMAN SERVICES COORD II
ENCOUNTER 00740 LAB CLINIC
05/06/10 12:46 LIEBER CORR INST
COMP
I/M REFUSED TO HAVE LABWORK DONE
REFUSED TO SIGN FORM
REFUSAL FOR INIATED AND SIGNED BY THIS WRITER AND OFFICER
I/M LABWORK FOR DR. MULBRY
FBS AND LIPID PANEL

('.

'-/

CONFIDENTIAL

P130·047

6875-EEEE-141

SIGNED OFF ON 05/06/10 @ 12:47 BY GWENDOLYN

TAYLOR-BISHOP, MEDICAL ASSISTA
COMP
39 YO AAM SEEN FOR FOLLOWUP , HE SAYS HE HAS BEEN OFF MEDS AND FEELS MORE
'RILED' AND HAS BEEN CURSING OUT THE C/OS, HE SAYS HEARING MORE VOICES AND
MOOD MORE LABILE, NOT SAD OR DEPRESSED NO SI HI, VAGUE ABOUT VOICES , NO VH
NO SIDE EFFECTS ON THE MEDS.
o RESTLESS BUT COOPERATIVE, SPEECH NL R/V/P, TP LINEAR AND APPROP, TC NO
SI HI VH, MEM AND CONC FAIR
A SCHIZOPHRENIA
P STELAZINE 5 AND COGENT IN 1 BID RENEWED YESTERDAY
WILL TURN IN NF REQUEST FOR SEROQUEL 400 BID
ROUTINE F/U
PLEASE DRAW, FASTING BS AND LIPIDS
SIGNED OFF ON 04/28/10 @ 15:02 BY LEONARD W MULBRY JR, UNCLASSIFIED
ORDER DIRECT TRANSMITTED TO PHARM. LABS tqRITTEN IN LAB BOOK NON FORM
FAXED WRITTEN IN BOOK PENDING APPROVAL ORIGINAL IN CHART.
SIGNED OPF ON 04/28/10 @ 17:19 BY KISRA
LINNEN, LICENSED PRACTICAL NURSE
ENCOUNTER 00738 MENTAL HEALTH CLI 04/27/10 10:01 LIEBER CORR INST
COMP
MED RENEWAL REQUEST.
COGENTIN 1MG BID
STELAZINE 5MG QHS
NOTES INDICATE NON-FORMULARY FOR NEURONTIN TURNED IN BY DR. MULBRY
BENZTROPINE
1MG
SIG;ONE 'rABLET PO BID
SIG:
START DATE: 04/27/10 TOTAL DAYS: 180
MD; MELIKIAN, MARGARET
TRIFLUOPERAZINE
SMG
BIG:ONE TABLET PO QHS
SIG:
START DATE: 04/27/10 TOTAL DAYS: 180
MD:MELIKIAN,MARGARET SIGNED OFF ON 04/27/10 @ 10:03 BY MARGARET
MELIKIAN, UNCLASSIFIED
MED RENEWAL. MEDS DIRECT TRANSMIT TO PHARM. MAR TO BE COMPLETED WHEN STICKE
RS AND HED ARRIVE
SIGNED OFF ON 04/27/10 @ 12:31 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NUR
ENCOUNTER 00737 SICK CALL
04/23/10 01:53 LIEBER CORR INST
COMP
I/M SEEN IN SC. C/O RASH IN GROIN, ON LEGS ru.D LEFT AC AREA
TEMP=098.2
~ULSE~ 70
RESP~20
BP~152/ 74
WEIGHT=225
PPD~ 0
FUNGAL RASH (TINEA)
1. SEE S.O. #20.
2. WASH AREA WITH SOAP AND WATER, RINSE WELL , AND DRY THOROUGHLY,
FOLLOWED BY A THIN TOPICAL APPLICATION OF LOTRIMIN
CREAM BID X 4 WEEKS.
FOUND NO SUPPLY IN STOCK
SIGNED OFF ON 04/23/10 @ 1:56 BY SHANNA
MORRALL, LICENSED PRACTICAL NURSE
OBTAIN STANDING ORDER TREATMENT MEDS FOR I/M
SIGNED OFF ON 04/26/10 @ 19:34 BY WILBUR J JONES, NURSE PRACTITIONER III
WILL DELIVER MED TO MAX FOR I/M
SIGNED OFF ON 04/27/10 @ 7:39 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NUR
ENCOUNTER 00736 MENTAL HEALTH CLI 03/19/10 13:09 LIEBER CORR INST
COMP
D-MET WITH I/M FOR INDIVIDUAL COUNSELING. I/M WILLING CAME 'ro CELL DOOR AN
D ENGAGED IN DISCUSSION. 1/1'1 RPT A/H OF FAMILY VOICES(DECEASED GRANDFATHE
R) I/M STS MEDICATION DOES NOT HELP WITH HALLUCINATIONS. I/M DENIES A/H/I
AND MEDICATION SIDE AFFECTS. I/M RPTS EATING AND SLEEPING WNL. I/M RPTS
HE WANTS TO GO TO KIRKLAND SINCE THE PERSONS FOR WHOM HE HAD SEPERATIONS AR
E NO LONGER AT KIRLAND CI.

** ENCOUNTER 00739 MENTAL HEALTH CLI 04/28/10 14:53 LIEBER CORR INST

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CONFIDENTIAL

6875-EEEE-142

**
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A-PRESENTED WITH NORMAL AFFECT, GOOD EYE CONTACT, PSYCHOSIS WAS NOT EVIDENT
PARTIALLY DRESSED: SUSPECT MALINGERING
P-CONTINUE TO MONITOR PER MENTAL HEALTH POLICY.
LORETTA AIKEN, CCCIV
SIGNED OFF ON 03/19/10 @ 13:17 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
ENCOUNTER 00735 SICK CALL
02/05/10 07:18 LIEBER CORR INST
COMP
r/M SEEN IN SICK CALL C/O DRY SKIN STATES THE SOAP IS INEFFECTIVE, WANTS TO
SEE MD
TEMP~098.0
PULSE= 56
RESP=20
BP=120/ 60
WEIGHT=222
PPD= 0
VITALS LISTED ABOVE ARE INACURATE, UNABLE TO OBTAIN vis D/T I/~l AGGITATION
UNABLE TO ASSES I/M SKIN I/M STATED HE SIMPLY WANTS TO SEE THE DOCTOR, NO 0
NE ELSE
REFFER TO MD
DEFFERED
SIGNED OFF ON 02/05/10 @ 7:21 BY SHANNA
MORRALL, LICENSED PRACTICAL NURSE
NEEDS TO BE COOPERATIVE vlITH MEDICAL STAFF
r/M CAN PURCHASE LOTION FROM CANTEEN
SIGNED OFF ON 02/05/10 @ 14:40 BY WILBUR J JONES, NURSE PRACTITIONER III
NOTED.
SIGNED OFF ON 02/05/10 @ 15:35 BY KISHA
LINNEN, LICENSED PRACTICAL NURSE
ENCOUNTER 00734 MENTAL HEALTH CLI 01/19/10 12:07 LIEBER CORR INST
COMP
39YO AAM SEEN FOR ROUTINE FOLLOW-UP. HE STATES WORSENING VOICES AND "ANTS 0
N SKIN". SYMPTOMS PRESENT SINCE 1996 BUT WORSE NOW. EXPRESSES COMPLIANCE WI
TH MEDS. NOT SAD OR DEPRESSED, NO SI HI. NO OTHER HALLUCINATIONS, NOT PARAH
OlD. NO SIDE-EFFECTS. NOT STIFF, NO ABNORMAL MOVEMENTS, SLEEPS OK.
0: CALM, COOPERATIVE AND QUIET. MOOD "MORE VOICES". SPEECH NORMAL RVP. TP
APPBOPRIATE. TC NO HI OR SI, BUT AH AND TACTILE HALLUCINATIONS. MEMORY AND
CONCENTRATION ARE FAIR. NO STI~FNESS OR TD.
A: SCHIZOPHRBNIA
P: STELAZINE TO 5 QHS
SEROQUEL 400 BID ALREADY RBNEWED: WILL FILL OUT NON-FORMULARY REQUEST
COGENTIN 1 BID ALREADY RENEWED
ROUTINE FOLLOW-UP
PLEASE DRAW LABS: FASTING BLOOD SUGAR AND LIPIDS
TRIFLUOPERAZINE
5MG
SIG:1 TAB PO QHS
SIG:
START DATE: 01/19/10 TOTAL DAYS: 90
MD:MULBRY,L. WILLIAM
SIGNED OFF ON 01/19/10 @ 12:16 BY LEONARD W MULBRY JR, UNCLASSIFIED
MEDICATION t'lRITTEN ON MEDICATION SHEET.
SIGNED OFF ON 01/19/10 @ 15:00 BY PAULETTE L SEABROOK, LICENSED PRACTICAL NU
ENCOUNTER 00733 SICK CALL
01/15/10 07:10 LIEBER CORR INST
COMP
1M WAS BROUGHT TO SICK CALL ROOM TO USE NAIL CLIPPERS.
TEMP=098.2
PULSE= 0
RESP= 0
BP~
0/ 0
WEIGHT=200
PPD= 0
DEFERRED
DEFERRED
SIGNED OFF ON 01/15/10 @ 7:13 BY REBECCA L BREWER, LICENSED PRACTICAL NURSE
ENCOUNTER 00732 MENTAL HEALTH CLI 01/13/10 10:26 LIEBER CORR INST
COMP
COULD NOT SEE TODAY DUE TO SHORT STAFF WILL RENEW STELAZINE 2 BID, SEROQUEL
400 BID AND COGENTIN 1 BID, AND SEE NEXT WEEK.
TRIFLUOPERAZINE
2MG
SIG:ONE TABLET PO BID
SIG:
START DATE: 01/13/10 TOTAL DAYS: 90
MD:MULBRY,L. WILLIAM
SEROQUEL XR 400MG (NON-FORMULARY EFF. 2/14/2010)

r'
"

CONFIDENTIAL

P130-049

6875-EEEE-143

/',

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SIG:ONE TABLET PO BID
SIG:
START DATE: 01/13/10 TOTAL DAYS: 90
MD:MULBRY,L. WILLIAM
1MG
BENZTROPINE
SIG:ONE TABLET PO BID
SIG:
START DATE;' 01/13/10 TOTAL DAYS: 90
MD:MULBRY,L. WILLIAM
SIGNED OFF ON 01/13/10 @ 10:33 BY LEONARD W MULBRY JR, UNCLASSIFIED
ORDER DIRECT TRANSMITTED TO PHARM.
SIGNED OFF ON 01/13/10 @ 11:27 BY KISHA
LINNEN, LICENSED PRACTICAL NURSE
ENCOUNTER 00731 MENTAL HEALTH CLI 01/07/10 10,08 LIEBER CaRR INST
COMP
INC NOTE: MET WITH 1M ON LOCKUP. 11M APPEARED AGITATED AND COMPLAINED OF
TACTILE HALLUCINATION. I/M STATES WHILE,HE IS TAKING HIS MEDICATIONS HALLU
CINATIONS PERSISTS. 11M RPTS EATING AND SLEEPING WNL. RPTD A/H BUT REFUSED
TO BE SPECIFIC.
A-PRESENTED AGITATED BUT COOPERATIVE, EXPERIENCING TACTILE HALLUCINATIONS,
ORIENTED X3, ORGANIZED THOUGHTS.
LORETTA AIKEN, CCCIV
SIGNED OFF ON 01/07/10 @ 10:18 BY LORETTA
AIKEN, HUMAN SERVICES COORD I
NARRATIVE 00730 NARRATIVE
12/05/09 18:27 LIEBER CORR INST
CaMP
DURING MED PASS ON EVENING OF 12/05 I/M BARTON, STOPPED RN TO STATE THAT HE
WAS EXPERIENCING CHEST PAIN. UPON VISUALIZATION 11M DID NOT APPEAR IN ACUT
E DISTRESS. NO SHORTNESS OF BREATH WAS NOTED. SKIN WAS WARM AND DRY TO Toue
C. PULSE WAS EVEN AND REGULAR AT A RATE OF 78. 11M RATED HIS PAIN AT A 5/10
AND DID NOT RnDIATE TO NECK, ARM, JAW. ALSO DENIED ANY NUMBNE?S TO UPPER AND
OR LOWER EXTREMITIES. COLOR WAS APPROPRIATE TO RACE. ASKED TO EXPLAIN ACTIV
ITIES 11M STATES THAT THE PAIN INCRBASES WHEN HE LIES FLAT AND BEGAN THIS P
M SHORTLY AFTER EATING HIS NOON MEAL AND THEN LYING DOWN TO REST. PAIN DOES
NOT INCREASE WITH DEEP BREATHS AND OR STRENOUS ACTIVITY. REASSURANCE OFFER
ED WITH REGARDS TO SOURCE OF PAIN. ( PROBABLY ESOPHAGEAL SPASMS SINCE START
ED SHORTLY AFTER EATING AND LYING DOWN). 11M HAPPY WITH EXPLANATION. TOLD I
/M TO TAKE ASA IF NOT ON BLOOD THINNERS OR IBUPROFEN FOR PAIN. IF PAIN CONT
INUES COULD TAKE SOME MYLANTA TO SEE IF THAT RELIEVES THE PAIN. INSTRUCTED
TO KEEP MEDICAL INFORMED OF CONDITION OF CHEST DISCOMFORT.
SIGNED OFF ON 12/05/09 @ 18:52 BY MONIQUE
O'BRIEN, REGISTERED NURSE I
ENCOUNTER 00729 SICK CALL
11/18/09 03:57 LIEBER CORR INST
COMP
I NEED MY TOE NAILS CLIPPED OFF. IT'S BEEN TWO MONTHS AND NO ONE HAS REPLAC
ED THE BROKE ONES OVER HERE ON LOCK-UP, THEREFORE PLEASE BRING THEM ON YALL
S NEXT SICK CALL.
TEMP~097.2
PULSE= 55
RESP=18
BP=152/ 91
WEIGHT=205
PPD= 0
1M CLIPPED TOE NAILS.
DEFERRED
DEFERRED.
SIGNED OFF ON 11/18109 @ 4:00 BY REBECCA L BREWER, LICENSED PRACTICAL NURSE
ENCOUNTER 00728 INSIDE APPOINTMEN 10129/09 16:10 LIEBER CORR INST
CaMP
11M HAD FOLLOW UP APPOINTMENT WITH GEN SURGERY SIP REMOVAL OF R HIP MASS. N
EEDS FOLLOW UP PRN.R HIP HEALED.
SIGNED OFF ON 10/29/09 @ 16:12 BY KAREN J GOECKEL, REGISTERED NURSE I
NOTED
SIGNED OFF ON 10/30/09 @ 15:02 BY ROBERT E BABB, UNCLASSIFIED
ENCOUNTER 00721 MENTAL HEALTH eLI 10/26/09 15:20 LIEBER CORR INST
COMP
PROPER DOSE COGNETIN 1 BID
BENZ'l'ROP 1NE
1MG
SIG:ONE TABLET PO BID
SIG:

CONFIDENTIAL

P130-050

6875-EEEE-144

C·'"
j

I""

\..j

P> START DATE: 10/26/09 TOTAL DAYS: 90
P> MD:MULBRY,L. WILLIAM
SIGNED OFF ON 10/26/09 @ 15:21 BY LEONARD W MULBRY JR, UNCLASSIFIED
MEDS DIRECT TRANSMIT TO PHARM
SIGNED OFF ON 10/26/09 @ 16:45 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NUR
** ENCOUNTER 00726 MENTAL HEALTH CLI 10/26/09 15:0B LIEBER CORR INST
COMP
39 YO AAM SEEN FOR ROUTINE FOLLOWUP. HE SAYS THAT HE IS DOING FINE, NO
PROBLEMS. NOT SAD OR DEPRESSED, NO 51 HI, THOUGHT OK, NOT AFRAID, SOME
V
VOICES BUT NOT TO BAD, DOES NOT WANT MORE MED. NO VH, NOT STIFF, NO ABN
MVTS. SLEEPS OK, NO SIDE EFFECTS
. 0
CALM COOPERATIVE, POOR EYE CONTACT, MOOD 'OK' SPEECH SPARSE, TP
LINEAR AND GD TC NO 51 HI VH, MEM AND CONC GOOD,
SCHIZOPHRENIA
A
vlILL RENEW MEDS
P
STELAZINE 2 BID, SEROQUEL 400 BID, COGENTIN 2 BID
ROUTINE F/U
P> TRIFLUOPERAZINE
2MG
p> SIG:ONE TABLET PO BID
P> SIG:
P> START DATE: 10/26/09 TOTAL DAYS: 90
P> MD:MULBRY,L. WILLIAM
P> SEROQUEL XR 400MG
P> SIG:ONE TABLET PO BID
p> SIG:
P> START DATE: 10/26/09 TOTAL DAYS: 90
P> MD:MULBRY,L. WILLIAM
2MG
P> BENZ TROPINE
P> SIG:ONE TABLET PO BID
P> SIG:
P> START DATE: 10/26/09 TOTAL DAYS: 90
P> MD:MULBRY,L. WILLIAM
SIGNED OFF ON 10/26/09 @ 15:16 BY LEONARD W MULBRY JR, UNCLASSIFIED
MEDS DIRECT TRANSMIT TO PHARM
SIGNED OFF ON 10/26/09 @ 16:45 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NUR
** NARRATIVE 00725 NARRATIVE
10/09/09 10:55 LIEBER CORR INST
COMP
I/M APPT WITH GEN SURGERY CANCEL 10/8 DUE TO SECURITY COURT RUN.
SIGNED OFF ON 10/09/09 @ 10:56 BY EVELYN
GADSON, MEDICAL ASSISTANT TECH I
NOTED
SIGNED OFF ON 10/09/09 @ 19:05 BY CHESTER
OGRODNIK, REGISTERED NURSE I
** ENCOUNTER 00724 MENTAL HEALTH CLI 10/06/09 09:07 LIEBER CORR INST
COMP
MEDS ABOUT TO EXPIRE WILL RENEW AND SEE SHORTLY
COGENTIN 1 BID, STELAZINE 2 BID, SEOQUEL 400 BID,
P> BENZTROPINE
1MG
P> SIG:ONE TABLET PO BID
P> SIG:
P> START DATE: 10/06/09 TOTAL DAYS: 90
P> MD:MULBRY,L. WILLIAM
P> TRIFLUOPERAZINE
2MG
P> SIG:ONE TABLET PO BID
P> SIG:
P> START DATE: 10/06/09 TOTAL DAYS: 90
P> MD:MULBRY, L. WILLIAM
P> SEROQUEL XR 400MG
P> SIG:ONE TABLET PO BID
P> SIG:
P> START DATE: 10/06/09 TOTAL DAYS: 90
P> MD:MULBRY,L. WILLIAM

CONFIDENTIAL

P130-051

6875-EEEE-145

SIGNED OFF ON 10/06/09 @ 9: 10 BY T.EONARD W MULBRY JR, UNCLASSIFIED
M!!;DS DIRECT TRANSMIT TO PHARM
. SIGNED OFF ON 10/06/09 @ 9:53 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NUR
** ENCOUNTER 00723 OUTSIDE RECOMMEND 10/02/09 12:03 LIEBER CORR INST
COMP
I/M RETURN FROM SU~GICAL CLINIC ON 10/1/09 WITH THE FOLLOWING ORDERS
NO STRENOUS ACTIVITY OR LIFTING OVER 10 LBS X 4 WEEKS BOTTOM BUNK X 4 WEEKS
FOLLOW UP IN 1 WEEK FOR SUTURE REMOVAL SURGERY CLINIC. I/M MAY COVER
INCISION SITE AS DESIRED OR MAY LEAVE OPEN TO AIR. SEROQUEL XR 400 MG PO
BID, TRIFLUO PERAZINE 2 MG PO BID COGENTIN 1 MG PO BID, VIT D 400 lU 5
CAPS PO QD PERCOCET 5/325 1-2 MG PO Q 4-6 HOUR PRN PAIN X7 DAYS.
SIGNED OFF ON 10/02/09 @ 12:11 BY KISHA
LINNEN, LICENSED PRACTICAL NURSE
FOLLOW ABOVE RECOMMENDATIONS. BOTTOM BUNK FOR 4 WKS. PERCOCET ORDERED. RETURN TO SURGICAL CLINIC IN 1 WK. CONSULT WRITTEN.
SIGNED OFF ON 10/02/09 @ 12:47 BY ROBERT E BABB, UNCLASSIFIED
-CONSULT FAXED TO DR BENIOR,PERCOCET ORDER FAXED TO KIRKLAND PHARMACY AND GI
VEN TO PHARlV'ACY
SIGNED OPF ON 10/02/09 @ 12:59 BY CHESTER
OGRODNIK, REGISTERED NURSE I
** NARRATIVE 00722 NARRATIVE
10/01/09 13:24 KIRKLAND INFIRMARY
COMP
COGENTIN IMG PO BID
SIGNED OPF ON 10/01/09 @ 13:26 BY THERESA B NKRUMAH, REGISTERED NURSE I
** NARRATIVE 00721 NARRATIVE
10/01/09 12:08 KIRKLAND INFIRMARY
COMP
INMATE IS BEING DISCHARGED FROM KCI INFIRMARY TO LIEBER C.I VIA AMBULATORY
ESCORTED BY OFFICER. IN STABLE HEALTH CONDITION.
DIET--REGULAR
MEDS--SEROQUEL XR 400MG PO BID
TRIFLUOPERAZINE 2MG PO BID
THERAGRAM M 1TAB PO QD
VIT.D 400IU, 5 CAPS PO QD
PERCOCET 5/325, 1-2 TABS PO Q4-6HRS PRN PAIN X 7 DAYS
MAY COVER INCISION SITE AS DESIRED OR MAY LEAVE OPEN TO AIR.
NO STRENUOUS ACTIVITY OR LIFTING OVER 10LBS X 4 WEEKS
BOTTOM BUNK X 4 WEEKS
FOLLW-UP IN 1 WEEK FOR SUTURE REMOVAL AT SURGERY CLINIC.
DX---S/p EXCISION RIGHT HIP MASS
PLACED CALL AND REPORT WAS GIVEN TO NURSE BROWN.
SIGNED OFF ON 10/01/09 @ 12:26 BY THERESA B NKRUMAH, REGISTERED NURSE I
** ENCOUNTER 00720 OUTSIDE APPOINTME 09/23/09 12:45 LIEBER CORR INST
COMP
I/M SCHEUDLEWITH TUOMEY REGIONAL MEDICAL, 129 WASHINGTON ST. SUMTER SC. I/M
PRE-R~GISTER WITH LATOYTA. I/M SURGERY WITH DR. LAUZON AN EXCISION OF HIP MA
SS.
SIGNED OFF ON 09/15/09 @ 12:50 BY EVELYN
GADSON, MEDICAL ASSISTANT TECH I
I/M NEEDS TO BE NPO 9/22/09.
SIGNED OFF ON 09/15/09 @ 12:52 BY EVELYN
GADSON, MEDICAL ASSISTANT TECH I
ON TX BOOK FOR 9 22 09.
SIGNED OFF ON 09/15/09 @ 13:01 BY DEMPSEY C HOWARD, UNCLASSIFIED
09/14/09 15:05 LIEBER CORR INST
COMP
** NARRATIVE 00719 NARRATIVE
INMATE HAS BEEN SCHEDULED FOR SURGERY AT TUOMEY FOR 9/23/09.
NEEDS TO ARRIVE AT 7AM.
MUST BE PRE-REGISTERED.
MUST BE NFO PAST MIDNIGHT THE NIGHT BEFORE SURGERY.
SCHEDULED FOR AN EXCISION OF RIGHT HIP MASS WITH DR. LAUZON.
LIEBER WILL NEED TO TRANSPORT.
SIGNED OFF ON 09/14/09 @ 15:08 BY FRANCES E CHAMBERS, LICENSED PRACTICAL NUR
MED RECORDS AWARE, WILL HAVE INSTRUCTION WHEN I/M IS REGISTERED
SIGNED OFF ON 09/14/09 @ 16:25 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NQR
** ENCOUNTER 00718 MENTAL HEALTH CLI 09/02/09 09:47 LIEBER CORR INST
COMP
INC. NOTE ***** PSYCH CLINIC F/U APPOINTMENT SCHEDULE FOR 10/21 ON MAX.

CONFIDENTIAL

P130-052

6875-EEEE-146

**
**

**
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CAROLYN H. BYNES, CCC
SIGNED O~F ON 09/02/09 @ 9:48 BY CAROLYN H BYNES, HUMAN SERVICES COORD I
ENCOUNTER 00717 OUTSIDE RECOMMEND 08/27/09 15:36 LIEBER CORR INST
COMP
INMATE TO SURGICAL CLINIC FOR SUBCUTANEOUS LEFT HIP TUMOR. RECOMMENDED FOR E
XCISION . CONSULTATION WRITTEN TO BE REVIEWED BY DOCTOR.
SIGNED OFF ON 08/27/09 @ 15:43 BY JOSEPHINE G BROWN, REGISTERED NURSE I
CONSULT FOR EXCISION WRITTEN.
SIGNED OFF ON 08/28/09 @ 15:21 BY ROBERT E BABB, UNCLASSIFIED
CONSULT FAXED TO DR BENIOR
SIGNED OFF ON 08/28/09 @ 15:36 BY CHESTER
OGRODNIK, REGISTERED NURSE I
ENCOUNTER 00716 MENTAL HEALTH CLI 08/19/09 16:12 LIEBER CORR INST
COMP
SAYS NOT GETTING COGENTIN, CHECKED WITH PHARACY, IT'S ON BACKORDER, THEY
WILL LOOK INTO IT.
.
SIGNED O~F ON 08/19/09 @ 16:13 BY LEONARD W MULBRY JR, UNCLASSIFIED
ENCOUNTER 00715 MENTAL HEALTH CLI 08/05/09 17:11 LIEBER CORR INST
CaMP
39 YO AAM SEEN FOR ROUTINE FOLLWUP. HE SAYS THAT HE IS NOT DEPRESSED OR
IRRITABLE, NOT SAD. HE SAYS HE STILL HEARS VOICES BUT HE ALWAYS DOES. THEY
DO NOT BOTHER HIM ENOUGH TO TAKE MORE MEDS. THE STIFf'NESS IS GONE, AND THE
COGENT IN IS HELPING. NO ABN MVTS. NO SI HI
o CALM AND COOPERATIVE. MOOD 'ALRIGHT' SPEECH NL R/V/P, TP LINEAR AND
GD, WELL ORGANIZED, TC NO SI HI BUT SOME AR, NO VH PARANOIA. MEM AND CONC
GOOD, NO TD NOT STIFF
LABS FROM MAY OK
A
SCHIZOPHRENIA
BETTER ON THIS DOSE AND NOT STIFF
P
STELAZINE 2 BID
SEROQUEL 400 B'rD
COGENTIN 2 BID
FOLLOWUP 8-12 WEEKS
SIGNED OFF ON 08/05/09 @ 17:18 BY LEONARD W MULBRY JR, UNCLASSIFIED
ORDER DIRECT TRANSMITTED TO PHAHM.
SIGNED OFF ON 08/05/09 @ 17:59 BY KISHA
LINNEN, LICENSED PRACTICAL NURSE
NARRATIVE 00714 NARRATIVE
08/04/09 02:04 LIEBER CORR INST
COMP
SICK CALL CANCELLED DUE TO SECURITY OFFICER SHORTAGE.
SIGNED OFF ON 08/04/09 @ 2:05 BY SANDRA
\'IEST, LICENSED PRACTICAL NURSE
NARRATIVE 00713 NARRATIVE
08/04/09 01:52 LIEBER CORR INST
COMP
I/M WRITES SICK CALL REQUEST FOR REFILL ON AMMONIUM LACTATE CREAM .•-aLL
FORWARD TO MD fOR RENEWAL.
SIGNED OFF ON 08/04/09 @ 1:53 BY SANDRA
WEST, LICENSED PRACTICAL NURSE
PALCE ON MED RENEWAL SHEET
SIGNED .O~F ON 08/04/09 @ 6:59 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NUR
ENCOUNTER 00712 MENTAL HEALTH CLI 07/29/09 16:10 LIEBER CORR INST
COMP
WILL RENEW MEDS AND SEE SHORTLY
SEOQUEL 400 BID, STELAZINE 2 BID, COGENT IN 1 BID
SEROQUEL XR 400MG
SIG:ONE TABLET PO BID
SIG:
START DATE: 07/29/09 TOTAL DAYS: 90
MD:MULBRY,L. WILLIAM
TRIFLUOPERAZINE
2MG
SIG:ONE TABLET PO BID
SIG:
START DATE: 07/29/09 TOTAL DAYS: 90
MD:MULBRY,L. WILLIAM
BENZTROPINE .
lMG
SIG:ONE TABLET PO BID
SIG:

r'"

'-./

CONFIDENTIAL

P130-053

6875-EEEE-147

c·

P> START DATE: 07/29/09 TOTAL DAYS: 90
P> MD:MULBRY,L. WILLIAM
SIGNED OFF ON 07/29/09 @ 16:13 BY LEONARD W MULBRY JR, UNCLASSIFIED
ORDER DIRECT TRANSMITTED TO PHAHM.
SIGNED OFF ON 07/29/09 @ 17:51 BY KISHA
LINNEN, LICENSED PRACTICAL NURSE
** ENCOUNTER 00'111 LAB CLINIC
OS/21/09 06:55 LIEBER CORR INST
COMP
LAB RESULTS REC'D FOR LIPID PANEL AND FBS
FILED IN CHART FOR REVIEW AND SIGNATURE
SIGNED OFF ON OS/21/09 @ 6:55 BY GWENDOLYN
TAYLOR-BISHOP, MEDICAL ASSISTA
** ENCOUNTER 00710 INSIDE APPOINTMEN OS/20/09 15:33 LIEBER CORR INST
COMP
I/M RECEIVE RX GLASSES AND SIGN EQUIPMENT SHEET.
SIGNED OFF ON OS/20/09 @ 15:34 BY EVELYN
GADSON, MEDICAL ASSISTANT TECH I
NOTED.
SIGNED OFF ON OS/20/09 @ 19:29 BY KIStffi
LINNEN, LICENSED PRACTICAL NURSE
** ENCOUNTER 00709 LAB CLINIC
05/19/09 06:20 LIEBER CORR INST
COMP
BLOOD DRAWN FOR LIPID PANEL AND FBS AS ORDERED
FASTING
SIGNED OFF ON 05/19/09 @ 6:22 BY GWENDOLYN
TAYLOR-BISHOP, MEDICAL ASSISTA
** ENCOUNTER 00708 SICK CALL
05/19/09 02:20 LIEBER CORR INST
COMP
S> I HAVE SCRATCHY SCALP SERIOUS PROBL~f. MY SKIN IS SUCH BAD CONDITION COULD
S> I HAVE AN ORDER FOR DIAL SOAP FOR MY DRY SCALLY SKIN.
0> TEMP=O
PULSE=
RESP=
BP=
WEIGHT=
PPD= 0
SKIN CONDITION ROUGH, DRY. SCELP PROBLEM HE HAS AN ORDER FOR THE MEDICATED
SHAMPOO. HE NEEDS AN ORDER FOR DIAL SOAM.
A> REFER TO NP/MD FOR DIAL SOAP ORDER.
SIGNED OFF ON 05/19/09 @ 2:30 BY JOSEPHINE G BROWN, REGISTERED NURSE I
RX LAC-HYTRIN, APPLY TOPICALLY QDAY #90 DAYS
SIGNED OFF ON 05/19/09 @ 10:30 BY WILBUR J JONES, NURSE PRACTITIONER III
MED DIRECT TRANSMIT TO PHARM
SIGNED OFF ON 05/19/09 @ 12:59 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NUR
** ENCOUNTER 00707 MENTAL HEALTH CLI 05/13/09 15:42 LIEBER CORR INST
COMP
39 YO AAM SEEN FOR ROUTINE FOLLOWUP. HE SAYS THAT HE IS STILL HEARING
VOICES AND SEEING SHADOWS, HE IS BETTER BUT FEELS HE NEEDS TO HAVE MORE OF
THE STELAZINE BACK TO HIS OLD DOSE OF 5MG. NOT STIFF, NO ABN MVTS, NOT
DEPRESSED, NO SI HI. NO OTHER SIDE EFFECTS.
o
CALM COOPERATIVE, CONSTICTED, POOR HISTORIAN, SPEECH MINIMAL BUT NL
R/V/P, TP SHORT APPROPRIATE, TC NO 31 HI, HEM AND CONC POOR.NOT STILL NO
ABN MVTS.
A
SCHIZOPHRENIA
REVIEW OF COMPUTER BACK TO 06 SHOWS NO STELAZINE 5, AND THE DX ON 06
AND 07 WAS NOT CLEAR, WILL BE CAUTIOUS WITH DOSE AND ADD COGENT IN
P
CONTINUE SEROQUEL 400 BID
STELAZINE TO 2 MG BID
COGENTIN 1MG BID
PLEASE DRAW LABS LIPID PANEL AND FBS
P> SEROQUEL XR 400MG
P> SIG:ONE TABLET PO BID
P> SIG:
P> START DATE: 05/13/09 TOTAL DAYS: 90
P> MD:MULBRY,L. WILLIAM
P> TRIFLUOPERAZINE
2MG
P> SIG:ONE TABLET PO BID
P> SIG:
P> START DATE: 05/13/09 TOTAL DAYS: 90
P> MD:MULBRY,L. WILLIAM
P> BENZTROPINE
lMG
P> SIG:ONE TABLET PO BID

CONFIDENTIAL

P130-054

6875-EEEE~148

P> SIG:
P> START DATE: 05/13/09 TOTAL DAYS: 90
P> MD:MULBRY,L. WILLIAM
SIGNED OfF ON 05/13/09 @ 16:06 BY LEONARD W MULBRY JR, UNCLASSIFIED
ORDER TRANSMITTED TO PHARM. LABS WRITTEN IN LAB BOOK FOR LIPID PANEL AND
FBS.
SIGNED OFF ON 05/13/09 @ 16:51 BY KISHA
LINNEN, LICENSED PRACTICAL NURSE
** ENCOUNTER 00706 MENTAL HEALTH CLI 05/0e/09 13:34 LIEBER CORR INST
COMP
MEDS NEED TO BE RENEWED, WILL DO SO AND SEE SHORTLY
TRIFLUOROPERAZINE 2MG QHS
SEROQUELXR 400 BID
P> TRIFLUOPERAZINE
2MG
P> SIG:ONE TABLET PO QHS
P> SIG:
P> START DATE: 05/08/09 TOTAL DAYS: 90
P> MD:MULBRY,L. WILLIAM
P> SEROQUEL XR 400MG
P> SIG:ONE TABLET PO BID
P> SIG:
P> START DATE: 05/0e/09 TOTAL DAYS: 90
P> MD:MULBRY,L. WILLIAM
SIGNED OFF ON 05/08/09 @ 13:38 BY LEONARD W MULBRY JR, UNCLASSIFIED
MEDS DIRECT TRANSMIT TO PHARM
SIGNED OFF ON 05/0e/09 @ 14:33 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NUR
** NARRATIVE 00705 NARRATIVE
04/22/09 11:26 LIEBER CORR INST
COMP
I/M APPT WITH DR. LEMON EYE DOCTOR CANCEL PER .LT. KING AND LT. MANIGAULT NO
T A GOOD DAY.
SIGNED OFF ON 04/22/09 @ 11:27 BY EVELYN
GADSON, MEDICAL ASSISTANT TECH I
NOTED.
SIGNED OFF ON 04/22/09 @ 12:51 BY KISHA
LINNEN, LICENSED PRACTICAL NURSE
** NARRATIVE 00704 NARRATIVE
03/25/09 15:21 LIEBER CORR INST
COMP
I/M APPT. RESCHEUDLE DUE TO COURT RUNS.
SIGNED OFF ON 03/25/09 @ 15:22 BY EVELYN
GADSON, MEDICAL ASSISTANT TECH I
SIGNED OFF ON 03/25/09 @ 18:54 BY BRENDA K KEAY, LICENSED PRACTICAL NURSE
** ENCOUNTER 00703 MENTAL HEALTH CLI 03/17/09 14:41 LIEBER CORR INST
COMP
I/M WAS VISITED BY COUNSELOR TO SEE IF ANY BEHAVIORAL CHANGES HAD OCCUR.
r/M STATED THAT HE WAS DOING OKAY AND THAT HE DID NOT NEED ANYTHING AT THIS
TIME. THAT HE WAS STABLE AND GETTING HIS MEDICATION CONSISTENTLY FROM THE
NURSES. HE DID NOT HAVE ANY MAJOR COMPLAINT.
A: DX. IMPRESSION: AS LISTED PREVIOUSLY
INMATE APPEARED TO BE STABLE AND DOING WELL. NO SIGNS OF A/V HALLUCINATION
OR DELUSIONAL PRESENTATION. HE WAS ALERT AN AFFECT viAS BRIGHT WITH MANNERIS
MS. COUNSELOR WILL CONTINUE TO DO F/U ON A MONTHLY BASIS OR PRN.
P: NEXT APPT: 4/09.
MELVIN RANSOM,HSCII
SIGNED OFF ON 03/17/09 @ 14:47 BY MELVIN
RANSOM, HUMAN SERVICES COORD II
~* ENCOUNTER 00702 TB CLINIC
03/09/09 12:27 LIEBER CORR INST
COMP
I/M PPD GIVEN 3/6/09 NEG. 3/9/09
SIGNED OFF ON 03/09/09 @ 12:27 BY CARLA
GASTON, UNCLASSIFIED
** ENCOUNTER 00701 SICK CALL
03/03/09 01:12 LIEBER CORR INST
COMP
S> I NEED SOME SHAMPOO; MY HEAD IS LOADED WITH EXTREME DRYNESS, FLAKES ARE
S> EVERYWHERE.
0> TEMP~097.3
PULSE= 46
RESP=20
BP=146/ 85
WEIGHT=199
PPD= 0
0> AT THIS TIME ONLY MILD DRYNESS NOTED AT SCALP.
A> DEFERRED
P> WILL FLAG FOR MD TO EVALUATE NEED FOR DANDRUFF SHAMPOO.
SIGNED OFF ON 03/03/09 @ 1:14 BY COLLEEN
SULLIVAN, REGISTERED NURSE I

CONFIDENTIAL

P130-055

6875-EEEE-149

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SHAMPOO ORDERf!:D
SIGNED OFF ON 03/04/09 @ 14:37 BY ROBERT E BABB, UNCLASSIFIED
ORDER GIVEN TO PHARMACY
SIGNED OFF ON 03/06/09 @ 19:07 BY CHESTER
OGRODNIK, REGISTERED NURSE I
ENCOUNTER 00700 MENTAL HEALTH CLI 02/25/09 14:38 LIEBER CORR INST
COMP
D: I/M STATED THAT HE WAS DOING WELL AND HAD MINOR SYMPTOMS OF DELUSIONS
AND WAS NOT EXPERIENCING A/V HALLUCINATIONS AND STABLE. STATED THAT HE WAS
RECEIVING HIS MEDICATION WITH NO DIFFICULTY AT THIS TIME. HE DID IMPLY THAT
THERE IS MOMENTS WHEN THE VOICES RETURNS BUT NOTHING HARMFUL IS PRESENTED
FOR ME TO HURT SOMEONE OR SELF.
A: DX. IMPRESSION: AS LISTED BY THE PHYSICIAN
INMATE APPEARED TO BE STABLE AND DOING WELL WITH NO INDICATIONS THAT YHE WA
S EXPERIENCING ANY A/H HALLUCINATION OR DELUSIONS. SPEECH WAS APPROPRIATE C
ALM WITH NO LOOSE ASSOCIATION.
MELVIN RANSOM,HSCII
SIGNED OFF ON 02/25/09 @ 14:47 BY MELVIN
RANSOM, HUMAN SERVICES COORD II
ENCOUNTER 00699 LAB CLINIC
02/18/09 12:00 LIEBER CORR INST
COMP
DISREGARD PREVIOUS ENC
BLOOD NOT DRAWN
INMATE REFUSED TO HAVE LABS DRAWN.
REFUSAL SHEET SIGNED AND FILED IN CHART
LABS FOR FBS AND LIPID PANEL
SIGNED OFr ON 02/18/09 @ 12:01 BY GWENDOLYN
TAYLOR-BISHOP, MEDICAL ASSISTA
CCC WILL r/u.
CAROLYN H. BYNES, CCC
SIGNED OFF ON 03/04/09 @ 9:09 BY CAROLYN H BYNES, HUMAN SERVICES COORD I
ENCOUNTER 00698 LAB CLINIC
02/18/09 11:59 ~IEBER CORR INST
COMP
BLOOD DRAWN FOR FBS AND LIPID PANEL AS ORDERED
FASTING
SIGNED OFF ON 02/18/09 @ 12:00 BY GWENDOLYN
TAYLOR-BISHOP, MEDICAL ASSISTA
ENCOUNTER 00697 MENTAL HEALTH CLI 02/13/09 14: 17 L<IEBER CORR INST
COMP
39 YO AAM SEEN FOR ROUTINE FOLLOWUP. IM SAYS THAT HE IS DOING WELL. HE SAYS
OCCASIONAL VOICES AND LITTLE PARANOIA BUT NOT BOTHESOME AND HE FEELS THAT
THE MEDS AREA ABOUT RIGHT, NOT ROWDY, SLEEPING WELL EATING vlELL, NO MOTOR SE
NO OTHER SE, NOT STIFF NO SI HI AVH
o CALM AND COOPERATIVE, MOOD 'ALRIGHT' MILDLY CONSTRICTED, SPEECH NL
R/V/P, TP LINEAR AND GD, TC NO sr HI AVH, MEM AND CONC GOOD NO ASN MVTS
A SCHIZOPHRENIA
STABLE
P RENEW SEROQUEL XR, 400 BID
. RENEW STELAZINE 2MG QHS
CHECK LIPID PAl~EL AND FASTING BLOOD SUGAR.
FOLLOWUP 3 MaS IF LABS OK
SEROQUEL XR 400MG
SIG:ONE TABLET BID
SIG:
START DATE: 02/13/09 TOTAL DAYS: 90
MD:MULBRY,L. WILLIAM
TRIFLUOPERAZINE
2MG
SIG:ONE TABLET QHS
SIG:
START DATE: 02/13/09 TOTAL DAYS: 90
MD:MULBRY, L. 1flILLIAM
SIGNED OFF ON 02/13/09 @ 15:03 BY LEONARD W MULBRY JR, UNCLASSIFIED
LABS PLACED IN LAB BOOK
MEDS RENEWED ON MAR
NOTED D.BASINGER RN

CONFIDENTIAL

P130-056

6875·EEEE-150

SIGNED OFF ON 02/13/09 @ 16:53 BY DARRELL A BASINGER, UNCLASSIFIED

** ENCOUNTER 00696 INSIDE APPOINTMEN 01/28/09 17:02 LIEBER CORR INST

s>
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A>
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\../

**
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COMP
riM REFUSED TO SEEN BY LEMON OPTOMETRY TODAY.
SIGNED OFF ON 01/28/09 @ 17:03 BY EVELYN
GADSON, MEDICAL ASSISTANT TECH I
SIGNED OFF ON 01/28/09 @ 19:55 BY BRENDA K KEAY, LICENSED PRACTICAL NURSE
ENCOUNTER 00695 MENTAL HEALTH CLI 01/13/09 13:41 LIEBER CORR INST
COMP
D: I/M STATED THAT HE WAS DOING WELL WITHOUT ANY TYPE OF EXPERIENCES WITH
A/V HALLUCINATION OR DELUSIONAL THOUGHTS. HE STATED THAT THE MEDICATION WAS
DOING VlELL AND HE DID NOT VlANT ANY CHANGES.COUNSELOR ADVISED HIM TO MAINTA
IN HIS FOCUS AND COUNCENTRATE ON INVOLVING HIMSELF INTO SOME TYPE OF ACTIV
ITY.
A: DX. IMPRESSION: SCHIZOPHRENIA
STABLE
INMATE APPEARED TO BE DOING WELL WITHOUT ANY INDICATIONS THAT HE WAS ~PERI
ENCING ANY MENTAL DISTURBANCE. HE IS TO BE MONITORED TO ENSURE STABILITY
IN TREATMENT. AFFECT BRIGHT WITH NO SIDE EFFECTS FROM MEDICATION.
INMATE WILL CONTINUE TO IMPROVE HIS BEHAVIOR BY ATTENDING GROUPS OFFERED
P: NEXT APPT 2/09
MELVIN RANSOM,HSCII
SIGNED OFF ON 01/13/09 @ 13:56 BY MELVIN
RANSOM, HUMAN SERVICES COORD II
ENCOUNTER 00694 DOCTOR'S CLINIC
12/12/08 11:23 LIEBER CORR INST
COMP
I/M p~ A SOFT TUMOR UNDER THE SKIN IN THE AREA OF THE RT HIP. I/M STATES T
HAT THE LESION USED TO BE THE SIZE OF HIS THUMB BUT HAS GROWN TO THE SIZE 0
F A BASEBALL. STATES IT IS ALSO PAINFUL.
TEMP=OOO.O
PULSE= 0
RESP= 0
BP= 0/ 0
WEIGHT; 0
PPD; 0
5 TO 6 CM SOFT BULGE COVERED BY NORMAL SKIN.
SOFT TUMOR ON RT HIP WHICH IS ENLARGING AND PAINFUL
CONSULT GENERAL SURGERY.
SIGNED OFF ON 12/12/08 @ 11:33 BY ROBERT E BABB, UNCLASSIFIED
CONSULT FAXED TO DR BENINOR
SIGNED OFF ON 12/12/08 @ 18:17 BY CHESTER
OGRODNIK, REGISTERED NURSE I
NARRATIVE 00693 NARRATIVE
12/05/06 19:06 LIEBER CORR INST
COMP
APPOINTMENT RESCHEDULED R/T SECURITY
SIGNED OFF ON 12/05/08 @ 19:06 BY CHESTER
OGRODNIK, REGISTERED NURSE I
ENCOUNTER 00692 MENTAL HEALTH CLI 11/21/08 14:19 LIEBER CORR INST
COMP
39 YO BM. SEEN FOR REG F/U ON MAX. TAKING SBROQUEL AND DOING "ALRIGHT".
1M LIKES THE MEDICATION AS IT KEEPS HIM CALMER AND HELPS HIM RELAX. STILL
HEARING SOME VOICES BUT IN GENERAL LESS WITH MEDICATION. -S/H, NO SIDE
EFFECTS. 1M AWARE HE WILL BE SVlITCHED TO XR SEROQUEL.
0: ALERT, CALM, COOPERATIVE, MOOD: BLUNTED, NOT OVERTLY PSYCHOTIC OR MANIC
A: SCHIZO
STABLE
P: CHANGE TO SEROQUEL XR 400MG BID
CONTINUE STELAZINE 2MG QHS
F/U 3 MOS - SOONER. IF PROBLEMS
SEROQUEL XR 400MG
SIG:TAKE ONE BID
SIG:
START DATE: 11/21/08 TOTAL DAYS: 90
MD:HIGGINS,EDMUND TRIFLUOPERAZINE
2MG
SlG:TAKE ONE QHS
SIG:
START DATE: 11/21/08 TOTAL DAYS: 90
MD:HIGGINS,EDMUND
SIGNED OPF ON 11/21/08 @ 14:25 BY EDMUND S HIGGINS, PSYCHIATRIST
MEDICATION ORDERS GIVEN TO PHARMACY,SENT TO CCC FOR F/U

CONFIDENTIAL

P130·057

6875-EEEE-151

c:
**

**
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SIGNED OFF ON 11/21/08 @ 18:55 BY CHESTER
OGRODNIK, REGISTERED NURSE I
MENTAL HEALTH WILL FOLLOv7 UP WITH INMATE.
LOLITA LEE, CCC.
SIGNED OFF ON 11/24/08 @ 7:54 BY LOLITA M LEE, HUMAN SERVICES COORD I
ENCOUNTER 00691 MENTAL HEALTH CLI 11/19/08 12:47 LIEBER CORR INST
COMP
D: I/M STATED THAT HIS FEELING HAD NOT CHANGED THAT HE DID NOT WANT ANY THI
NG FROM THE MENTAL HEALTH COUNSELOR AND THAT HE SHOULD BE LEFT ALONE. THAT
THE COUNSELOR HAD NOTHING TO OFFER HIM SEE YOU LATER AND GET AWAY FROM HIS
DOOR.
A: DX. IMPRESSION: NO CHANGES FROM THE PREVIOUS DX HX.
INMATE COUNTINUES TO REFUSE MENTAL HEALTH SERVICES BUT IS COMPLIANT WITH HI
S MEDICATION. COUNSELOR WILL CONTINUE TO MONITOR HIS BEHAVIOR AND ENSURE TH
AT HE MAINTAIN HIS MEDICATION REGIM8N.
P: NEXT APPT: PRN
MELVIN RANSOM,HSCII
SIGNED OFF ON 11/19/08 @ 12:56 BY MELVIN
RANSOM, HUMAN SERVICES COORD II
NARRATIVE 00690 NARRATIVE
11/18/0e 19:54 LIEBER CORR INST
COMP
DR BABB OR NP JONES. THIS I/M IS WONDERING WHY HE HAS NOT SEEN THE MD FOLLO
WING THE X RAY OF HIS HIP. HE SAYS THE KNOT IS THE SIZE OF A SOFTBALL AND C
AUSES HIM PAIN. THE HIP X RAY WAS NEGATIVE HE IS NOT ACCEPTING THIS HE THIN
KS THE NURSES ARE DENYING HIM MEDICAL CARE. HE SAYS DRS AT OTHER INSTITUTIO
NS HAVE TOLD HIM THE KNOT NEEDS TO BE REMOVED.
HIS REQUEST IS THAT HE BE SCHEDULED TO SEE A DR. SO THAT THE REMOVAL OF THI
S KNOT CAN BE DISCUSSED.
THANK YOU FOR YOU HELP.
SIGNED OFF ON 11/18/08 @ 20:07 BY N. J DUNN, REGISTERED NURSE I
SIGNED OFF ON '11/21/08 @ 10:34 BY DEBRA
AUSTIN, REGISTERED NURSE I
SEE MD/NP.
SIGNED OFF ON 11/21/08 @ 13:10 BY ROBERT E BABB, UNCLASSIFIED
APPOINTMENT IN NP BOOK
SIGNED OFF ON 11/21/08 @ 19:00 BY CHESTER
OGRODNIK, REGISTERED NURSE I
11/14/08 03:02 LIEEER CORR INST
COMP
NARRATIVE 00689 NARRATIVE
I/M SIGNED UP FOR SICKCALL RE. KNOT ON RT.SIDE OF HIP. THIS IS GETTING
WORSE. XRAYS ARE WNL M.D MOST LIKLY IS NOT GOING TO REMOVE KNOT. NOTE S
SENT TO I/M.
SIGNED OFF ON 11/14/08 @ 3: 05 BY LINDA
CALDWELL, LICENSED PRACTICAL NURSE
10/24/08 02:24 LIEBER CORR INST
COMP
NARRATIVE 00688 NARRATIVE
THIS I/M REFUSED SICK CALL
SIGNED OFF ON 10/24/UB @ 2:25 BY JOSEPHINE G BROWN, REGISTERED NURSE I
ENCOUNTER 00687 DOCTOR'S CLINIC
10/03/08 08:56 LIEBER CORR INST
COMP
XRAY OF LS SPINE SHOWS SLIGHT NARROWING OF L5-S1 DISC SPACE. HIP XRAY WAS R
EAD AS WNL'S. (LT HIP).
SIGNED OFF ON 10/03/08 @ 8:58 BY ROBERT E BABB, UNCLASSIFIED
ENCOUNTER 00686 DOCTOR'S CLINIC
09/17/08 11:57 LIEBER CORR INST
COMP
AMMONIUr.f LACTATE PRESCRIBED FOR DRY SKIN.
AMMONIUM LACTATE
12%
SIG:APPLY TO DRY SKIN AS NEEDED.
SIG:
START DATE: 09/17/08 TOTAL DAYS: 90
MD:BABE,ROBET SIGNED orr ON 09/17/08 @ 11:58 BY ROBERT E BABB, UNCLASSIFIED
MEDS DIRECT TRANSMIT TO KCI PHAHM
SIGNED OFF ON 09/17/08 @ 15:08 BY DEBRA
AUSTIN, REGISTERED NURSE I
ENCOUNTER 00685 MENTAL HEALTH CLI 09/16/08 15:15 LIEBER CORR INST
COMP
D: I/M REFUSED TO COMMUNICATE WITH COUNSELOR WHEN COUNSELOR VISITED HIM AT
HIS HOLDING CELL IN SMU. HE STATED THAT HE DID NOT WONT ANY ASS AND HE DID
NOT v10NT TO SEE THE COUNSELOR. HE APPEARED TO BE A BIT ANXIOUS \,lHEN HE WAS
COMMUNICATING. HE HAD JUST SEEN THE PSYCHIATRIST AND ADDITIONAL MEDICATION

CONFIDENTIAL

P130-058

6875-EEEE-152

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WAS ADMINISTRED.
A: DX. IMPRESSION: SCHIZOPHRENIA (A SYMTOMATIC)
INMATE APPEARED TO BE STABLE AND ANIMATED. HE WAS NOT EXPERIENCING ANY A/V
HALLUCINATION OR DELUSIONAL THOUGHTS. HE DID NOT EXJ;>RESS ANY SUICIDAl. IDEAT
IONS. HE APPEARED TO BE COHERENT BUT WAS REFUSING SERVICES FROM COUNSELOR.
P: NEXT APPT: 10/08.
MELVIN RANSOM,HSCII
SIGNED OFF ON 09/16/08 @ 15:38 BY MELVIN
RANSOM, HUMAN SERVICES COORD II
NARRATIVE 00684 NARRATIVE
09/05/08 09:55 LIEBER CORR INST
COMP
APPT WITH MD RESCHEDULED DUE TO INCLEMENT WEATHER
SIGNED OFF ON 09/05/08 @ 10:14 BY DEBRA
AUSTIN, REGISTERED NURSE I
ENCOUNTER 00683 MENTAL HEALTH CLI 09/04/08 12:4B LIEBER CORR INST
COMP
1M SEEN !!OR F/U AFTER ADDING STELAZINE TO HIS SEROQUEL. Hi RPTS DOING
BETTER - IMPROVED REST AND CALMER. RPTS NO CHANGE IN VOICES BUT BETTER
ABLE TO IGNORE THEM. -SIDE EFFECTS. LIKES THIS COMBO AND WOULD LIKE IT
CONTINUED WITHOUT CHANGE.
0: MET WITH 1M AT HIS CELL DOOR IN MAX WITH DR RANSOM,
ALERT, CALM,
COOPERATIVE, MOOD: OK, NOT OVERLY PSYCHOTIC OR MANIC
A: SCHIZOA - STABLE
P: CONTINUE STELZINE 2MG QHS AND SEROQUEL 400MG BID
F/U 3 MOS
SOONER IF PROBLEMS
SEROQUEL
400MG
SIG:TAKE ONE BID
SIG:
START DATE: 09/04/08 TOTAL DAYS: 90
MD:HIGGINS,EDMUND TRIFLUOPERAZINE
2MG
SIG:TAKE ONE QHS
SIG:
START DATE: 09/04/08 TOTAL DAYS: 90
MD:HIGGINS,EDMUND SIGNED OFF ON 09/04/08 @ 12:52 BY EDMUND S HIGGINS, PSYCHIATRIST
ORDERS NOTED.
SIGNED O~F ON 09/04/08 @ 13:18 BY SHEREENA L JAMES, REGISTERED NURSE I
NARRATIVE 00682 NARRATIVE
08/28/08 10:54 LIEBER CORR INST
COMP
UA NORMAL. NP JONES MADE AWARE
SIGNED OFF ON 08/28/08 @ 10: 55 BY DEB'RA
AUSTIN, REGISTERED NURSE I
ENCOUNTER 00681 LAB CLINIC
08/28/08 06:03 LIEBER CORR INST
COMP
JONES
LAB RESULTS REC'D FOR URINALYSIS
FILED IN CHART FOR REVIEW AND SIGNATURE
SIGNED OFF ON 08/28/08 @ 6: 03 BY G~lENDOLYN
TAYLOR-BISHOP, MEDICAL ASSISTA
NOTED
SIGNED OFF ON 08/28/08 @ 7:29 BY WILBUR J JONES, NURSE PRACTITIONER III
ENCOUNTER 00690 LAB CLINIC
08/27/08 06:17 LIEBER CORR INST
COMP
URINE COLLECTED FOR URINALYSIS AS ORDERED
NON FASTING
SIGNED OFF ON 08/27/08 @ 6:18 BY GWENDOLYN
TAYLOR-BISHOP, MEDICAL ASSISTA
ENCOUNTER 00679 SICK CALL
08/27/08 04:46 LIEBER CORR INST
COMP
KNOT ON HIP IS STILL CAUSING ME MUCH PAIN AND AGAIN I AM REQUESTING TO HAVE
IT REMOVED THROUGH SURGERY. IT'S ON MY RIGHT HIP AND IT STARTED OFF THE SI
ZE OF A PENCIL ERASER. NOW 1'1' IS THE SIZE OF A HALF OF A BASEBALL.
TEMP=097.0
PULSE= 60
RESP=18
BP=130/108
WEIGHT=199
PPD= 0
RIGHT HIP HAS BASEBALL SIZE MOVABLE LUMP. THE AREA IS SOFT, TEMPERATURE OF
SKIN NORMAL. WILL REFER TO MD FOR EVALUATION.
SEE ABOVE
SIGNED OFF ON 08/27/08 @ 4:52 BY N. J DUNN, REGISTERED NURSE I

CONFIDENTIAL

P130-059

6875-EEEE-153

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SEE MD/NI'.
SIGNED OrF ON 08/27/08 @ 10:58 BY ROBERT E BABB, UNCLASSIFIED
ON NI' BOOK
SIGNED OFF ON 08/27/08 @ 18:20 BY DENISE
NORWOOD, LICENSED PRACTICAL NURSE
ENCOUNTER 00678 X-RAY
08/22/08 07:49 LIEBER CORR INST
COMP
X-RAY LErT HIP; FINDINGS; NO FRACTURES ARE IDENTIFIED. JOINT SPACES ARE
WEL MAINTAINED.
CONCLUSION; NO ACUTE PROCESS.
LUNBAR SPINE, AI' AND LATERAL VIEWS- COMPARISON IS MADE WITH PREVIOUS EXAMIN
ATION DATED 6/14/2001
FINDINGS; AGAIN NOTED IS SOME SLIGHT NARROWING AT THE L5-S1 DISC SPACE. NO
FRACTURES ARE IDENTIFIED.
CONCLUSION; SLIGHT NARRmlING IS NOTED AT THE LS-S1 DISC SPACE, A FINDINGS
NOTED PREVIOUSLY.
SIGNED orF ON 08/22/08 @ 7:56 BY PENNY J HAMBURGH, LICENSED PRACTICAL NURSE
AGREE WITH NOTED FINDINGS ABOVE
SEE ENCOUNTER 651 CONCERNING LEFT SIDED ABDOMINAL AND HIP PAIN
NEED UA DONE, IF NOT ALREADY DONE. IF DONE, PLEASE GIVE MD/NP RESULTS
WILL APPOINT TO MD/NI' AFTER UA RESULTS ARE AVAILABLE.
SIGNED OPF ON 08/26/08 @ 10:12 BY WILBUR J JONES, NURSE PRACTITIONER III
U/A PLACED IN LAB BOOK
SIGNED orF ON 08/26/08 @ 10:26 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NUR
NARRATIVE 00677 NARRATIVE
08/07/00 08:56 LIEBER CORR INST
C~MP
AI'PT WITH MD R/S'ED. NOTE SENT TO SCHEDULING DEPT TO SCHEDULE XRAY
SIGNED OFF ON 08/07/08 @ 8:58 BY DEBRA
AUSTIN, REGISTERED NURSE I
ENCOUNTER 00676 INSIDE APPOINTMEN 00/04/08 14:19 LIEBER CORR INST
COMP
SEEN IN SMU AT CELL DOOR FO~ VISION SCREEN: OU 20/40
OS 20/40
00 20/40
l/M C/O CONSTANT BLURINESS OF HIS EYES STATES IT IS REAL BAD WHEN HE ATTEMP
TS'TO READ. ~YE SCREEN GIVEN TO NEDICAL RECORDS FOR APPT. WITH DR. LEMON
TO BE SCHED.
SIGNED OFF ON 08/04/08 @ 14:22 BY PENNY J HAMBURGH, LICENSED PRACTICAL NURSE
NOTED.
SIGNED OFF ON 08/04/08 @ 14:58 BY DEMPSEY C HOWARD, UNCLASSIFIED
ENCOUNTER 00675 MENTAL HEALTH CLI 08/04/08 12:22 LIEBER CORR INST
COMP
REVIEW CHART, RECENT CRT ENTRIES AND SPOKE WITH OFFICER ON SMU. 1M DX WITH
SXHIZOA. DOING BETTER WITH SEROQUEL BUT CONTINUES TO HEAR VOICES, FEEL
THINGS ARE CRAWLING ON HIM AND SMELL FIRE. 1M SAYS HE WAS DOING BETTER
WHEN HE TOOK STELAZINE. -S/H, -SIDE EFFECTS
WOULD LIKE TO ADD ON LOW DOSE OF STELAZINE, BUT DOSE NOT WANT COGENTIN
0: ALERT, CALM, COOPERATIVE, SEEMED A BIT DISTRESSED
A: SCHIZOA
REMAINS SYMPTOMATIC
P: CONTINUE SEROQUEL 400MG BID
ADD STELAZINE 2MG QHS
F/U 1 MOS
TRIFLUOPERAZINE
2MG
SIG:TAKE ONE QHS
SIG:
START DATE: 08/04/08 TOTAL DAYS: 60
MD:HIGGINS,EDMUND SEROQUEL
400MG
SIG:TAKE ONE BID
SIG:
START DATE: 08/04/08 TOTAL DAYS: 60
MD:HIGGINS,EDMUND

(-'.
'-./

CONFIDENTIAL

P130·060

6875-EEEE-154

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SIGNED OFF ON 08/04/08 @ 12:27 BY EDMUND S HIGGINS, PSYCHIATRIST
COPIED AND GIVEN TO PHARMACY.
SIGNED OFF ON 08/05/08 @ 7:29 BY DEMPSEY C HOWARD, UNCLASSIFIED
ENCOUNTER 00674 MENTAL HF,ALTH eLI 07/15/08 15:03 LIEBER CORR INST
COMP
D: I/M STATED THAT HE WAS DOING WELL AND DID NOT NEED ANYTHING FROM MENTAL
HEALTH AT THIS TIME. STATED THAT HE WAS GETTING HIS MEDICATION AND FOLLOWIN
G MEDICATION REGIMEN. HE \'lAS STABLE AND DOING WELL.
A: OX. IMPRESSION: AS PREVIOUSLY LISTED FROM PHYSICIAN
INMATE WAS VERY COOPERATIVE AND CALM. NO EVIDENCE OF A/V HALLUCINATION OR D
ELUSIONAL THOUGHTS. SPEECH COHERENT WITH NO INTANGIBILITY. NO LOOSE ASSOCIA
TION NOTED.
P: NEXT APPT: 8/08.
MELVIN RANSOM,HSCII
SIGNED OFF ON 07/15/08 @ 15:10 BY MELVIN
RANSOM, HUMAN SERVICES COORD II
NARRATIVE 00673 NARRATIVE
07/10/08 16:16 LIEBER CaRR INST
CaMP
I/M CONTINUITY OF CARE FOR TRANSFER TO COURT IS COMPLETED.
SIGNED OFF ON 07/10/08 @ 16:17 BY KATHERINE
SCOTT, MEDICAL ASSISTANT TECH
SIGNED OFF ON 07/10/08 @ 16:27 BY DEBRA
AUSTIN, REGISTERED NURSE I
NARRATIVE 00672 NARRATIVE
07/10/08 09:54 LIEBER CORR INST
COMP
APPT WITH MD R/S'ED AS XRAY NOT COMPLETE. NOTE SENT TO SCHEDULING DEPT.
SIGNED OFF ON 07/10/08 @ 9:55 BY DEBRA
AUSTIN, REGISTERED NURSE I
ENCOUNTER 00671 INSIDE APPOINTMEN 07/04/08 15:01 LIEBER CORR INST
COMP
1M SEEN RASH ON ARM AND LEG NOTED STARTED ON HYDROCORTOSONE CR 2 % APPLY TO
AREA AFTER WASHING AREAS WITH SOAP AND H20,DRY AND APPLY SM AMOUNT TO EFF
ECTED SKIN AS NEEDED WILL MONITOR
SIGNED OFF ON 07/04/08 @ 15:03 BY CHESTER
OGRODNIK, REGISTERED NURSE I
NOTED
SIGNED OFF ON 07/07/08 @ 10:21 BY JOSEPH H POWELL, NURSE ADMINISTRATOR/MGR I
NARRATIVE 00670 NARRATIVE
06/17/08 11:25 LIEBER CORR INST
COMP
CLOSED
SIGNED OFF ON 06/17/08 @ 14:27 BY DEMPSEY C HOWARD, UNCLASSIFIED
ENCOUNTER 00669 X-RAY
06/26/08 10:20 LIEBER CORR INST
COMP
I/M APPT. SCHEUDLE 6/26.
SIGNED OFF ON 05/30/08 @ 10:21 BY EVELYN
GADSON, MEDICAL ASSISTANT TECH I
SIGNED OFF ON 05/30/08 @ 12:48 BY DEBRA
AUSTIN, REGISTERED NURSE I
NARRATIVE 00668 NARRATIVE
OS/29/08 08:09 LIEBER CORR INST
CaMP
XRAY NOT COMPLETED. APPT WITH MD R/S'ED. NOTE SENT TO SCHEDULING DEPT TO
R/S XRAY
SIGNED OFF ON OS/29/08 @ 8:10 BY DEBRA
AUSTIN, REGISTERED NURSE I
OS/24/08 01:00 LIEBER CaRR INST
NARRATIVE 00667 NARRATIVE
COMP
I/M REFUSED TO COME TO SICK CALL.
SIGNED OFF ON OS/24/08 @ 1:00 BY LINDA
CALDWELL, LICENSED PRACTICAL NURSE
ENCOUNTER 00666 MENTAL HEALTH CLI OS/21/08 14:24 LIEBER CORR INST
COMP
D: I/M STATED THAT HE DID NOT WANT TO BE BOTHERED BY COUNSELOR AND ASKED T
o GET AWAY FROM HIS DOOR. THAT HE DID NOT NEED ANYTHING FROM COUNSELOR AND
HE WAS OKAY. COUNSELOR GRANTED HIS REQUEST.
A: OX. IMPRESSION:PSYCHOSIS NOS. IN REMISSION
COUNSELOR VISITED I/M IN SMU, HE WAS READING A BOOK AND NOT DISTURBING ANYO
NE. HE APPEARED TO BE STABLE AND SHOWED NO SIGN OR SYMPTOM OF MENTAL ILLNES
S, A/V HALLUCINATION OR DELUSIONAL THOUGHTS. HE CLAIMS THAT HE WAS STABLE A
ND HE DID NOT NEED ANYTHING FROM MENTAL HEALTH. AFFECT BRIGHT WITH NO CHAM
CTERISTIC Ol!' MENTAL DISORDERS.
MELVIN RANSOM,HSCII
SIGNED OFF ON OS/21/08 @ 14:36 BY MELVIN
RANSOM, HUMAN SERVICES COORD II
NARRATIVE 00665 NARRATIVE
05/12/08 22:01 LlEBER CORR INST
COMP
I/M SIGNED UP FOR SICK CALL. COULD NOT SEE TODAY FOR SICK CALL PER C/O DUE
TO SECURITY STAFFING ISSUES.

CONFIDENTIAL

P130·061

6875-EEEE-155

SIGNED OFF ON 05/12/08 @ 22:02 BY MELISSA A WEAVER, REGISTERED NURSE I

** ENCOUNTER 00664 MENTAL HEALTH CLI 05/12/08 15:21 LIEBER CORR INST

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COMP
1M WAS ASSESSED AT CELL DOOR AT SMU. HE REPORTS NO AH THAT IS DISTURBING NO
W- DOING WELL WITH SEROQUEL.MOOD- HAPPY, ADEQUATE-SLEEP, ENERGY AND APPETIT
E. NO 51, NO SIDE EFFECTS- REPORTED. NO ISSUES TO DISCUSS. SPOKE ABOUT CURR
ENT EVENTS.
o GROOMED, COOPERATIVE, PLEASANT, MOOD-S/10. NO NEUROLEPTIC INDUCED PARK.
SX, NO AKATHISIA, MOTOR- FLUID- TP- LOGICAL, TC- NO SI, .STABLE AH, NO DELUS
IONS I AND J- FAIR
A: PSYCHOSIS NOS
IN REMISSION- SEROQUEL
P: SCHEDULE FU AS PLANNED
SEROQUEL 400 MG BID- RENEWED THRU- 7/08
SIGNED OFF ON 05/12/08 @ 15: 26 BY PRESTON B FITZGERALD, NURSE' PRACTITIONER I
ENCOUNTER 00663 MENTAL HEALTH CLI 05/12/08 09:43 LIEBER CORR INST
COMP
PTS SEROQUEL WAS INCREASED IN FEB, BUT FOLLOW-UP HAS NOT OCCURED. MEDS
HAVE TERMINATED. WILL RENEtl} SEROQUEL AND REQUEST TIMELY FOLLOW-UP.
P: SEROQUEL 400MG BID
SEROQUEL
400MG
SIG:TAKE ONE BID
SIG:
START DATE: 05/12/08 TOTAL DAYS: 90
MD:HIGGINS,EDMUND SIGNED OFF ON 05/12/08 @ 9:44 BY EDMUND S HIGGINS, LICENSED PSYCHOLOGIST
COPIED AND GIVEN TO PHARM.
SIGNED OFF ON 05/13/08 @ 10:03 BY DEMPSEY C HOWARD, UNCLASSIFIED
ENCOUNTER 00662 MENTAL HEALTH CLI 04/29/08 14:41 LIEBER CORR INST
COMP
D: I/M STATED THAT HE WAS A LITTLE UPSET D\.!E TO NOT GETTING ENOUGHT SLEEP T
HE LAST PAST FEW DAYS. HE DID NOT NO IF HE NEEDED MORE MEDICATION OR HE NEE
DED HIS MEDS ADJUSTED. HE STATED THAT WAS HIS ONLY PROBLEM.
A: DX. IMPRESSION: AS LISTED PREVIOUSLY FROM THE DR.
INMATE WAS A BIT ADJITATED AND ANGRY BUT HE WAS ABLE TO COMMUNICATE WITH CO
UNSELOR EFFECTIVELY. HE APPEARED TO BE IN NO IMMEDIATE STRESS OR MENTAL HEA
LTHEPISODES. HE DID NOT SHOW ANY SIGNS OF DECOMPENSATION OR A/V HALLUCINAT
IONS.
P: NEXT APPT: 5/08.
MELVIN RANSOM,HSCII
SIGNED OFF ON 04/29/08 @ 15:17 BY MELVIN
RANSOM, HUMAN SERVICES COORD II
NARRATIVE 00661 NARRATIVE
04/15/06 01:48 LIEBER CORR INST
COMP
REFUSED TO COME TO SICK CALL.
SIGNED OFF ON 04/15/08 @ 1:49 BY COLLEEN
SULLIVAN, REGISTERED NURSE I
NARRATIVE 00660 NARRATIVE
04/10/08 14:44 LIEBER CORR INST
COMP
APPOINTMENT RESCHULED FOR AFTER X-RAY IN MAY
SIGNED OFF ON 04/10/08 @ 14:45 BY CHESTER
OGRODNIK, REGISTERED NURSE I
NARRATIVE 00659 NARRATIVE
04/03/08 08:19 LIEBER CORR INST
COMP
MD APPT SCHEDULED FOR TODAY HAS BEEN R?S"ED AS I?M HAS NOT HAD XRAY DONE YE
T

SIGNED OFF ON 04/03/08 @ 8:19 BY DEBRA

AUSTIN, REGISTERED NURSE I

** ENCOUNTER 00658 MENTAL HEALTH CLI 03/25/08 10:25 LIEBER CORR INST

COMP
D: 11M STATED THAT HE WAS FEELING ALRIGHT AND TAKING IT ONE DAY AS IT COMES
. STATED THAT HE WAS GETTING HIS MEDICATION AND NOT HAVING ANY MENTAL STRES
S AT THIS TIME. HE IMPLY THAT HE WAS READY TO GET BACK ON THE YARD.
A: DX.IMPRESSION: HX OF SCHIZOPHRENIA PARANOID TYPE
INMATE WAS VERY APPROPRIATE AND CALM WHEN COMMUNICATING WITH COUNSELOR. HE
DID NOT SHOW ANY SIGNS OF DECOMPENSATION OR A/V HALLUCINATIONS DURING THE S
ESSION. HE WAS ALERT AND DEMONSTRATED THAT HE COULD COMPREHEND WITHOUT ANY
DIFFICULTY.
P: NEXT APPT: 4/08:

CONFIDENTIAL

P130-062

6875-EEEE-156

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MELVIN RANSOM,HSCII
SIGNED OrE' ON 03/25/08 @ 10: 32 BY MELVIN
RANSOM, HUMAN SERVICES COORD II
NARRATIVE 0065-' NARRATIVE
' 03/10/08 06:06 LIEBER CORR INST
COMP
I/M HYDROCERIN CREAM EXPIRED AND I/M WANTS RENEWED. HYDROCERIN NON-FORMULAR
Y NOW. WOULD YOU LIKE TO ORDER SOMETHING ELSE?'
SIGNED OFF ON 03/10/08 @ 6:07 BY MELISSA A WEAVER, REGISTERED NURSE I
HAS TO BE BOUGHT IN CANTEEN.
SIGNED OFF ON 03/10/08 @ 15:43 BY ROBERT E'BABB, UNCLASSIFIED
NOTED
SIGNED OFF ON 03/10/08 @ 15:48 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NUR
~~COUNTER 00656 MENTAL HEALTH CLI 02/29/08 15:20 LIEBER CORR INST
COMP
0: I/M SEEN FOR HIS MENTAL HEALTH F/U. I/t-i STATED I AM DOING THE SAME THE M
EDICSTION IS NOT HELPiNG ME, I HAVE BEEN ON ALL TYPES OF MEDICATION AND SEE
N EVERY DOCTOR AT SCDC AND NOBODY OR NOTHING IS HELPING ME. I WANT YOU TO T
ARE ME OFF MENTAL HEALTH, I WANT TO SIGN MYSELF OFF MENTAL HEALTH. I/M COMP
LAINS OF HEARING VOICES TELLING HIM THAT seDe HAS THE WRONG PERSON AND WE A
RE HOLDING AGAINST HIS WILL. 11M REPORTS FEELING FIRE IN HIS BODY.
A: OX: SCHIZOPHRENIA PARANOID TYPE
GAF-50
I/M APPEARED TO BE A/O X3; MOOD APPEARED TO BE ANGRY. GOOD EYE CONTACT. I/M
REQUESTING TO BE TAKEN OFF MENTAL HEALTH, DUE TO HIS HX OF MENTAL ILLNESS
HE WILL REMAIN ON MENTAL HEALTH. I/M REPORTS COMPLIANT WITH MEDS.
P: WILL F/U IN 30 DAYS
SIGNED OFF ON 02/29/08 @ 15:31 BY TANYA F MCCANTS, HUMAN SERVICES COORD I
ENCOUNTER 00655 MENTAL HEALTH CLI 02/25/08 10:04 LIEBER CORR INST
COMP
GLUCOSE AND FASTING LIPIDS FOR YRLY SDA MONITOR WERE- WNL-2/22/0a
P: ~VISE 1M OF FINDINGS- NL
NO FURTHER MONITOR FOR 2008 REQUIRED
SIGNED OFF ON 02/25/08 @ 10:06 BY PRESTON B FITZGERALD, NURSE PRACTITIONER I
ENCOUNTER 00654 LAB CLINIC
02/25/08 07:48 LIEBER CORR INST
COMP
LAB'RESULTS REC'D FOR LIPID PROFILE AND FBS
FILED IN CHART FOR DR'S REVIEW AND SIGNATURE
SIGNED OFF ON 02/25/08 @ ;:48 BY GWENDOLYN
TAYLOR-BISHOP, MEDICAL ASSISTA
vULL REVIEW'.
SIGNED OFF ON 02/25/08 @ 8:33 BY PRESTON B FITZGERALD, NURSE PRACTITIONER I
ENCOUNTER 00653 LAB CLINIC
02/25/08 07:46 LIEBER CORR INST
COMP
FOUND OPEN. CLOSED
SIGNED OFF ON 02/25/08 @ ;:47 BY DEMPSEY C HOWARD, UNCLASSIFIED
ENCOUNTER 00652 DENTAL CLINIC
02/22/08 15:39 LIEBER CORR INST
COMP
OTHER DENTAL DISORDER*
COMPLAINTS OF #10. FOOD PART I CAL STUCK BETWEEN THE TEETH
SIGNED OFF ON 02/22/08 @ 15:39 BY CANDACE A WIGFALL, MEDICAL ASSISTANT TECH
ENCOUNTER 00651 DOCTOR'S CLINIC
02/22/08 12:41 LIEBERCORR INST
COMP
11M SEEN IN MAX EXAM ROOM. HE C/O> 2 YRS OF PAIN ON LT SIDE OF ABD, HIP, A
ND BACK. STATES HIS KIDNEYS WERE CHECKED IN THE PAST AND WERE APPARENTLY AL
RIGHT. RECORDS SHOW HE HASN'T SEEN A MEDICAL DOCTOR IN OVER 2 YRS. OFFICER
STATES THAT l/M HAS TROUBLE SITTING AND WALKING.
TEMP=OOO. 0
PULSE= 0
RESP= 0
BP= 0/ 0
WEIGHT= 0
PPD= 0
ABD IS SOFT AND NONTENDER. NO CVA T~DERNESS. PAIN WITH MANIPULATION OF LT
HIP.
LT HIP PAIN
XRAY LT HIP AND LUMBAR SPINE. U/A. MOTRIN 800MG TID WITH FOOD. RECHECK AFTE
R XRAYS.
SIGNED OFF ON 02/22/08 @ 12:51 BY ROBERT E BABB, UNCLASSIFIED
XRAY FORM SUBMITTED FOR SCHEDULING
FlU APPT SCHEDULED
MEDS DIRECT TRANSMIT TO KCI PHARMACY

CONFIDENTIAL

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6875-EEEE-157

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SIGNED OFF ON 02/22/0B @ 13:04 BY DEBRA
AUSTIN, REGISTERED NURSE I
ENCOUNTER 00650 MENTAL HEALTH CLI 02/21/08 15:36 LIEBER CORR INST
COMP
INC NOTE;
TX T~~ UPDATED TX PLAN. I/M MENTAL HEALTH STATUS WILL REMAIN MENTALLY ILL
WITH A DX: PSYCHOSIS, PLEASE SEE HARD COPY OF TX PLAN IN MEDICAL RECPRDS. N
EXT UPDATE WILL BE 5/21/08.
TEru1 MEMBERS-----T. MCCANTS,CCC AND C. BYNES,CCC
TANYA MCCANTS,CCC
SIGNED OFF ON 02/21/08 @ 15:37 BY TANYA F MCCANTS, HUMAN SERVICES COORD I
ENCOUNTER 00649 LAB CLINIC
02/21/08 09:22 LIEBER CORR INST
COMP
LABS DRAWN FOR FilS AND LIPID PANEL AS ORDERED
FASTING
SIGNED OFF ON 02/21/08 @ 9:22 BY GWENDOLYN
TAYLOR-BISHOP, MEDICAL ASSISTA
ENCOUNTER 00648 MENTAL HEALTH CLI 02/11/08 14:52 LIEBER CORR INST
COMP
1M IS SEEN FOR FU AT SMli. HE HEARS VOICES, INSIDE HEAD, UN FAMI LAR , HE HEARS
VOICES TELLING HIM THAT HE IS NO GOOD. HE STARTED HEARING VOICES FOR 1995.
HE HAS TAKEN MEDS OF ALL KINDS AND N9THING HELPED. HE HEARS VOICES ALL THE
TIME EXCEPT AT SLEEP. SLEEP- OK, ENERGY- OK, MOOD- HAPPY, FULL OF ENERGY.
HE HAS ONE CHILDREN- GOING TO SCHOOL. MAX OUT IN 6 YRS.
0: ALERT, COOPERATIVE, COGNITIVE CAN CONCENTRATE, IF VOICES HEARD- TP- BLOC
KING, NO PSYCHOMOTOR AGITATION, DELUSIONS OF PARANOIA, AH POS. I AND J- IMP
AIRED. LOW MENTAL APTITUDE.
A: SCHIZOPHRENIA PARANOID TYPE, PARTIAL REMMISISON WITH SEROQUEL AT 600 MG.
P START 400 MG BID - TOTAL 800 MG TRIAL TO ReDUCE AH FROM 18 HRS TO 12 HRS
PER DAY.
SEROQUEL
400MG
SrG:TAKE 1 TABLET BID.
SIG:
START DATE: 02/11/06 TOTAL DAYS: 90
MD:FITZGERALD,PRESTON LAB FOR FASTING GLUCOSE LEVEL NOW FOR SDA MONITOR OF SEROQUEL AND FACTING L
IPIDS.
SIGNED OFF ON 02/11/08 @ 15:08 BY PRESTON B FITZGERALD, NURSE PRACTITIONER I
COpy TO PHARM
LABS IN LAB BOOK
SIGNED OFF ON 02/12/08 @ 8:17 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NUR
ENCOUNTER 00647 MENTAL HEALTH CLI 01/31/08 13:37 LIEBER CORR INST
COMP
INC NOTE;
I/M SCHEDUEL TO BE SEEN IN PSCY CLINIC ON 2/11/08.
TANYA MCCANTS,CCC
SIGNED OFF ON 01/31/08 @ 13:37 BY TANYA F MCCANTS, HUMAN SERVICES COORD I
ENCOUNTER 00646 MENTAL HEALTH CLI 01/25/08 12:04 LIEBER CORR INST
COMP
D: I/M SEEN FOR HIS MENTAL HEALTH F/U. I/M COMPLAINS OF HEARING VOICES, FEE
LING FIRE IN MY BODY AND BUGS CRAWLING OVER ME . I CAN'T SEE THE FIRE OR TH
E BUGS. I SEE SHADOWS IN MY ROOM. I/M REPORTS TAKEN SEREQUEL, BUT REPORTS I
WANT TO GET BACK ON MY STELAZINE AN DBENEDRYL TO HELP WITH THE VOICES TELL
ING ME TO HURT MY SELF AND THAT I AM A PROPHET.
Al I/M APPEARED TO BE A/O X3; MOOD APPEARED TO BE PLEASANT WITH GOOD EYE CO
NTACT. WE DISCUSSED HIS CONCERNS AND SOME COPING SKILLS TP DEAL WITH HIS DI
AGNOSIS.
P: cce MADE REFERRAL TO BE SEEN IN PSYCH CLINIC. WILL F/U IN 30 DAYS OR PRN

TANYA MCCANTS,CCC
SIGNED OPF ON 01/25/08 @ 12:15 BY TANYA F MCCANTS, HUMAN SERVICES COORD I
** NARRATIVE 00645 NARRATIVE
11/27/07 04:39 LIEBER CORR INST
COMP
r/M SEND REQUEST TO STAFF STATING THAT HE DO NOT \.]ANT DOUBLE PORTIONS ANY M
ORE STATED THAT HE HAS NOT BEEN GETTING THEM FOR OVER A YEAR, AND SINCE SOM

c-:'
CONFIDENTIAL

P130-064

6875-EEEE-158

c
**

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EONE ELSE HAS BEEN GETTING HIS FOOD HE WANTS IT TO STOP. VOICED NO OTHER
COMPLAINT.
SIGNED OFF ON 11/27/07 @ 4:41 BY SANDRA
JONES, LICENSED PRACTICAL NURSE
SIGNED OFF ON 11/27/07 @ 16:57 BY BRENDA K KEAY, LICENSED PRACTICAL NURSE
ENCOUNTER 00644 MENTAL HEALTH CLI 11/19/07 13:55 LIEBER CORR INST
COMP
1M WAS SEEN AT LOCKUP. HE SAID THAT SEROQUEL CAUSES TO REDUCE VOICES AND PS
YCHOSIS. OTHERWISE GOOD, NO CONSTANT VH HE CAN DISTSRACT VOICES TEMPORARY.
DENIES 51, OR HI, OR DELUSIONS. STILL THINKS ABOUT STARTING FIRES.
0: GROOMED, COC PERAT IVE, MAKES LIMITED EYE CONTACT, TP- LOOSE ASSOC, TC- NO
SIt AVH POS. DELUSION OF SITTING FIRES STILL APPARENT. I AND J- IMPAIRED. S
AID HE IS READY TO GO THE YARD. NO EPS.
A PSYCHOSIS NOS
P: DC BENADRYL IT ADDS TO CONCENTRATION SIDE EFFECTS AND CONFUSION
INCREASE SEROQUEL TO 600 MG AT NIGHT.
SEROQUEL
400MG
SIG:TAKE 1 TABLET AT BEDTIME
SIG:
START DATE: 11/19/07 TOTAL DAYS: 90
MD:FITZGERALD,PRESTON SEROQUEL 200MG
SIG:TAKE 1 TABLET WITH 400 MG AT BEDTIME.
SIG:
START DATE: 11/19/07 TOTAL DAYS: 90
MD:FITZGERALD,PRESTON SIGNED OFF ON 11/19/07 @ 14:01 BY PRESTON B FITZGERALD, NURSE PRACTITIONER I
SIGNED orF ON 11/21/07 @ 16:37 BY DENISE
NORWOOD, LICENSED PRACTICAL NURSE
ENCOUNTER 00643 MENTAL HEALTH CLI 10/22/07 11:27 LIEBER CQRR INST
COMP
INC NOTE;
TEAM UPDATED TX PLAN. I/M MENTAL HEALTH STATUS WILL REMAIN MENTALLY ILL WIT
H A DXi PYSCHOSIS. PLEASE SEE HARD COPY OF TX PLAN IN MEDICAL RECORDS. NEXT
UPDATE i'HLL BE 12/5/07.
TEAM MEMBERS----T. MCCANTS,CCC AND C. BYNES,eCC
TANYA MCCANTS,CCC
SIGNED OFF ON 10/22/07 @ 11:28 BY TANYA F MCCANTS, HUMAN SERVICES COORD I
ENCOUNTER 00642 MENTAL HEALTH eLI 10/04/07 12:23 LIEBER CORR INST
eOMP
RENEW MEDS.F/U IN 80 DAYS
DIPHENHYDRAMINE ELIXER
12.5MG/SCC
SIG:TAKE SOMG IN THE AM AND AT BEDTIME PO DAILY
SIG:
START DATE: 10/04/07 TOTAL DAYS: 90
MD:FITZGERALD,PRESTON SEROQUEL 200MG
SIG:TAKE 2 TABLETS PO AT BEDTIME
SIG:
START DATE: 10/04/07 TOTAL DAYS: 90
MD:FITZGERALD,PRESTON SIGNED OFF ON 10/04/07 @ 12:28 BY PRESTON B FITZGERALD, NURSE PRACTITIONER I
NOTED
SIGNED OFF ON 10/04/07 @ 13:32 BY JOSEPH H POWELL, NURSE ADMINISTRATOR/MGR I
ENCOUNTER 00641 MENTAL HEALTH CLI 08/24/07 13:50 LIEBER CORR INST
eOMP
38 YEAR OLD AAM SEEN IN SMU FOR PSYCH F/U. WITH C/O THAT HE FEELS HIS ROOM
IN ON FIRE AND HE SMELLS FIRE. C/O A/H BUT SAYS VOICES ARE CONTINIOUS. USUA
LL A/H ARE INTERMITTENT SO NOT REALLY TRUE A/H. NO SI, HI.
A STABLE FOR HIM
P CONT MEDICATION SEROQUEL 600 MG HS AND BENADRYL 50 MG BID.
STEPHEN K BAKER MD
SIGNED OFF ON 08/24/07 @ 13:57 BY STEPHEN K BAKER, PHYSICIAN II

(~
CONFIDENTIAL

P130-065

6875-EEEE-159

r"
\,.

** ENCOUNTER 00640 SICK CALL

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08/23/07 23:51 LIEBER CORR INST
COMP
I/M SEEN POR SICK CALL STATING HE HURT HIS ARM AND WANTING SOMETHING FOR DR
Y SKIN
TEMP=098.3
PULSE= 72
RESP=20
BP=132/ 70
WEIGHT=182
PPD= 0
I/M APPEARS TO HAVE DRY SKIN ON HIS UPPER EXTREMITIES AND TRUNK. ARM DOES N
OT APPEAR SWOLLEN OR BRUISED AT PRESENT TIME.
REQUESTING HYDROCERIN CREAM FOR SKIN
TOLD TO TAKE TYLENOL OR MOTRIN FOR ARM PAIN.
SIGNED OFF ON 08/23/07 @ 23:58 BY DARRELL A BASINGER, UNCLASSIFIED
HYDROCERIN CR ORDERED.
SIGNED OFF ON 08/24/07 @ 13:50 BY ROBERT E BABB, UNCLASSIFIED
NOTED
SIGNED orF ON 08/27/07 @ 14:22 BY KATHY
MCCULLOUGH, LICENSED PRACTICAL NUR
ENCOUNTER 00639 MENTAL HEALTH CLI 08/13/07 13:56 LIEBER CORR INST
COMP
D: I/M SEEN FOR HIS MENTAL F/U. I/M COMPLAINS OF FIRE IN HIS BODY, AND HIS
ROOM CATCHING ON FIRE. I/M REPORTS HEARING VOICES AND SEEING. SHADOWS IN HIS
ROOM. I STOPPED GOING OUT FOR REC BECAUSE OF THE HEAT AND THE THINGS CRAWLI
NG ON MY BODY I CAN'T SEE THEM BUT I FEEL IT.
A: OX: PYSCHOSIS
GAF-50
I/M APPEARED TO BE A/O X3; MOOD APPEARED TO BE ANXIOUS WITH GOOD EYE CONTAC
T. I/M REPORTS COMPLIANT WITH MEDS.
P: WILL F/U IN 30 DAYS OR PRN.
TANYA MCCANTS,CCC
SIGNED orF ON 08/13/07 @ 14:09 BY TANYA r MCCANTS, HUMAN SERVICES. COORD I
ENCOUNTER 00638 MENTAL HEALTH CLI 07/20/07 14:45 LIEBER CORR INST
COMP
S}38YOAAM WITH DX ?SYCHOSIS VS DELUSIONAL DO. 1M IN FOR ROUTINE FOLLOWUP.
1M BELIEVED HE WAS BEING SEEN BY MEDICAL. 1M RPTS CONTINUING TO HAVE
AVH OF SPIRITS IN CELL. IM RPTS VOICES TELL HIM TO KILL SELF. 1M RPTS
THAT HE CAN FEEL AND SMELL FIRE IN HIS CELL. 1M PAS BEEN IN ICS IN PAST A
NO REQUIRED TX AT GILLIAM.
O}APPEARS OLDER THAN STATED AGE, MOOD IRRITABLE, RPTS AH OF VOICES TELLING
HIM HE FIREBOMBED A CHURCH. HE ALSO RPTS VB OF SHADOWY FIGURES.
DENIES SI/HI.
A) PSYCHOSIS
P)INCREASE SEROQUEL TO 600MG QHS
RTC 1MO.
SEROQUEL 300MG
SIG:TWO TABLETS PO QHS.
SIG:
START DATE: 07/20/07 TOTAL DAYS: 90
MD:MELIKIAN,MARGARET SIGNED orF ON 07/20/07 @ 14:50 BY MARGARET
MELIKIAN, PHYSICIAN II
NOTED TO MAR. A. DOLPHIN, LPN
SIGNED OFF ON 07/23/07 @ 10:03 BY ARLOA
DOLPHIN, LICENSED PRACTICAL NURSE
ENCOUNTER 00637 DOC'l'OR' S CLINIC
06/29/07 13: 53 LIEBER CORR INST
COMP
RENEW MEDS
SEROQUEL
400MG
SIG:TAKE ONE TAB AT NIGHT
SIG:
START DATE: 06/29/07 TOTAL DAYS: 90
MD:COBB,THOMAS SIGNED OFF ON 06/29/07 @ 13:55 BY THOMAS
COBB, PHYSICIAN II
NOTED ON MAR.
SIGNED OFF ON 06/29/07 @ 21:20 BY LYNNE M MALDEN, REGISTERED NURSE II
ENCOUNTER 00636 DOCTOR'S CLINIC
06/29/07 13:49 LIEBER CORR INST
COMP
RENEW ME OS

CONFIDENTIAL

P130-066

6875~EEEE-160

Exhibit 6

Access to Psychiatrists: Edward Barton
..
.

Date

AMR Bates Pages

Elapsed Time

'~-" . ·r; . ;~'

- l'··

09/08/10

EEEE-140

Barton sees Dr. Mulbry

01/11/11

EEEE-137

Over 120 Days pass before Barton
sees psychiatrist again (Dr. Mulbry)

EEEE-135

Over 120 days pass before Barton
scheduled for psych clinic. He
refuses to see Dr. Wood

EEEE-133

Over 6 months after last psych
clinic, Barton has psychiatric
assessment with Dr. Wood

05/16/11

07/26/11

Source: Barton AMR (Pltfs' Ex. 130)

PLTF. DEMO.

PX64

Exhibit 7

CUMULATIVE DISCIPLINARY DETENTION SENTENCES
1

BY MENTAL HEALTH STATUS

Mental Health
Classification
L1
L2
L3
L4
L5
All L
Non-L

Average
Cumulative DD
2
Sentences
381 days
129 days
961 days
659 days
148 days
657 da~s
383 days

SCDC Electronic Database on January 13, 2012.
Average cumulative disciplinary sentence by mental health classification as of
September 1, 2011 for inmates who have received disciplinary detention
sentences.
1

PLAINTIFF'S
TRIAL EXHIBIT

ID: <1812-6942-1582 v. 1

P234-001

234

Exhibit 8

Licensed
Counselors

Counselors
Without Licenses

Source: 0000-1773-7190 (PItts' Ex. 89)

PLAINTIFF'S
TRIAL EXHIBIT

P088-001

Exhibit 9

Page 1

STATE OF SOUTH CAROLINA
COURT OF COMMON PLEAS
COUNTY OF RICHLAND
T.R., P.R., K.W. and .M. on behalf of
themselves and others similarly situated;
and Protection and Advocacy for People
with Disabilities, Inc.,
Plaintif
vs.

CASE NO. 2005-CP-40-02925

State of South Carolina; South Carolina
Department of Corrections; and Jon
Ozmint, as Director of the South Carolina
Department of Corrections,
Defendants.
WITNESS:

JONNY WILLIAMS

DATE:

September 28, 2009

TIME:

11:07 a.m.

LOCATION:

South Carolina Department of
Corrections Headquarters
4444 Broad River Road
Columbia, South Carolina

TAKEN BY:

Attorneys for the Plaintiffs

REPORTED BY:

YVONNE R. BOHANNON
Registered Me t Reporter,
Certi ed Realtime Reporter

COMPUSCRIPTS, INC.
A Full-Service Court Reporting Agency
Post Office Box 7172
Columbia, South Carolina 29202
1-803-988-0086
1-888-988-0086
www.compuscriptsinc.com

j
j

Page 22 !
1

I think it helps a lot when they have

the support from the counselor, and the counselors

meet with them, like I say, on a regular basis and

provide group therapy and we provide coping skills,

how to cope with those type of stressors.

think it's beneficial to have a counselor that

helps them deal with that.
Q.

So I

Is it a stressor for them to be away

from their' family members and loved ones?
A.

10
11

individual.

don't.

That again just depends on the
Some -- some adjust well and some

What affect does,

In your experience as

a counselor, being in a small, confined space have

someone on who is mentally ill?

;

For the most part I think they do well

if, you know,

like I say, if they -- they

they counselor, they do pretty well.

they're taking their medication, and
h~ve

the support of

What effect does mental illness have on

an inmate's ability to -- to comply with rules of

prison?

None.

None?

None.

~------------------------------------------------------------------~----------~I'

Exhibit 10

MI with
DD Sentences 2

MI with Recorded
GBNA Disposition3

1,252

Sources:

1 SCDC Electronic Database

Rate of MI
GBNA Dispositions4

produced January 13,2012.

all inmates with "L n mental health classification on September 1, 2011 who received a disciplinary
detention sentence for an infraction after June 10, 2009.

2 Includes

with "L" classification on September 1, 2011 receiving a GBNA determination for an infraction.
Earliest reported GBNA infraction is June 11, 2009.

3 All inmates

4 Rate

determined by 25 + 1,069.

PLAINTIFF"S
TRIAL EXHIBIT

243

P243-001

DO
Mental Health
Classification

GBNA
Dispositions

Sentence
Imposed

Dates of
Service
Calculated

Yes

Sentence
Dates
Removed

~---

All L

Source:

Yes

Non L

Yes

Total

Yes

1 SCDC

Electronic Database produced January 13, 2012.
Includes all GBNA disposition codes reported for all inmates in SCDC custody on September 1, 2011

21ncludes 25 inmates, two of whom each received two GBNA determinations for a total of 27.

PLAINTIFF'S
TRIAL EXHIBIT

242

P242-001

Exhibit 11

Thursday, April 2, 2009
3:15 PM

Anderson placed in rec cage

3:30 PM

Counselor Ransom speaks with Anderson

5:35 PM

Anderson on CI in rec cage

April 2, 2009 at 3: 15 PM

Friday, April 3, 2009

Anderson in rec cage on CI

April 6, 2009 at 6:00 AM

10:30AM
6:00 PM

Anderson in rec cage

6:30 PM

Anderson in rec cage on 15 min. CI
Saturday, April 4, 2009

5:30AM

Anderson in rec cage on CI

9:30AM

Anderson escorted to bathroom

6:15AM

Anderson on CI in rec cage
Sunday, April 5, 2009

6:00AM

Anderson in shakedown area stripped out

7:00 PM

Anderson on 15 min. cell check
Monday, April 6, 2009

6:00AM

Anderson on 15 min. cell check

86.75. Hours
on CI in Rec Cage
Source: SMU Logs, HHH 4265-4273 (Pltfs' Ex. 68)

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Exhibit 12

SOUTH CAROLINA DEPARTMENT OF CORR1~CTIONS
OFFICE OF INSPECTOR GENERAL
DIVISIOl~LQJ~:l~~~E~11G~110NS

Report of:
Date of Report:
Case Number:

Status: C

Lloyd R Greer
June 8, 2008
32-0097

TITLE:
SubjectlVictim:
Complainant:
Category:
Location:
Date:

Inmate Jerome Laudman, SCDC #247082 '
Captain Robert Jolmson" Employee #023061
Inmate Death
Lee Correctiona.l Institution
February 18,2008

SYNOPSIS OF INVESTIGATION:
On February 18, 2008, Captain Robel1 Jol111son contacted Investigator Lloycl Greer in reference
to the death of inmate Jerome Laudman who was found unresponsive in his cell located in the
Super-Max section of the Special Management Unit (SMU) of Lee Conectional Institution.
Captain Johnson stated that inmate Laudman had "Jeen transported to Toumey Medical Center
and later died.
Upon arrival at Lee Correctional Institution Investigator Greer spoke with Head Nurse Jeri
Andrews as to what had taken place with inmate Laudman. Nurse Andrews stated that Lt.
Jonathan Goodman had contacted Medica.l stating that Laudman had been found unresponsive in
his celL Andrews stated that when she arrived at Laudman's cell she observed Laudman lying on
the floor in feces and vomit. Andrews noted that there were food trays with molding/decaying
food between the cell doors, His breathing was shallow; however, he had some movement in his
amlS. Laudman was removed from his cell and tnmsp011ed to Lee Medieal where he received
medical attention until arrival of EMS personnel, who took over the care of inmate Laudman.
Investigator Greer then went inmate Laudman's cell to photograph and secure the area. Upon
arriving at the cell, one of the contraband officers was in the process of securing the cell per
instruction of Captain Johnson . Investigator Greer photographed the cell area inside and out, and
secured the outer door with security pressure tape. During the course of documenting the area,
Investigator Greer did not notice any smell of feces, vomit or any of the details that had been told
him by Nurse Jeri Andrews. There was a distinct odor of cleaning supplies. Investigator Greer
questioned Lt. Goodman as to who cleaned the area p,r:ior to his arrival. Lt. Goodman stated that
the area had not been cleaned or anything removed from the cell area. He further stated that the
cell room was in the exact same condition as when the inmate was found un-responsive.

6875-IG-0900
CONFIDENTIAL

CASE NUMBER: 32-0097

SYNOPSIS, CONTINUED: (A-2)
On Febmary 19,2008, Investigator Lloyd Greer was advised that the autopsy was compkted and
the cause of death has been mled natural causes. The pathologist indicated that Laudman had
suffered a heart attack. Bodily fluids were sent to toxicology as nonna] protocol to determine if
there were any other contributing factors.
Investigator Greer returned to the Super-Max unit and again photographed the cell area, and
released the cell to be used.

LAUDMAN'S MOVE TO A SUPER .MAX CIDLL-FEBRUARY 7, 2008
Associate Warden Margaret BeJl advised that a videotape had been done when inmate Laudman
was transferred from the main population to Supe.r-Max. The tape was viewed; however, it
contained less that a few minutes of taping and then went blank.
Officer Paget James stated that he assisted Lt. Amhony Davis in removing Laudman from his
cell in the main building of SMU and helped escort him to a Super-Max cell on February 7,
2008. James alleged that when they got to the area, Lt. Davis physically threw Laudman into the
cell. They then learned that this was the wrong cell and had to take Landman back out. When
they got to the right cell, Lt. Davis physically threw Laudman into that cell. James alleged that
Lt. Davis shoved Laudman in the cell handcuffed and Laudman fell on the concrete bunk.
Officer James stated he was not sure why Lt. Davis had done this; however; Davis appeared to
be angry. Laudman had not been resisting.
Lt. Davis stated that on the day inmate Laudman was moved to Super-Max, he was assisti.ng Lt.
Gertrude Jenkins, who was having Laudman transferred to the Super-Max unit. He is not sure of
the reason for Laudman's transfer. Prior to moving, inmate Laudrnan was given several
directives to back up to the door and be handcuffed; however, he refused. Lt. Jenkins gave the
directive to use chemical munitions and aftenvard inmate Laudman complied with the d.irectives
and was transported to Super-Max. (Medical records show that Laudman was seen after the use.
of chemical munitions.)
Lt. Davis stated that he had no orders or knowledge of why inmate Laudman was being
trans felTed and was merely acting on Lt. Jenkins' request. When inmate Laudman was removed
lYom the cell, he and Officer Paget James were the officers who escorted Laudman to the SuperMax cell. Officer Gerald Price, Sgt. Robbie JenkiJls and Lt. Gertrude Jenkins were also present.

Lt. Davis denied that Laudman was placed in the wrong room initially. Laudrnan was taken
directly to room 27. Davis denied using excessive force. Davis stated he was not aware that
inmate Laudman's personal belongings had not gone with him. Lt. DaViS stated that Laudman
had been given these items several times in the past and wou ld only destroy them. Lt. Davis

6875-IG-0901
CONFIDENTIAL

CASE NUMBER: 32-0097
SYNOPSIS, CONTINUED: (A-3)
stated that he would not have been aware that an inmate had been in Super-Max unit for eleven
(11) days without anything accept his jumpsuit unless an officer or other supervisor cqmes to
him and advises him of the situation. He had not checked on Laudman since the day Laudman
was placed in Super··Max.
Special Management Unit Administrator Bmce Obennan was interviewed and stated that inmate
Laudman was placed in the Super-Max unit because he had been trashing his room, was
uncooperative, and parading around naked. Obenl1an did not know who requested or gave
authority for inmate Laudman to be placed on Super-Max. He believes that Captain Ronnie
Cribb wasthe one who notified him that inmate Laudman was being transfened to Super-Max. A
lieutenant would not nonnally have the authority to place an inmate on Super-Max.
Correctional Counselor Jake McFadden was interviewed and stated that he was scheduled to
meet with Laudman on a monthly basis; however) he would look in on him occasionally while
working with other inmates in the Special Management Unit (SMU). During the first week of
December 2007, officers stated that Laudman became loud and boisterous and \J,las placed. on
crisis intervention for about five days. McFadden stated he \vas never told about Laudrnan being
transferred to a Super-Max cell. Since be was Laudman's pnmary mental health counselor, the
officers should have notified him if Laudman wa~; not taking his medication, not eating, or
demonstrating bizarre behavior. McFadden stated that to his knowledge, inmate Laudrnan was
progressing along nom1ally Once an inmate was placed on crisis intervention, it is required that
the inmate be seen on a daily basis to evaluate his behavior until such time as the counselor feels
that the inmate was no longer a threat. McFadden further stated that inmate Laudman was not on
crisis intervention during the time he was in the Super-Max area, and no record of any pro blems
were brought to his attention.
Sgt. DelTick Anderson stated that he did not know why Laudman was placed in Super-Max.
Laudman had been moved there while he was off duty. Anderson stated that when he had seen
inmate Laudman, he was alert and talking. He did not know why inmate Laudman did not have
any of the basic needs, like mattress, blanket, or any type of clothing as the other shift had placed
Laudman in Super-Max and did not communicate with him. Sgt. Anderson stated that he was
unaware of inmate Laudman's condition; however,. he was aware that Laudman was not on crisis
intervention. Anderson stated that "had he focused on inmate Laudman's lack of mattress, and
blankets, he would have addressed the problem."
Lt. Gertrude Jenkins stated that most of her dealings with inmate Laudman were when he was on
Crisis Intervention in Cell # 33. Inmate Laudman refused everything such as clothing or shower,
that was offered to him; however be ,vGuld eat and drink.
Jenkins stated that she tried to talk
with inmate Laudman on several occasions with negative results. Jenkins stated that she
discussed inmate Laudman's hygiene and filthy room with Captain Ronnie Cribb and suggested
that they should place Laudman in Super-Max where a shower was located inside the cell. Lt.
Jenkins stated that Captain Cribb authorized the move of inmate Laudrnan to the Super-Max
section.
6875-IG-0902
CONFIDENTIAL

CASE NUMBER: 32-0097

SYNOPSIS, CONTINUED: (A-4)
Captain Ronnie Cribb was interviewed conceming the authorization of inmate Laudman's
transfer to Super-Max and he denied authorizing the transfer. Captain Cribb stated that he: did not
make any such authorization, nor does he recall any conversation with Lt. Jenkins involvjng the
movement of inmate Laudman.
Inmate Eric Washington alleged that Laudman was physically thrown into the cell in hand cuffs
when he was brought to the super max cell. This excessive use of force was witnessed by officers
who even complained to the inmates.
Inmate Adrian Brunson alleged that the officer initially threw Laudman inside cell # 29 then
moved him when advised by Lt. Jenkins that it was ail occupied celL The officers then drug
Laudman out of 29 and took him to 27. Laudman was kind of crazy and talked to himself.
Laudman was cussing and after they left, he was saying things like, "Yaw! come on back, I'm
going kill y'al1." When Laudman would not give 'tiP the handcuffs, Lt. Davis wanted to take the
matter further. Davis was saying things like, "Man let me in there, let me in there." That'~: when
Officer Grate stepped up, and said, "Man, just give me the cuffs man. Come on man please
man." He does not know whether Grate was doing it because it was time to go home or he
actually cared:
Inmate Carlos Sumpter was intervie\ved and stateq that Laudman was moved off of the main
population area mainly because he smel1ed so bad, During the course of preparing him to be
moved, he overheard officers mocking inmate Laudman because of the smell coming from his
cell. Sumpter further stated that Laudmart was handled pretty rough when taken to Super-Max
without any justification.

tAUDMAN'S TIME IN SUPER MAX-FEBRUARY 7-18, 2008
Inmate Eric Washington was interviewed in reference to information he stated that he had
concerning inmate Jerome Laudman. Inmate Washington made several comments concerning
inmate Laudman and how he was ignored by officers and was left to himself for long periods of
time. Washington stated that when officers were told that they needed to check on Laudman,
they would advise that the situation was "out of their hands."
Inmate Adrian Brunson was also interviewed and stated when inmate Laudman was placed in the
Super-Max cell the officers did not allow him anything. Brunson stated that on the day Laudman
was found, he and inmate Eric Washington hl;td been banging 011 the cells trying to get officers to
check on Laudman because they had not heard anything from him for at least a couple of days,
According to Brunson, because of Laudman's mental condition he would always be making
noises and ShIff; however, for a couple of days they had not heard anything from him at all.
Bmnson states that he informed Officer S.bepard several times and Shepard would tell the
supervisors and then tell him that it was "out of bis hands,"

6875-IG-0903
CONFIDENTIAL

CASE NUMBER: 32-0097
SYNOPSIS, CONTINUED: (A-5)
Sgt. Roy Cooper stated that he was in the Super-l\1ax unit on February 11,2008 to pick up
inmate Dominique Gallman, SCDC #287238, for court. While in the Super-Max unit he looked
i~ on inmate Laudman and saw that he was sitting and stooped over like he was real weak or
sick. Cooper also states he saw food trays piled up between the doors and noted that Laudman
was naked and his room was bare. Sgt. Cooper stated that he wondered why Laudman was in
Super-max, especially in the condition he was in, because this was not a crisis intervention cell.
Cooper said he was going to notify the unit captain or the administrator; however, he did not
notify anyone because he has brought issues up in the past, and was advised to '~leave it alone
and mind his own business." Cooper does not believe that the unit is nl11 according to policy and
procedures.
Officer Gregory Grate was interviewed and stated that he was not working the clay inmate:
Laudman was found; however, he did work a few days during the time Laudman was in the
Super··Max unit. Officer Grate stated that he did his security checks on the inmates as usual and
they seemed ok. He had noted that Laudman did not have any type of clothing, blankets, and
towels, or any items in his room at all. Officer Grate initially stated that he thought Laudman
might have been on Crisis Intervention; then stated Laudman had been "stripped out" because of
his mental condition. Officer Grate stated Laudman being stripped of all their things was
probably their punishment for not complying.
Lt. Jenkins states that she did notice that inmate Laudman's room had a foul odor because he
would not clean up anything. Jenkins stated that she did witness food, water and possibly urine in
his room at times; however, she never saw feces. Inmate Laudman did not have any basi.c needs
in his cell because he would not take anything, she tried to give him. Jenkins recalls speaking to
one of the counselors concerning Laudman and his refusal to take anytlling; however, she cannot
remember which counselor she spoke to.
Inmate Adrian Brunson stated that he did not hear anything for three or four days. He and inmate
Washington told Officer Shepard that something was wrong with Laudman, that he was not
eating or taking his medicine. When officers would come around and ask Laudman something all
he did was hold his head up. Laudman did not even get out the bed. Shepard told him that he had
he told his supervisors and "it was out of his handEi." Officer James also said, "Man, it's out of
my hands." When he asked them to help Laudman, all of the officers would say, "Well man, I
spoke to the lieutenant 3 or 4 times. I spoke to the Sergeant; it's out of my hands." Officer James
said that Lt. Davis told him, "Don't even worry about that. Go ahead and finish what you were
doing on the rock."

CELL CHECK LOGS
A review of the cell check revealed, only two for mmate Jerome Laudman. These two pages
covered the time frame of Febmary 10, 2008 thrOllgh February 18, 2008. The time frame for
Friday, February 15, 2008 was blank and ~ihowed no security check on inmate Laudman for that

6875-IG-0904

CONFIDENTIAL

CASE NUMBER: 32-0097
SYNOPSIS, CONTINUED: (A-6)
date. Entries for February 13, 2008, beginning at '7: lOAM and continuing every hour until 6:20
PM, showed the same initials written in black pen. The initials appear to be (GM) indicating
possibly Lt. Gainey Mickens. On February 18, 2008, the exact same black pen entry is detected
for inmate Laudman under the initials of (DA) for the times of 8:00 Alvf, 10:45 AM, and 1:30
PM, which is the time listed for when Laudman \Vas found unresponsive. The initials (DA) are
for Officer Derrick Anderson who was named in the medical report as the officer who notified
Lee Medical.
On April 16, 2008, Officer Gainey Mickens was questioned as to the initials shown on inmate
Laudman's security check sheet for February 13,2008. Officer Mickens stated that the entries
made on that date were not his initials nor did he authorize anyone to use his signature. Officer
Mickens also signed a verification of signature to lhat effect.
Security cell check sheets for imnate Eric Washington and inmate Adrian Brunson's records for
February 13, 2008 show the same times a!l inmate Laudman's for that date.

THE DAY OF LAUDMAN'S DEATH··FEBRUARY 18,2008
Officer Timothy Shepard stated that he was working the moming of tht;~ incident and had notified
his supervisor, Sgt. Derrick Anderson, multiple times that Laudman needed help. Earlier that day
he checked on Laudman and saw that he was laying on the floor in feces and stuff. Sgt. l~nderson
told him "not to stress about it." Officer Shepard stated he continued to notify his supervisor that
/{
Laudman needed help and was lying in his own f(:ces; however, his complaints were ignored.
Officer Shepard states he continued to check on Liudman and noted that he stayed in the !mme ~
position the whole morning. Officer Shepard stated that he did not notify any othe~ supervisor
because he was told to follow the chain of command. When Sgt. Anderson finally came to check
on Laudman, Anderson did not open the doors, ju:~t looked in the window and called for Medical
personneL
Sgt. Anderson stated that they were Sh011 personnel on the day of the incident and be helped feed
the inmates in Super-max. He noted that during the breakfast meal, inmate Laudman was up and
walking around and took his breakfast tray from him. Anderson stated that Laudman also took
his lunch tray. Anderson stated that at approximately 4:45 PM, (Note: Laudman was arrived at
the hospital emergency room at 2:00 PM) he saw inmate Laudman lying on the floor and not
responding. He advised Lt. Goodman of the situation and that they needed to call Lee Medical.
Sgt. Anderson stated that talked to Nurse Stephanie Brown or Nurse Jeri Andrews "until they
stressed him out" and he let Lt. Goodman talk to thent He was stressed because the nursiJag
personnel were worried about going into the cell and kept saying they were not going to go into
the cell. Anderson states that it was about 25-30 minutes before medical arrived and when they
arrived they were real hesitant, not wanting to go into Laudumn's cell. They were worried about
jackets and stuff to cover them because they did not want to get s tuff from the cell on

6875-IG-0905

CONFIDf.N'fl AL

CASE NUMBER: 32-0097
SYNOPSIS, CONTINUED: CA-7)
them. The officers did not bring Laudman out of tbe room because the nursing staff wanted them
to wait for the hospice workers before moving inmate Laudman. He does not Jmow specifically
why the officers did not assist in bringing Laudman Ollt of the room; however, they were trying
to get things situated for a gurney and the nurses cbd not want to go in the room, because it was
nasty and mthy.
Lt Goodman stated that he was working C-Control when Sgt. Derrick Anderson told him that he
needed to check on inmate Laudman. Goodman stated that he saw Laudman's condition then
returned to the front and called medical personnel. Goodman states that this was around 1: 30 or
2:00 PM. Nurse Jeri Andrews called him back and he informed her that Laudman was not
responding and they needed to come to SMU. The nurses advised him that they were going to
wait until count cleared; however, he told them they needed to come now. Goodman stated that
when the nurses arrived they looked in on Landman and sent a nurse back to the medical unit to
get some gowns and stuff. The nurse returned with some Hospice workers and a stretcher.
Goodman stated that they had to go to Medical to get gowns and stuff, so they would not get the
stuff on Laudman's body on them. Goodman initially stated that officers are not allowed to move
an inmate for Medical; however, he then stated that Nurse Andrews told them to leave Laudman
there and wait till the nurse came back with Hospice workers.
Nurse Staci Thompson stated that when they arrived at Laudman's cell the officer unlocked the
door so they could do a better assessment. When the door was opened she noticed a large amount
of white Styrofoam food trays that had collected between the outer and inner door. Several of the
trays contained partially eaten and rotting food, Wl th mold growing on them. One of the officers
directed an inmate to sweep the trays out of the way so that inmate Laudman could be moved.
She observed that Laudman was breathing: and had some slight movem(~nt in his extremities.
Laudman and the area where he was lying facedown was covered in vomit and feces. Nmse
Thompson stated that in her opinion, the D:;cal matter found on Laudman had most likely been
there for a period oftime. The stench was also very prevalent and was "one of the worst smells
she has ever encountered."
Registered Nurse Jeri Andrews was interviewed and stated that she responded to the unit in
reference to an inmate being down and was told that he vomited on himself. Upon arriving at the
unit, they were met by Sgt. Anderson and Lt. Johnathan Goodman. Both officers were wearing
masks, and escorted them to the Super-Max unit. Nurse Andrews stated that there was a tenible
smell coming from the Super-Max section and it "vas noticeable before you even got to the area.
Upon arriving at Laudman's cell, the stench was terrible. When one of the officers opened the
outer door, she saw at least 15-20 Styrofoam food trays between the inner and outer doors. Nmse
Andrews advised Lt. Goodman and Sgt. Anderson that inmate Laudman needed to be removed
£i'om the cell so she could evaluate his problems. Nurse Andrews stated that 1. . 1. Goodman and
Sgt. Anderson refused to remove Laudman, 8tating to each other, "I'm not going in there." She
offered both officers gloves and lab coats to remove Laudman; however, they refused. Andrews.

6875-IG-0906

CONFIDENTIAL

CASE NUMBER: 32··0097

SYNOPSIS, CONTINUED: (A-B)
then requested that Nurse Brown return to Medica.!, retrieve medical equipment so she could
obtain vitals on Laudman, and bring back two hospice workers to help remove Laudman from
the cell. While Nurse Brown was getting the supplies, she asked Lt. Goodman what problems
Laudman was exhibiting. Goodman initially stated that Laudman had been fine; however, he
then said that Laudman had been weak an weeke11d. Goodman then changed his story a third
time, vaguely stating this was the first he had seen anything. Andrews stated that she never got
an exact response.
Andrews stated that after a period of time, Nurse Brown returned with the two hospice inmate
workers and advised that she (Brown) hac! to wait until the count cleared before she could take
the hospice workers with her. Nurse Andres stated that this delayed her assessment of Laudman
about a half hour. At this time Laudman was extreme~y Gold to the touch. Andrews stated that
they transported Laudman to Lee Medical where they' began to help him breath with assistance,
tried to waml him up and began cleaning llim up.
Special Management Unit Administrator Bruce Oberman was interviewed and stated that the
delay in the response of hospice workers ahould not have happened in an emergency situation;
however, the officers should have assisted the medical staff since they have access to gloves and
protective equipment. Oberman futther stated that the time frame that elapsed before a supervisor
checked on inmate Laudman was also unacceptable.
Inmate Uuno Baum stated that on the day of the incident two officers came to the front of the
SMU unit and said that an inmate was passed out or not breathing right. Lt. Jonathan Goodman
called for medical personnel.to come check on the inmate. When medical personnel arrived Lt.
Goodman called Baum and inmate Attie Bums and directed them to clean out the foyer area
between Laudman's doors. Inmate Baum stated tbat there were several days' worth of trays
piled between the doors. After removing the tray~; from the doorway, Baum stated the nurse told
Lt. Goodman and Sgt. Derrick Anderson that inri.1ate Laudman needed to be picked up and.
moved to Medical, so she could evaluate his condition. Lt. Goodman and Sgt. Anderson both
refused to help move inmate Laudman stating, " I'm not picking him up, he's covered in shit."
Dlmate Ellison, a hospice worker who assisted in removing Laudman, was also interviewed.
Ellison stated that he did not observe any l:ype of blankets, towels, mattress or any clothing
except a yellow jumpsuit inside the shower area. He also related that Laudman was covered in
fecal matter as well as vomit.
THE DEATH SCENE
Inmate
Washington alleged that after Laudman was removed from his cel1 inmates were
sent to clean up the cell.
Inmate Brunson stated that after Laudman \-vas taken out of his cell, they sent an inmate to clean
up the cell before investigators arrived.

6875-1G-0907

CONFIDENTIAL

CASE NUMBER: 32-0097

SYNOPSIS, CONTINUED: (A-9)
Nurse Thompson was shown the photographs that Investigator Greer had taken the day inmate
Laudman was found. Thompson stated that some one had cleaned the room and the photographs
did not depict what she saw.
Nurse Andrews was shown several photographs of Laudman's cell on tbe day that Investigator
Greer had arrived to secure the area. Upon looking at the photographs, Nurse Andrews stated
that the pictures did not reflect what she had seen that night and the cell area had been cleaned up
significantly.
Inmate Uuno Baum stated that on the day inmate Laudman was found in Super-Max, he and
inmate Artie Burns were directed by Lt. Jonathan (J'oodman to clean out the food trays that were
piled up between the doors. This was done while the nurses were there to check on inmate
Laudman. Baum stated that a short time after imnate Laudman was removed, Lt. Goodman told
him that Laudman had died and he needed the cell cleaned up as fast as possible "because
investigators were coming from the South Carolina Law Enforcement Division {SLED)." Baum
stated that Goodman told him that he needed it done and for Baum to "get it cleaned up and get
out of the way before the investigators arrived." Inmate Baum stated that he tJien went and got
the cleaning supplies and equipment and deaned the room up like he was told. He scrapped up
all of the feces, and vomit from the bed and floor area, and then mopped the area down with
chemicals. After this, he went up to the main area, where Lt. Goodman asked about Laudman's
jumpsuit. Baum stated he returned and got the jurnpstlit from the shower area and placed it in the
trash with all of the rest of the feces and vomit that had been cleaned up from the room. The
trash was then thrown away. Lt. Goodman later advised him that ifhe was questioned about the
Laudman incident, he did not have to answer any questions or say anything concerning inmate
Laudman or the cleaning of his cell. Goodman also advised him that "it would be best if he said
nothing about it."
Goodman denied having the cell cleaned. Captain Arend.a Thomas told him not to touch anything
because it was a crime scene. Goodman insisted that the cell was in the exact same condition at
the time Investigator Greer arrived, as it was when im11ate Landman was removed.
MEDICALIMENTAL REVIEW

Correctional Counselor Jake McFadden was interviewed and stated that he became acquainted
with inmate Jerome Laudman several years ago when he entered the system. Inmate Laudman
was diagnosed with Schizophrenia, along with some degree of mental retardation ..McFadden
stated that he was scheduled to meet with Laudman on a monthly basis; however, he would look
in on him occasionally while working with other inmates in the Special Management Uni1:
(SMU). For the most part, inmate Laudman was cooperative; however, Laudman had a speech
impediment, which made him difficult to understa.nd. During the first week of December 2007,
officers stated that Laudman became loud and boisterous and he was placed on crisis
intervention for about five days. McFadden stated he was never told about Laudman being

6875-IG-0908
CONFIDENTiAL

CASE NUMBER: 32-0097
SYNOPSIS, CONTINUED: (A-1O)
transferred to a Super-Max cell. Since he was Laudman's primary mental health counselor, the
officers should have notified hi m if Laudman was 110t taking his medication, Dot eating, or
demonstrating bizarre behavior. McFadden stated that to his knowledge, inmate Laudman was
progressing along normally
McFadden stated that he had never known inmate Laudman to be aggressive toward him or any
other staff member. Although Laudman was easily distracted, and would get agitated, he never
saw Laudman as a threat to anyone other than him~lelf. Only counselors or m!;dical persorulel
couldplace an inmate on crisis intervention. Once an inmate was placed on crisis intervention,
it is required that the inmate be seen on a daily basis to evalu.ate his behavior until such time as
the counselor felt that the inmate was no longer a threat. McFadden further stated that inmate
Laudman was not on crisis intervention during the time he was in the Super-Max area, and no
record of any problems were brought to his attention.
Inmate Brunson stated that he heard Laudman ask the Ilurse on night shift for his medication and
tell her that he needed to get out of there. The nun;ewould say, "I can't get you out of here sir."
Laudman would say, "Can you get me some help?" and the nurse would say, "Sir, there's
nothing wrong with you." Brunson said that staff would come down there and laugh wheri they
gave Laudman his medication because Laudman would make grunting noises (Brunson
demonstrates by making grunting sounds like all ape), like he was crazy. Sometimes the officer
would say, "Fuck hi111, he don't want no medication." They would then leave. The nurse cannot
over ride the officer and if the officer says, "Let's go, then it's time to go.
Inmate Eric Washington stated that he does not know if Laudman was taking bis medication.
However, he does know that either Thursday or Friday (February 14 or 15, 2008) Laudman
stopped taking his medication. Laudman was not getting up to receive the medication so the staff
considered that a refusal. Laudman was refusing his food also. Also on Thursday or Friday
Laudman stopped making any noise.
The medical records that were received from Tourney Hospital of Inmate Laudman were
reviewed. Medical records indicate that inmate Laudman was brought to the emergency room
unresponsive at 2:20 PM, and had been incubated in the field due to cessation of breathing.
Blood pressure was 00/00 pulse: 49. The medical notes indicated that Laudman was coveTed in
dirt, urine, and feces. According to the notes Emergency Medical Services had found Laudman
cold, and apneic (Cessation of Breathing). Laudman's upper extremities showed cyanosis, a
bluish discoloration, of skin due to lack of oxygen, bilaterally and the body was cold, pale and
dusky. Laudman's body core temperaUlre 80.6 F JJ1dicating hypothermia. Laudman was
pronounced deceased at 5:20 PM.

6875-IG-0909
CONFIDENTIAL

CASE NUlYIBER: 32-0097

SYNOPSIS, CONTINUED: (A-ll)
A review of SCDC Medical Encounters revealed Ihat inmate Laudman had over 917 encounters
with Medical prior to his death. However, he only had five entries from January 1, 2008 until his
death. Laudman had at least thirteen admissions to the Gilliam Psychiatric Hospital since July
2003.
On January 2,2008, Staff reported that Laudman was threatening to harm himself. Landman was
seen by CCC G. Breon who stated that Capt. Cribb reported that Laudman was refusing to move
to another cell so they are going to leave him in #34. Breon noted that Laudman had been
stripped out by security staff and was wrapped in CI blanket. Laudman shook head "no" when
asked ifhe was having thoughts of harming himself. Breon felt Laudman had made threats in
order to stay in the CI cell and was now denying since "he got his way." Breon concluded that
crisis intervention was not needed.
On January 22, 2008, Dr. Michael Kirby, Psychiatrist, evaluated Laudman for unusual behavior,
Le. talks to himself and his cell is a mess. Kirby stated that according to a c/o who knows him
well, Laudman is eating well and sleeps. Kirby stated that Laudman has trouble with his speech.
Landman says he is taking is meds and is not manipulating to go to GPH. Kirby noted no grossly
bizarre behaviors but shows an odd curling of his lips when speaking. Prescribed Seroquel,
Wellbutrin, and Diphenhydramine
On January 28,2008, Laudman attended a Seizure Clinic in SMU Medical. Laudman reported
"no seizure lately," stated he was okay and wanted to go back to his room.
On February 8, 2008, at approximately 12:38 AM, Laudman was checked by Nurse Wiggins
after Chemical force was used by officers. Lapdman nodded that he understood instructions to
flush eyes every 15 minutes. No acute distress noted.
On February 18,2008, at approximately 1:05 PM, Nurse Andrews received call from C/O
Anderson that Laudman was in cell lying ip feces and not verbally responding. Anderson stated
that they had not been in cell "as he was in Superrnax." Andrews stated that when she arrived
inmate Laudman was prone on floor naked with what appeared to be feces and/or vomit covering
his body. There was an extremely foul odor coming from inmate's cell. Lt. Goodman stated he
was not sure how long LAudman had been on the :f1oor. The outer door to the cell was opened
and there were numerous Styrofoam food trays on the floor, some with mold on them. Andrews
noted that Laudman moved his arms when called; however, she "was unable to enter the cdl for
security reason." Nurse called for equipment and hospice workers placed IIM on stretcher. The
IJM was taken to SMU Medical where he was unresponsive and his pupils were fixed and
dialated. lIM's skin very cold to touch. IIM taken to Medical.
Nurse Andrews noted that there were larg(~ bruises on bilateral hip bones, suggestive ofhi])s
pressing against a hard surface for a long period of time.

6875-IG-0910
CONFIDENTIAL

Exhibit 13

October 15, 2008
Nelson Mullins Riley & Scarborough, LLP
Attn: Daniel Westbrook
Keenan Building, Third Floor
1330 Lady Street
Post Office Box 11070(29211)
Columbia South Carolina 29201
Re: South Carolina Department of Corrections
Lee Correctional Institution
Dear Mr. Westbrook
During September 15, 16, 2008 we site visited the Lee Correctional Institution (Lee CI)
along with Steve Martin, Esq. We received a tour of general population housing units,
programming areas (e.g. educational building, gym, dining area etc.), health services unit
and the special management unit (which included a "supermax" section consisting of
two wings (four cells per wing). We also had the opportunity to interview Janet
Woolery, M.D.
During this site visit Jeffrey L. Metzner M.D. interviewed 12 inmates within the special
management unit (SMU) as well as reviewing their mental health records contained in the
automated medical records (also known as the CRT). Dr. Metzner also reviewed selected
paper records of these inmates. Appendix I provides a summary of these inmate
interviews and data that provided the basis for various findings summarized later in this
report.
In addition, during this site visit, Raymond F. Patterson, M.D., interviewed and/or
reviewed the records on an additional 25 inmates housed in general population or crisis
cells. Appendix II provides a summary of Dr. Patterson's inmate interviews and record
reviews.
Prior to this site visit we had the opportunity to review the deposition transcripts of the
following persons:
1. John Solomon, Ph.D.(director of mental health services, SCDC),
2. Josephine Mitchell, R.N., M.S., C.S. (program manager for outpatient mental
health services),
3. Linda Dunlap, R.N. (clinical health director for the division of health services),
4. Joseph Powell, R.N. (healthcare authority),
5. Bruce Oberman, MSW (SMU administrator at Lee CI),
6. Jake McFadden, B.S. (clinical correctional counselor III),
7. Susan Breon (clinical correctional counselor III), and
8. Paul Dennis (lead clinical correctional counselor III).

PLAINTIFF'S
TRIAL EXHIBIT
200S.GP-40-02925

P004-001

PLT.1143

Lee Correctional Institution
Re: Mental Health Services
Page 6 of 14

Dr. Woolery reported that the medication passes in the SMU occurred at 4 a.m., shortly
after noon and from 5 pm to 6 pm.

Findings
Significant problems in the mental health system at Lee CI were apparent based on our
site visit and review of relevant discovery documents. This report will provide a summary
of these problems.
The 'psychiatrist staffing allocation is inadequate. Dr. Woolery provided 12 hours per
week of psychiatrists' time which translates into a .3 PTE position. It was unclear how
much time is provided by Dr. Wood based on information received from Dr. Woolery.
Assuming that Dr. Wood provides eight hours of psychiatric services per month, the total
FTE psychiatrist time would be increased by only 0.05 FTE to .35 FTE. A task force
'report by the American Psychiatric Association (American Psychiatric Association.
Psychiatric Services in Jails and Prisons. 2nd edition. Washington, D.C.: American
Psychiatric Association, 2000) recommends 1.0 PTE psychiatrist for every 150 inmates
prescribed psychotropic medications. It is likely that at least 180 inmates at Lee CI were
prescribed psychotropic medications. Unfortunately the exact number was not obtainable
during our site visit related to the lack of an adequate management information system at
Lee CI.
In addition, there are problems associated with the use of the psychiatrist, which may be
related to the staffing allocation issue. These problems include the psychiatrist's lack of
familiarity with relevant policies and procedures, lack of input into pertinent policy
decisions, minimal involvement with the treatment planning process, lack of significant
involvement with inmates on crisis intervention status and use of the automated medical
records exclusively in contrast to supplementing its use with the paper medical record
that includes relevant information from past providers including the Gilliam Psychiatric
Hospital and various community mental health providers.

Special Management Unit
The psychiatrist's lack of presence in the housing units within the SMU, especiaUy the
supermax section, is very concerning from a clinical perspective. The supermax section
of the SMU is not an appropriate housing unit for any inmate and is highly likely to
exacerbate symptoms of mental illness in an inmate who has such an illness. This was
confirmed by interview of inmates with mental illness who were housed in this section
(refer to Appendix I). Conditions of confinement within the supermax section included
lack of access to the recreational cages, limited access to shower (related, in part, to
malfunctioning showers within the cells), very poor hygienic conditions within the cells
(i.e., they were filthy and smelled badly) and significant social isolation related' to the
nature of the physical plant. Many of these cells had what had been known during the
1970s as "dog nms" that were both dehumanizing and resulted in increased isolation.

PLT.1148

P004-006

Disciplinary Self-Help Litigation Manual - Side