Investigation of Restraint Device Use
in Iowa’s County Jails

Appanoose County Jail
Jefferson County Jail
Polk County Jail
Wapello County Jail
Woodbury County Jail

Iowa Citizens’ Aide/Ombudsman
William P. Angrick II

Issued: November 5, 2008
Released: February 19, 2009

Contributors
Lead Investigator
Andy Teas

Investigators
Linda Brundies
Jeff Burnham
Bert Dalmer
Barbara Van Allen
Kyle White

Intern (Research Assistant)
Chris Natynski

Legal Counsel
Ron Rowland

Deputy Ombudsman
Ruth Cooperrider

 
 

Table of Contents
EXECUTIVE SUMMARY ...........................................................................................................................1
ROLE OF THE OMBUDSMAN..................................................................................................................8
OVERVIEW: COMPLAINT ALLEGATIONS ......................................................................................10
GETTING STARTED: IDENTIFYING ISSUES OF RESTRAINT USE ............................................12
A.
TRYING TO FIND A POLICY ................................................................................................. 13
B.
CORRECTIONAL STANDARDS ............................................................................................ 14
C.
MEDICAL STANDARDS ......................................................................................................... 16
D.
MENTAL HEALTH STANDARDS.......................................................................................... 17
CURRENT NATIONAL TRENDS ON RESTRAINT DEVICE USE ...................................................21
A.
INMATE DEATHS AND MONETARY JUDGMENTS .......................................................... 21
B.
RESTRAINT DEVICES AS TORTURE ................................................................................... 22
C.
USE OF RESTRAINTS IN MHIS AND NURSING HOMES .................................................. 24
1.
Reduction of Restraint Use in MHIs ................................................................................... 24
2.
Reduction of Restraint Use in Nursing Homes.................................................................... 25
LAW, POLICIES, STANDARDS, AND GUIDELINES..........................................................................27
A.
INTAKE SCREENING FOR MENTAL HEALTH................................................................... 27
1.
Federal CRIPA Investigations ............................................................................................. 28
2.
NCCHC Publications and Standards ................................................................................... 29
3.
ACA Standards.................................................................................................................... 31
B.
MENTAL HEALTH ASSESSMENT AND TREATMENT...................................................... 32
1.
Federal CRIPA Investigations ............................................................................................. 32
2.
NCCHC Standards and Recommendations ......................................................................... 33
3.
ACA Standards.................................................................................................................... 34
C.
USE OF RESTRAINTS ............................................................................................................. 35
1.
Federal CRIPA Investigations ............................................................................................. 35
2.
The Federal Bureau of Prisons Policies............................................................................... 36
a.
Placement and use of four-point restraint..................................................................... 36
b.
Medical and mental health reviews .............................................................................. 37
c.
Documentation ............................................................................................................. 38
3.
NCCHC Standards and Recommendations ......................................................................... 38
4.
ACA Standards.................................................................................................................... 39
5.
CMS Regulations ................................................................................................................ 40
6.
Other Resources .................................................................................................................. 43
D.
TIME LIMITS ............................................................................................................................ 45
1.
E.R.C. Inc. Policy ................................................................................................................ 45
2.
Iowa Law and Case Law ..................................................................................................... 46
3.
Other Sources for Length of Time....................................................................................... 48
ANALYSIS...................................................................................................................................................49
A.
REVIEW OF RESTRAINT DEVICES USED IN IOWA COUNTY JAILS............................. 49
1.
Manufacturer Testing and Research .................................................................................... 49
2.
Adverse Medical Effects of Restraint Use........................................................................... 50
3.
Preferred Attributes of a Restraint Device........................................................................... 51
B.
STANDARDS FOR ALL JAILS ............................................................................................... 53
1.
New Detainee Intake Screening .......................................................................................... 53

i

2.
3.
4.
5.
6.
7.
8.

Assessment of Screened Inmates......................................................................................... 54
Decision to Place Inmate in Restraint Device: When to Use.............................................. 55
Continuous Monitoring, 15-Minute Checks, and Periodic Reviews ................................... 57
Medical Reviews During Restraint Device Use .................................................................. 60
Consultation with A Mental Health Professional ................................................................ 63
Written and Video Documentation...................................................................................... 65
Time Limits ......................................................................................................................... 66

GENERAL RECOMMENDATIONS FOR JAILS ..................................................................................68
JEFFERSON COUNTY JAIL – FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS.......70
A.
FINDINGS OF FACT ................................................................................................................ 70
1.
Intake Screening and Medication ........................................................................................ 70
2.
Treatment Received Prior to Restraint Chair Use ............................................................... 73
3.
Immediate Facts and Circumstances of Restraint Chair Use............................................... 74
a.
April 17, 2007 .............................................................................................................. 74
b.
April 23, 2007 .............................................................................................................. 75
c.
April 24, 2007 .............................................................................................................. 75
d.
April 30, 2007 .............................................................................................................. 76
4.
Doctor Approval for Continued Use ................................................................................... 77
5.
Civil Commitment ............................................................................................................... 79
B.
ANALYSIS, CONCLUSIONS, AND RECOMMENDATIONS............................................... 79
1.
Mental Health Screen and Assessment................................................................................ 79
2.
Mental Health Services After Intake ................................................................................... 81
3.
Use of the Restraint Chair ................................................................................................... 83
a.
When to use.................................................................................................................. 83
b.
Documentation ............................................................................................................. 87
c.
Consultation with medical and mental health staff....................................................... 89
d.
When to release ............................................................................................................ 91
WOODBURY COUNTY JAIL – FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS......93
A.
FINDINGS OF FACT ................................................................................................................ 93
1.
Intake Screening and Treatment Before Restraint Device................................................... 93
2.
Immediate Facts and Circumstances of Restraint Devices Use........................................... 93
B.
ANALYSIS, CONCLUSIONS, AND RECOMMENDATIONS............................................... 95
1.
Intake Screening and Response to Medical Requests.......................................................... 95
2.
Decision to Use Restraint Devices ...................................................................................... 96
3.
Type of Restraint Device Used............................................................................................ 99
4.
Medical Review of Inmate in Restraint Chair ................................................................... 101
5.
Notification of Mental Health Professional....................................................................... 102
6.
Written and Video Documentation.................................................................................... 103
APPANOOSE COUNTY JAIL – FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS ...106
A.
FINDINGS OF FACT .............................................................................................................. 106
1.
Inmate Reception and Placement in Restraint Chair ......................................................... 106
2.
Restraint Chair Monitoring................................................................................................ 106
B.
ANALYSIS, CONCLUSIONS, AND RECOMMENDATIONS............................................. 108
1.
Medical and Mental Health Review During Restraint Chair Use...................................... 108
2.
Potential Use of Taser Device While in Restraint Chair ................................................... 110
3.
Toilet Breaks ..................................................................................................................... 111
4.
Video Documentation........................................................................................................ 112
WAPELLO COUNTY JAIL – FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS........114
A.
FINDINGS OF FACT .............................................................................................................. 114

ii

1.
2.
B.

Placement in Restraint Chair ............................................................................................. 114
Documentation of Restraint Chair Use.............................................................................. 115
ANALYSIS, CONCLUSIONS, AND RECOMMENDATIONS............................................. 116
1.
Application of Restraints................................................................................................... 116
2.
Observation and Documentation ....................................................................................... 118
3.
Video Monitoring .............................................................................................................. 119

POLK COUNTY JAIL – FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS.................121
A.
FINDINGS OF FACT .............................................................................................................. 121
1.
Inmate Monitoring During Restraint Chair Use ................................................................ 121
2.
Documentation .................................................................................................................. 123
B.
ANALYSIS, CONCLUSIONS, AND RECOMMENDATIONS............................................. 124
1.
Fifteen-Minute Checks ...................................................................................................... 124
2.
Periodic Review ................................................................................................................ 125
3.
Medical Review................................................................................................................. 127
4.
Written Documentation ..................................................................................................... 127
5.
Video Monitoring and Documentation.............................................................................. 129
SYSTEMIC MENTAL HEALTH AND PROFESSIONAL RESOURCE CHALLENGES...............131
A.
IOWA DEPARTMENT OF CORRECTIONS REENTRY PLANS ........................................ 131
B.
MENTAL HEALTH COURTS................................................................................................ 133
1.
Woodbury County ............................................................................................................. 135
2.
Rock Island County, Illinois.............................................................................................. 136
3.
Essential Elements of a Mental Health Court.................................................................... 137
C.
MULTI-COUNTY JAILS ........................................................................................................ 140
GLOSSARY...............................................................................................................................................141
APPENDIX A: EMERGENCY RESTRAINT CHAIR .........................................................................143
APPENDIX B: ORGANIZATION RESEARCH CHART....................................................................145
APPENDIX C: BRIEF JAIL MENTAL HEALTH SCREEN ..............................................................150
JEFFERSON COUNTY JAIL’S REPLY ...............................................................................................152
WOODBURY COUNTY JAIL’S REPLY ..............................................................................................155
APPANOOSE AND WAPELLO COUNTY JAILS’ REPLY ...............................................................158
POLK COUNTY JAIL’S REPLY ...........................................................................................................166
OMBUDSMAN COMMENT ...................................................................................................................169

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Executive Summary
The use of full-body restraint devices is a widespread practice in Iowa’s county jails.
Full-body restraints come in the form of restraint chairs, boards, and beds, including two
such devices manufactured in Iowa. Iowa law, which refers to these as four- and fivepoint restraints, states they are only to be used when an inmate is a threat to self, others,
or jail security. However, the Ombudsman found they were also used on inmates who
caused minor disruptions or in response to an inmate’s verbal abuse. In some cases, the
restraints were used on inmates with known mental illness who were acting out, though
no attempts were made to seek medical or mental health reviews for those inmates while
restrained, leading to extended use of the restraint device.
The Ombudsman believes restraint devices can be a useful tool to safely control an
inmate, but concerns arise when the devices are not used in accordance with
manufacturer policies or used for reasons other than those allowed by Iowa law. The
Ombudsman also has concerns about the devices’ effect on inmate life and safety, given
the cases of inmate deaths associated with their use outside of Iowa. These cases have
often been followed by civil suits with verdicts reaching millions of dollars.
In January 2006 the Ombudsman received a complaint from Lillian Slater, who claimed
abusive treatment by Scott County Jail staff during its use of a restraint chair. That
investigation resulted in a critical report issued in June 2007. Since receiving Ms.
Slater’s complaint, the Ombudsman has reviewed additional complaints of restraint
device use by county jails. These cases provide examples of jail staff failing to follow
Iowa law, jail policy, or recommended standards set forth by professional organizations
in the corrections field. The cases also highlight some of the major shortcomings in Iowa
law and county jail policies as it relates to the mentally-ill offender and the use of
restraints.
Iowa law gives little guidance on the screening and treatment of mentally-ill jail inmates
or on the use of restraint devices. For guidance on these issues, the Ombudsman
reviewed standards and publications from professional organizations dealing with
correctional health care, including the American Correctional Association and the
National Commission on Correctional Health Care. The Ombudsman also relied on
research articles, guidelines, and publications from the Centers for Medicare and
Medicaid, American Psychiatric Association, the Federal Bureau of Prisons, the National
Institute of Corrections, the National GAINS Center, and the U.S. Department of Justice
– Civil Rights Division.
Relying on these resources, the Ombudsman identified a number of issues to address in
this report. These include: (1) mental health intake screening of new inmates; (2) follow
up mental health assessment for inmates who screen positive for mental illness; (3) when
to use restraint devices; (4) what type of restraints are appropriate; (5) monitoring
restrained inmates; (6) medical and mental health reviews of inmates; (7) documentation
of restraint use; and (8) time limits for restraint use. The Ombudsman reached a number
of conclusions for each of the five county jails examined in this report, based on the

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Ombudsman Investigative Report 
 
 
 
minimum standards that should be employed in all cases of inmate mental health and
restraint use, as described below:
Mental Health Screening. During the Ombudsman’s investigations, the Iowa Department
of Corrections adopted administrative rules requiring a mental health screen for all
inmates entering a county jail. However, the rules provide little guidance on what
questions should be included in the screening tool and provide little guidance on what
staff should do with the collected information. The Ombudsman reviewed the Brief Jail
Mental Health Screen endorsed by the National GAINS Center, a federal agency that
focuses on developing services for adults in the justice system who have mental illness
and substance use disorders. The screen is an eight-question form that takes two to three
minutes to complete. Depending on the responses from the inmate, the tool can identify
offenders requiring a mental health referral for further assessment. Jail staff only require
brief informal training in order to administer the screen. Based on the research and
testing of the screen, the Ombudsman encourages Iowa’s county jails to use this screen,
or another health-authority-approved form.
Mental Health Assessment. Iowa law is silent on seeking treatment for inmates who
screen positive for mental illness. It only states that a jail must have a “plan” for
treatment, but does not require the jail to initiate the plan. Federal courts have found that
under the Eighth Amendment, a correctional facility cannot ignore the mental health care
needs of inmates. The Ombudsman believes that every inmate who screens positive for a
potential mental illness should be assessed by a mental health professional. The
requirement is consistent with national organizations’ professional standards.
A standing relationship with a mental health professional enables the professional to
know the scope and limitations of the jail and further determine if the holding facility
cannot meet the mental health needs of the offender requiring a transfer. A county jail
should work with its county central point of coordination to find psychiatrists,
psychologists, psychiatric nurses, or psychiatric social workers who may provide services
for the jail. Such services may be provided via telemedicine in the event the county jail
lacks those services in its own community.
Types of Restraint Devices. The Ombudsman reviewed medical articles and lectures
relating to different types of restraints and the adverse medical conditions associated with
them. Positional asphyxiation is one of the leading causes of death from restraint use. Of
primary concern are restraint devices that immobilize the inmate in the prone position.
This can affect breathing by restricting movement of the inmate’s chest and abdomen. In
addition, any restraint device that uses straps across the inmate’s chest can restrict
breathing. Devices that place the inmate in the supine position may result in aspiration if
the inmate has a reduced level of consciousness, commonly caused by the use of drugs or
alcohol.
Restraint devices that reduce the risk of asphyxiation include a restraint chair with
shoulder straps to control the upper torso that do not cross the chest or abdomen. The
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Executive Summary 
 
 
 
 
upright position of the chair also reduces the risk of aspiration, where an inmate might
choke on vomit.
When to Use Restraints. Iowa law provides only three situations when four- and fivepoint restraints can be used: When the inmate is (1) a threat to self, (2) a threat to others,
or (3) a jeopardy to security. However, the Ombudsman reviewed cases where jail staff
placed inmates in restraints when only minor damage to a cell occurred, the inmate posed
no other threat to jail staff other than verbal abuse, or when the immediate threat to safety
or security had already passed. The Ombudsman concludes the use of restraints in these
instances violated federal constitutional law, Iowa law, and jail policy. Restraint devices
must only be used when the inmate is an immediate and ongoing threat to themselves or
others, or is jeopardizing jail security. Use of restraints after a need has passed indicates
the restraint is being used for punitive reasons contrary to Iowa law.
Monitoring. Iowa law requires 15-minute personal visual observation of the inmate and
the restraint application. In several cases, jails could not provide evidence the required
15-minute checks were conducted. In one case, the 15-minute check consisted only of
viewing the inmate through a cell door. The Ombudsman interprets Iowa law as
requiring jail staff to not only check whether the inmate is alive and breathing, but also
check the application of the restraints, which includes circulation checks. The
Ombudsman questions whether such checks can be effectively done by looking at an
inmate through a cell door window.
While Iowa law states that restraints can only be used for the amount of time necessary to
alleviate the condition causing the restraint, it does not require periodic reviews to
determine if an inmate can be released. A majority of the jails the Ombudsman
investigated could not provide documentation an inmate was periodically reviewed to
determine if the continued need for restraints was warranted. In accordance with federal
case law, the Ombudsman concludes that jails must provide documentation an inmate
continues to be a threat to self, others, or jeopardizes jail security to justify the restraint.
The most effective way to make this determination is to conduct periodic reviews of the
inmate and note the inmate’s actions and disposition.
Medical Reviews. Iowa law does not require medical reviews of the inmate, regardless
of how long an inmate is restrained. With no medical review requirement, the
Ombudsman found occasions when medical consultations were not done at any time
during restraint use, even when the restraint lasted 12 hours. Others attempted
consultation over the phone, though the manufacturer of the restraint chair used
frequently in Iowa recommends “direct medical supervision” of any inmate left in the
restraint chair for more than two hours.
The Ombudsman has concerns about a lack of medical oversight because of inmate
deaths in other states that resulted from adverse medical conditions such as pulmonary
embolisms and dehydration. Following manufacturer recommendations and relying on
professional correctional standards, the Ombudsman believes a jail should have an inmate
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Ombudsman Investigative Report 
 
 
 
reviewed in-person by a medical professional every two hours. The in-person medical
review is necessary for the medical staff to check the inmate’s vital signs. Jails should at
least notify their medical authority immediately when restraints are applied.
Mental Health Reviews. Whether reported by the inmate or discovered during the
investigation, the Ombudsman found in each case where restraints were used for six or
more hours, the inmate had a history of mental illness. The Ombudsman has concerns
that the extended use of restraints could be attributed to the mental illness. In each case
of extended restraint use, a mental health professional was never consulted. The
Ombudsman concludes when an inmate has a known or suspected mental illness, jail staff
should contact a mental health professional to determine if the cause of the violent
behavior is related to a mental illness and whether immediate mental health intervention
may be necessary.
An existing mental illness may be determined by relying on the mental health screen
conducted when the inmate is admitted to the jail. It could also be determined based on
statements by the inmate after admission or observation of unusual behavior by jail staff.
The Ombudsman also believes that extensive use of the restraint device for periods of six
or more hours should raise concerns of mental illness even if the inmate reported no prior
mental illness.
Documentation. Iowa law requires that all decisions and actions be documented when a
jail inmate is placed in four- and five-point restraints. The Ombudsman believes this
includes the initial decision to place the inmate in restraints, each 15-minute check, the
decision to release or keep an inmate in restraint during a periodic review, and any
medical or mental health observations of the inmate. The cases reviewed in the
Ombudsman’s report provide examples of when a jail failed to document one or more of
these actions or decisions. The Ombudsman believes that if a jail cannot provide
documentation of an action or decision, the action was not taken or the decision was not
made.
In addition to written documentation, the Ombudsman believes a jail should video record
the placement, use, and release of the inmate in the restraint device. Video
documentation enables supervisors to review actions and procedures jail staff took or
failed to take to determine if a change in procedure is needed or if staff need additional
training. It can also effectively rebut accusations that jail staff physically abused an
inmate or used the restraint device improperly. The Ombudsman was able to use video
documentation in one investigative case to conclude the inmate’s allegations were not
true. In another case where a jail disputed an inmate’s account of events, the
Ombudsman could not reach the same conclusion because the jail had erased the
recording that could have supported its position.
The Ombudsman recommends jails retain video copies of restraint device use for a period
of at least two years, consistent with the statute of limitations for tort claims.

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Executive Summary 
 
 
 
 
 
Time Limits. The Ombudsman analyzed case law and professional standards to
determine what, if any, time limits should apply to restraint device use. The Ombudsman
concludes that for the safety of the inmate and staff, a specific time limit should not be
set. Releasing an inmate who still has violent or suicidal tendencies could result in the
serious injury or death of the inmate or jail staff. In the absence of a time limit, the
Ombudsman emphasizes the need for the 15-minute checks, periodic reviews of the
inmate, medical and mental health reviews of the inmate, as well as the documentation of
each decision and action.
Systemic Mental Health Challenges. The Ombudsman recognizes the difficult situation
jails face when housing mentally-ill inmates. During the investigations, jail officials
expressed frustration with the revolving door of the mentally ill who come into the jail,
enter the correctional system, and then are released with little or no oversight or services
available after their release. This results in the inmate committing additional crimes and
beginning the incarceration process over. The higher recidivism rate for inmates with
mental illness compared to those without mental illness is well-documented throughout
the country and in Iowa. This requires a review of the quality of mental health treatment
in Iowa outside the walls of the county jails.
The Ombudsman reviewed the recommendations of a recent report funded by the Iowa
Department of Corrections. The report found a need to address inmates’ mental health
needs upon release from prison in order to stop the cycle of continuous inmate
incarceration. The report recommended dividing the parole docket so certain counselors
only handle parolees with mental health needs. These parole officers would receive
specialized training on mental health issues to address the unique needs of these inmates.
The report also made reference to re-entry coordinators in each of Iowa’s judicial districts
whose task would include finding community services for offenders with mental health
needs.
The Ombudsman reviewed the concept of mental health courts that would have
jurisdiction over misdemeanant offenders. Mental health courts have proven effective
when intervening after a minor crime has been committed. The mental health court
brings together community resources to offer services and treatment to the offender as an
alternative to going to jail. The overall goal of the court is reducing recidivism and
preventing the inmate from escalating to more violent crimes. While this is a growing
trend in the country, only one such court exists in Iowa. However, that court has reported
impressive statistics since its inception in 2001 in terms of reducing recidivism and the
time the inmates spent in its county jail.
Addressing the needs of the mentally-ill inmate in county jails requires a change both by
the jail as well as the culture of community-based services in Iowa. There is little doubt
jails have seen an increase in the numbers of inmates with mental health needs, due in
large part to the lack of community funding and resources. This leaves jails which lack
expertise in mental health care as the de facto caretakers for these individuals. However,

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Ombudsman Investigative Report 
 
 
 
ignoring the special needs of these inmates while the state struggles with mental health
management can lead to dire consequences for the inmate, the jail, and staff.
Recommendations. The Ombudsman makes the following recommendations regarding
inmate screening and restraint device use for all jail facilities:
1. A jail should incorporate a health-authority-approved mental health screen to be
used on all newly admitted inmates soon after entering the jail. A screen should
possess the following qualities:
•
•
•
•

The screen has been vetted and approved by a mental health
organization for its accuracy in identifying mental health conditions;
The screen is brief and easy to administer;
Limited training is needed for a screening officer to use the form;
The screen notifies an officer when to refer an inmate for further
mental health assessment based on the responses of the inmate.

2. Inmates who screen positive for a mental illness must receive further assessment
by a mental health professional. Assessments for referred inmates may require a
jail to enter a formal relationship with a mental health professional who can
become knowledgeable of the jail’s services and limitations, and can accurately
determine if the inmate needs to be transferred to another facility.
3. Restraint devices must only be used when an inmate is an imminent risk to the
inmate’s self or others, or is jeopardizing jail security. Verbal abuse alone is not
sufficient reason to place an inmate in a restraint device. Use of a restraint device
should cease immediately when the condition causing the need for the restraint is
no longer present. Jail policy should detail the conditions when an inmate may be
restrained and when an inmate should be released.
4. When the circumstances allow for it, jail staff must consider using less restrictive
alternatives to restraint devices, which ensures the safety of the inmate and others.
When a less restrictive alternative is not used, jail policy should require staff to
report what alternatives were considered and the reason for not employing them.
5. When a jail uses video for continuous monitoring of the inmates, the video must
provide a clear and accurate view of the inmate’s body, including torso,
extremities, and face. Staff must be able to identify emergency conditions on the
video immediately when they arise.
6. Personal, visual observation of the inmate and the restraint application every 15
minutes is required under Iowa law. This should include checking the inmate upclose and face-to-face for adverse medical conditions.

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Executive Summary 
 
 
 

 
7. Jails should conduct periodic reviews of the inmate for the purpose of determining
whether the inmate can be released from the restraint device. After each review,
staff should document whether the inmate was released and if not, the reason for
keeping the inmate in the restraint device. Periodic reviews should be conducted
at least every hour.
8. A jail’s restraint chair policy should, as a minimum standard, incorporate the
recommended procedures for use found in the manufacturer’s instruction manual.
That policy should also include recommended medical reviews of the inmate
placed in the restraint device.
9. Absent specific manufacturer recommendations, a jail should incorporate medical
review procedures in its policy that require direct, in-person medical reviews of a
restrained inmate by a physician, nurse, physician’s assistant, nurse practitioner,
or other appropriate licensed medical professional.
10. The person conducting the medical reviews should be a medical professional who
is employed or contracted by the jail for the purpose of conducting medical
reviews and assessments of the inmates. Medical reviews of an inmate should not
be conducted by a person employed as an officer or administrator of the jail, even
if the officer or administrator is a licensed medical professional.
11. A jail should incorporate in its policy a requirement to contact a mental health
professional whenever an inmate with a known or suspected mental health
condition is placed in a restraint device. In the event any inmate is required to be
held for longer than a few hours, a mental health professional should be
contacted. To accommodate facilities that may not have a mental health
professional in their immediate area, mental health reviews of an inmate may be
conducted by telemedicine, enabling the mental health professional to view and
talk to the inmate through video from an off-grounds location.
12. Jail staff must document all decisions and actions when an inmate is placed in
four- and five-point restraints. This includes the reason the inmate was placed in
restraints, who ordered the inmate to be placed in the restraints, observations
during 15-minute checks, observations of medical reviews conducted on the
inmate, and the decision to release the inmate or keep the inmate in restraints after
periodic reviews. Such documentation should be as detailed as possible.
13. All facets of restraint device use should be videotaped, including placement,
duration of use, and release. Jails should retain video copies of restraint device
use for a period of at least two years.

The Ombudsman also directs some of these recommendations to the five specific jails
whose incidents and issues were investigated.

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Role of the Ombudsman
The Office of Citizens’ Aide/Ombudsman (Ombudsman) is an independent and impartial
investigative agency located in the legislative branch of Iowa state government. Its
powers and duties are defined in Iowa Code chapter 2C.
The Ombudsman investigates complaints against Iowa state and local government
agencies. The Ombudsman can investigate to determine whether agency action is
unlawful, contrary to policy, unreasonable, unfair, oppressive, or otherwise objectionable.
The Ombudsman may also decide to publish the report of the findings and conclusions,
as well as any recommendations for improving agency law, policy, or practice. If the
report is critical of the agency, the agency is given the opportunity to reply to the report,
and the reply is attached to the published report.
The investigations of each county jail cited in this report were initiated by contacts from
jail inmates who raised allegations of abuse involving a restraint chair or board. The
investigations were conducted by a lead investigator and assistant ombudsman. For
purpose of this report, all investigative actions are ascribed to the Ombudsman. The
Ombudsman based his findings and conclusions on the original allegations from the
inmates, written and video documentation from the jails, and interviews and
interrogatories from jail staff. This report is the result of those investigations as well as
interviews with professionals in the fields of medicine and corrections, reviews of
professional standards of practice from medical and correctional organizations, and
analysis of research articles from the fields of mental health, medicine and corrections.
The Ombudsman also interviewed the owner of E.R.C. Inc., Tom Hogan, which
manufactured the restraint chair that is the primary, though not exclusive, focus of this
report. Mr. Hogan provided valuable insight into the intended use of his restraint chair
and his concerns about its potential for abuse.
During the investigation, the Ombudsman addressed the Iowa Board of Corrections and
the Iowa Legislature’s Administrative Rules Review Committee when additional
administrative rules were being promulgated that could affect county jails’ use of
restraint devices. The Ombudsman took the opportunity to raise additional rules for
consideration that he believed were essential to address mental health needs of inmates
and basic procedures to follow when restraint devices are required. While the suggested
rules were not adopted at that time, each has been incorporated as recommendations in
this report.
This report is meant to serve several purposes. Along with its attempt to provide
comprehensive minimum standards for screening inmates for potential mental illness,
guidelines for restraint device use, and actions to take for recognizing when to seek
outside placement of inmates, this report will address the specific actions taken in each
case and the unique circumstances that accompany them. Many of the jails have
cooperated with our investigation. Our purpose is not to single-out certain jails and our
discussion is not aimed to be punitive. These cases provide valuable insight of the issues
faced by each jail that others can learn from, not just the jail that is the focus of the

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Role of the Ombudsman

 
recommendations. The jails mentioned in this report have a right to know the findings
and conclusions from our investigations.

9

 
 

Overview: Complaint Allegations
The Ombudsman received a letter from T.H. on May 22, 2007. In his letter, T.H.
introduced himself and made some extraordinary claims. He listed his IQ at 190 and
claimed he had completed most of a master’s degree program in the Science of Creative
Intelligence at Maharishi University. He provided the subjects of four books he had
written or will soon write, including Caught in a Dream: Visions of Robin Hood, relating
his experience of robbing a bank and giving the money to the poor. He described himself
as working for the past 40 years as “an undercover, real life investigative reporter.” His
complaint against the Jefferson County Jail included experiencing four heart attacks due
to bipolar medication prescribed by the University of Iowa Hospitals and Clinics, which
was further aggravated by the “exotic cooking oil” used by the local hospital kitchen that
provides meals for the jail. He also complained that despite his solicitation to provide jail
staff free counseling, he had been subjected to constant harassment.
The issue that stood out to the Ombudsman was T.H.’s description of being placed in a
restraint chair, which he referred to as a “Torture Chair,” on four separate occasions in
late April 2007 for time periods of 2½ hours, 6½ hours, 12½ hours, and 10½ hours,
respectively.
There is little doubt that T.H. is very intelligent. This is evident from his writing samples
as well as acknowledgments from the sheriff and jail administrator. There is also little
doubt that T.H. suffers from severe mental illness, as was evident from these same
sources.
***
G.A. entered the Woodbury County Jail on June 25, 2006, “self-medicating” with
methamphetamine and marijuana for his diagnosed bipolar disorder, paranoid
schizophrenia, and conduct disorder. When G.A. entered the jail, it took two months
before mental health professionals evaluated him and prescribed Seroquel, a moodaltering drug commonly used for bipolar disorder and schizophrenia. That two-month
delay may have been too late. The day after G.A. began taking Seroquel, he broke a light
fixture in his cell, threatened officers with a sharpened tooth brush, injured an officer who
was trying to subdue him, and was placed in a restraint chair. The day after that, a
special law enforcement team was called to extract G.A. from his cell when an officer
noticed padding torn from the cell window. He was placed in a restraint chair for seven
hours. No medical reviews were done while G.A. was in the restraint chair for those
seven hours and no doctors were consulted. The jail could provide no video
documentation of G.A. in the restraint or provide an explanation how G.A. remained a
threat for those seven hours. For the next two months, mental health professionals
continued to adjust G.A.’s medication.
***

10

Overview:  Complaint Allegations

 
T.F. wrote the Ombudsman on February 3, 2007. She claimed her rights were violated
by the Centerville Police Department, but admitted she did not remember the arrest due
to “mental disorders” and drinking while on medication. However, she could recount her
experience at the Appanoose County Jail, when officers placed her in a restraint chair for
ten hours soon after her arrest. She could also recall hollering for someone to let her out
of the chair so she could use the bathroom, and an officer threatening to “Taser” her if
she did not shut up. She remembers defecating soon after while still restrained in the
chair.
***
J.L. contacted the Ombudsman in May 2007 claiming the Wapello County Jail did not
respond to his reported breathing condition. J.L. had been arrested for public intoxication
when he got in an argument and yelled at a mother and daughter he saw on the street.
After reviewing security tapes and officer incident reports, the Ombudsman had
reservations about J.L.’s credibility on his breathing claim. However, based on this same
documentation, the Ombudsman raised serious concerns on J.L.’s second claim: that an
officer struck him while he was in the restraint chair.
***
M.B. wrote to the Ombudsman in February 2008 claiming a correctional officer at Polk
County Jail strapped him to a chair, strangled him, and told him he was going to beat him
all day. M.B. further claimed the officer pushed bamboo sticks under his fingernails and
said he was going to kill M.B. The Ombudsman reviewed the security video capturing
the placement and use of the restraint chair and could not substantiate any of the actions
M.B. described, other than being strapped to a restraint chair. The Ombudsman did note
problems with required monitoring and checks during the restraint, including the failure
to conduct periodic checks during much of M.B.’s restraint lasting 4 hours and 40
minutes.

11

 
 

Getting Started: Identifying Issues of Restraint Use
Iowa law provides little guidance on the use of restraint devices in the jail setting. The
use of the restraint chair, and other forms of restraints such as boards and beds, is largely
unregulated in both their form and function.1 While these devices vary widely in their
form and design, they serve the same purpose of preventing aggressive inmates from
hurting themselves, others, or causing a security threat. They also share the same
common characteristics of securing a person’s legs, arms, and torso to the device, often
with nylon straps.2
There are no standards for what type of restraint is acceptable, and state law does not
provide manufacturer regulations on the shape and design of restraint devices. As a
result, jails often refer to the manufacturer’s guidelines to develop their own policies, but
there is no requirement to adopt the manufacturer’s recommended use. Manufacturers of
restraint devices used in Iowa include both in-state and out-of-state companies, so
guidelines can vary even on similar devices depending on where the device was
purchased. This places much of the discretion of policy language in the hands of the
sheriff and/or jail administrator, the county officials in charge of the jail.
The Ombudsman has received complaints in the last two years from inmates claiming
abuse by jail officers who placed them in restraint chairs and on restraint boards and who
were physically abused while restrained in these devices. With the use of restraints
largely unregulated by Iowa law or policy, questions arose early in the Ombudsman’s
investigations, including:
•
•
•
•
•
•

Under what circumstances can correctional staff place an inmate in restraints?
What is the maximum amount of time an inmate can remain in a restraint device?
What medical concerns arise for someone restrained for an extended period of
time longer than two hours?
How are restroom breaks and food and water breaks facilitated, if at all, during
time spent in restraints?
What medical or mental health concerns arise when an inmate with a mental
illness is placed in restraints?
Should inmates with mental illnesses be handled differently than inmates with no
known mental illness?

The Ombudsman recognizes jails of different sizes, staffing, and funding resources may
experience unique challenges. An overarching concern with the restraint devices is the
use of medical supervision when an inmate requires an extended confinement in the
restraint. A small county jail will struggle to have medical personnel in-house or on
1

Restraint devices often include metal and plastic handcuffs and leg irons, various electrical and chemical
devices, and full body restraints such as chairs, boards, and beds. Throughout this report, the terms
“restraints” and “restraint devices” are intended to refer to restraint chairs, restraint boards, and restraint
beds, unless otherwise denoted. The term “four- and five-point restraints” includes restraint chairs,
restraint boards, and restraint beds.
2
See Appendix A for an example of a restraint chair used in Iowa and reviewed in this report.

12

Getting Started:  Identifying Issues of Restraint Use

 
location at the jail to observe an inmate compared to a larger urban facility that will
typically have medical staff available during each shift. For this reason, the Ombudsman
will address restraint guidelines that have universal application despite the size of the
facility.
Because Iowa law does not address for many of the concerns raised by this office, the
Ombudsman reviewed state and federal case law; researched publications from
correctional, medical and mental health fields; analyzed county policies from across Iowa
and from other states; and interviewed experts working in the fields of corrections,
medicine, and mental health.
This report will examine these resources, the complaints received by the Ombudsman’s
office about restraint device use, and what changes, if any, in jail procedures need to be
made in each case. This report will also address current dilemmas facing the correctional
and mental health situation in Iowa and programs the Ombudsman believes can address
these problems.

A. Trying to Find a Policy
In limited circumstances, the need for restraints and the potential benefit it has on violent
inmates and staff trying to control those inmates is recognized by this office. The
question is not whether the use of restraints should be available to correctional personnel.
If used correctly, restraints can be a safe and effective tool to prevent inmates and
patients from harming themselves and others. Rather, the question is what restrictions
and regulations should accompany their use.
The use of restraint devices in county jails is briefly addressed in the Iowa Administrative
Code rule 201 – 50.13(2)(f). This provision places the following requirements on
restraint device use:
•
•
•
•
•
•

Restraint devices will be used only when the inmate is a threat to self or others, or
jeopardizes jail security.
A restraint device is not to be used as a means of punishment.
Approval for restraint use must come from a facility supervisor.
The inmate must be clothed or covered to maintain privacy.
The inmate will be restrained for only the amount of time it takes to alleviate the
condition causing the restraint.
Four- and five-point restraint shall be used only when other types of restraints
have proven ineffective.3

If placed in a four- or five-point restraints, which includes most restraint chairs, boards,
and beds, correctional staff must:
3

IOWA ADMIN. CODE r. 201 – 50.13(2)(f) (2008).

13

Ombudsman Investigative Report
 
 
 
(1) Observe the inmate continuously (a CCTV system may be used),
(2) Conduct personal visual (non-CCTV) observation of the prisoner and the
restraint device application at least every 15 minutes,
(3) Include consideration of an individual's physical and health condition, such as
body weight, in the restraint guidelines, and
(4) Document all decisions and actions.4
Some jails go beyond the basic requirements of Iowa law. Jefferson County Jail, which
has one of the more detailed written policies reviewed by this office, lists the classes of
inmates that correctional officers cannot place in their Emergency Restraint Chair
(restraint chair or ERC). The list includes pregnant women, small children, people with
obvious neuromuscular disorders, and inmates with open or sutured wounds. Many
larger county jails, such as Scott, Woodbury, and Polk, do not provide for such
restrictions. Jefferson County’s policy also makes it clear that only those members of the
Jefferson County Sheriff’s Office/Correctional Facility who are trained in the restraint
chair’s application are authorized to use the restraint chair. Iowa law, as well as other
county policies included in this report, is silent on who is authorized to use the chair.
Though not required under Iowa law, jail policies also frequently place a maximum time
limit on the use of the restraint device, usually between two and four hours. For
continued use beyond the designated time limit, supervisor approval is required, and in
some cases a medical professional must supervise its use. However, since no
requirement exists, jails are not consistent with what maximum time frame is required or
if one is required at all.

B. Correctional Standards
Private, national accreditation organizations, such as the American Correctional
Association (ACA) and the National Commission on Correctional Health Care
(NCCHC), provide guidelines for facilities seeking accreditation. They do not act as a
governing body that can force compliance on non-member facilities, and the policies are
not geared specifically toward Iowa counties by taking into consideration Iowa’s laws,
policies, and judicial system. The policies also do not address the specific use of restraint
chairs, boards, or beds; however, they do provide useful instructions for restraint device
use.
The Iowa Law Enforcement Academy (ILEA) provides training to Iowa law enforcement
officers with services ranging from psychological testing of law enforcement applicants
to providing education to officers. The ILEA provides training to correctional officers
through its “Jail School,” coordinated by Willis Roberts. The Jail School offers several
courses annually on a wide range of topics faced by jails. However, one training topic
ILEA does not cover is the use of restraint chairs, boards, and beds. According to Mr.
Roberts, ILEA does not provide operational or procedural training of these devices since
4

Id.

14

Getting Started:  Identifying Issues of Restraint Use

 
manufacturers provide most of the training. In addition, ILEA providing restraint device
training could potentially result in their involvement in legal actions.
To determine the basic legal standards for restraints in the jail setting – beyond the very
limited requirements provided by the Iowa Administrative Code – one must turn to the
courts. State and federal courts have used varying standards for the “use of force”
question to determine whether placement in a restraint device violated a detainee’s rights.
Even the courts are not consistent on what standard to apply.5 The U.S. District Court for
the Northern District of Iowa used an “objective reasonableness” test in Ogden v.
Johnson and Sanders v. Zeller when determining whether correctional officers’ actions
constituted excessive force.6 However, the same court in Roger v. Dunn used an Eighth
Amendment “malicious and sadistic” test to determine excessive force.7 In
circumstances involving jail disturbances, the “malicious and sadistic” test requires the
court to look at whether the officials’ actions were taken “‘in a good faith effort to
maintain or restore discipline’ or whether they acted ‘maliciously and sadistically for the
very purpose of causing harm.’”8
Regardless of the standard used in a particular case, courts have found the restricted use
of a restraint device does not violate a detainee’s constitutional rights under both the
“objectively reasonable” and “sadistic and malicious” standard. In Sanders, using the
“objective reasonableness” standard, the court concluded the use of a restraint board in
that case was reasonable “as long as it is only used for the amount of time necessary to
restore order.”9 The court weighed the inmate’s injury of being placed on the restraint
board against the jail’s administrative interests in safety, security, and efficiency.10 In
Ogden, the same federal district court determined placement to be reasonable on an
inmate who became disruptive, belligerent, and assaultive during his processing.11
5

One factor in this disagreement is a dispute over what provision of the Constitution applies. As the
Eighth Circuit Court of Appeals pointed out in Wilson v. Spain, 209 F.3d 713, 715 (8th Cir. 2000),
“[b]etween arrest and sentencing lies something of a legal twilight zone. The Supreme Court has left open
the question of how to analyze a claim concerning the use of excessive force by law enforcement ‘beyond
the point at which arrest ends and pretrial detention begins,’ and the circuits are split.” (quoting Graham v.
Connor, 490 U.S. 386, 395 n.10) (1989).
6
Ogden v. Johnson, No. C00-0034, 2002 WL 32172301, at *2 (N.D. Iowa Sept. 5, 2002), Sanders v.
Zeller, No. C04-0067, 2006 WL 1192924, *4 (N.D. Iowa April 28, 2006).
7
Rogers v. Dunn, No. C00-0188-PAZ, 2001 U.S. Dist. LEXIS 22710 (N.D. Iowa Nov. 27, 2001). See also
Fuentes v. Wagner, 206 F.3d 335 (3d Cir. 2000) (court used a “malicious and sadistic” standard for a
pretrial detainee placed in restraint chair).
8
Rogers, No. 00-0188-PAZ, 2001 U.S. Dist. LEXIS 22710, at *8 (citing Starbeck v. Linn County Jail, 871
F.Supp. 1129, 1147 (N.D. Iowa 1994)). The U.S. District Court for the District of Nebraska used a
“reasonably related” test when it reviewed a “use of force” claim involving a restraint chair in Birdine v.
Gray, 375 F.Supp.2d 874 (D. Neb. 2005). An article in the CORRECTIONAL LAW REPORTER pointed out
this may have been the incorrect test, compared to other courts that used the “malicious and sadistic” test
established in Hudson v. McMillian, 503 U.S. 1 (1992). William C. Collins, Judge Finds Stun Gun
Preferable to Other Force Techniques, 18 CORRECTIONAL L. REP. 54, 64 (2007).
9
Sanders, No. C04-0067, 2006 WL 1192924, at *4.
10
Id.
11
Ogden, No. C00-0034, 2002 WL 32182301, at *2. In THE MENTALLY DISORDERED INMATE AND THE
LAW, author Fred Cohen believes the distinction between standards used by the court(s) is an important one

15

Ombudsman Investigative Report
 
 
 
The court did not address the issue of an objective maximum time limit for restraint use
in Ogden or Sanders.12 However, in Ogden, the court upheld a jury verdict that found the
arrestee’s five-hour placement on a restraint board by Linn County Jail staff was
unreasonable. The arrestee showed he was held on the board long after the need for
restraint had ended, and the jury found this constituted excessive force. In approving the
jury award, the court determined the board was “more than just uncomfortable. It is a
restraint that should be used only for the amount of time necessary to restore order.”13 In
a similar case against the Linn County Jail, the same court found the jail could not justify
the continued restraint of an inmate that lasted for eight hours and violated the inmate’s
Eighth Amendment rights.14

C. Medical Standards
Iowa law does not require medical reviews of detainees placed in restraint devices, and it
is silent on any review requirement regardless of the length of time an inmate is placed in
restraints. The Ombudsman contacted the Iowa Board of Medicine (IBOM) about the
standards for medical professionals’ involvement in the use of restraints.15 In response,
the IBOM said it did not possess “the necessary expertise regarding proper procedures for
medical approval of the use of restraint devices in the jail setting.”16 Despite the fact that
some county jails across the state use medical professionals to evaluate an inmate’s
placement and continued use of a restraint device, the IBOM, which has authority to
review the actions of those same medical professionals, declined to provide guidance on
this issue.
Even absent a legal requirement under Iowa law, some jails incorporate in their policy a
medical review process by qualified medical personnel for inmates placed in restraints.
Jefferson County Jail’s policy has incorporated such a process if an inmate is to remain in
restraints for more than two hours:

when concerning “deliberate indifference” for inmates with mental illness, compared to “willful, wanton
and malicious” when restraints are used on “an unruly prisoner.” “For a prisoner with mental illness, there
must be some involvement by a mental health professional who should early assess the impact on the
prisoner’s course of treatment. This could not be required in the straight use of force on disruptive
prisoner.” FRED COHEN, THE MENTALLY DISORDERED INMATE AND THE LAW ¶ 12.4[3] (1998). This report
will address the need for medical and mental health reviews of inmates depending on their needs,
regardless of the legal standard courts apply in these circumstances.
12
In Sanders, the inmate was placed in the restraint for only 25 minutes. No. C04-0067, 2006 WL
1192924, at *2.
13
Ogden, No. C00-0034, WL 32172301, at *3.
14
Rogers, No. 00-0188-PAZ, 2001 U.S. Dist. LEXIS 22710, at *14.
15
The IBOM’s response, and the case from which the Ombudsman request was made, is discussed in
greater detail during the Jefferson County Jail discussion later in this report.
16
E-mail from Kent M. Nebel, Dir. of Legal Affairs, Iowa Bd. of Med., to Andy Teas, Assistant
Ombudsman, Iowa Citizens’ Aide/Ombudsman (Jan. 7, 2008, 16:00 CST) (on file with author).

16

Getting Started:  Identifying Issues of Restraint Use

 
Inmates may be held in the ERC no more than 2 hours without direct
medical supervision, doctor or nurse while doing range of motion
exercises.17
Separately, under the “Medical Concerns” section, Jefferson County’s policy states:
Inmates may be held in the ERC for no more than 2 hours without the
direct supervision of medical personnel (Doctor/Nurse).18
As part of its restraint chair placement, Scott County Jail requires medical staff be
notified of a pending restraint use and must inspect the restraints when they are applied.
A supervisor may be used if medical staff is not available.
Secondary resources provide insightful guidelines for the use of isolation and restraints in
the correctional setting, but these resources often do not require compliance from their
target audience. Instead, the sources reflect the acceptable trend practitioners should
follow in a particular field. The American Psychiatric Association (APA) published a
resource document titled Use of Restraint and Seclusion in Correctional Mental Health
Care (Resource Document), which analyzed the use of restraints for mental health
intervention in jails and prisons and provided a guideline on the medical review of
patients placed in restraints.19
The National Commission on Correctional Health Care (NCCHC) provides standards a
jail must follow for its accreditation, as well as for jails wanting to comply with national
standards in the field of health services in corrections. While private organizations such
as these do not require legal compliance under Iowa law, the Ombudsman identifies the
importance of these guidelines for determining the proper procedures a jail should follow
for inmate intake screening and restraint use later in this report.

D. Mental Health Standards
At least three cases the Ombudsman investigated dealt with inmates who were previously
diagnosed with severe mental illness. The decision to use restraints becomes more
difficult when an inmate has a mental illness and exhibits aggressive behavior because of
the illness. Questions arise whether such inmates should be treated in the same manner
as other inmates who do not have a mental illness. What was the cause that triggered the
inmate’s aggressive behavior? Will the restraint only agitate the inmate further and
require extensive restraint use, unlike an inmate with no mental illness? What
17

JEFFERSON COUNTY JAIL POLICY AND PROCEDURE I-10A at 6, Supervision (2007) (emphasis omitted).
Id.
19
JEFFERY L. METZNER ET AL., COUNCIL ON PSYCHIATRY AND LAW, THE USE OF RESTRAINT AND
SECLUSION IN CORRECTIONAL MENTAL HEALTH CARE (2006). The Resource Document deals with
situations in the correctional setting to maintain safety for the period of time an inmate waits to be
transferred to a psychiatric setting. Extended stays in restraints can be caused by administrative delays in
the transfer.
18

17

Ombudsman Investigative Report
 
 
 
psychological effect will the restraints have on the inmate? Is there an alternative to
placing an inmate in restraints, such as possibly preventing the aggressive behavior from
arising in the first place?
The population of mentally-ill inmates in state and federal jails and prisons has long
exceeded the number of patients housed in psychiatric hospitals. Nationally, the number
of psychiatric beds has decreased dramatically from 500,000 in 1955 to only 59,000 in
2000.20 During approximately this same time period, from 1955 to 2005, Iowa went from
having 198 public psychiatric beds for every 100,000 residents to only 8 beds.21 The
closing of mental-health institutions was due to the development of psychotropic
medications during the 1950s, which was accompanied by a national movement to
downsize psychiatric hospitals in favor of community-based services.22 However, state
and federal budgets did not provide adequate funding for community-based programs,
resulting in people with mental illness becoming homeless and/or incarcerated.23
The closing of mental hospitals and the underfunding of supplementary community-based
programs turned jails and prisons into the primary treatment facilities for individuals with
mental illness. It is estimated the rate of mental illness inside prison populations is three
times higher than in the general U.S. population.24 In December 2006 there were 3,535
Iowa inmates out of a total of 8,600 who were diagnosed with a mental illness.25
While the number of mentally-ill individuals in jails and prisons is increasing in Iowa, the
number of mental health institution beds is decreasing. According to the Iowa
Department of Human Services, the largest state mental health institution held 90 patients
in 2005.26 That same year, the Critical Care Unit at Iowa State Penitentiary held 143
offenders with mental illness, making it the largest mental health facility in the state.27
Despite these increased numbers in mentally-ill inmates entering jails and prison,
corrections officials are left to be the de facto caretakers of mentally-ill inmates.

20

MARY BETH PFEIFFER, CRAZY IN AMERICA 38-39 (2007) (based on statistics compiled by the U.S.
Substance Abuse and Mental Health Services Admin, U.S. Dept. of Health and Human Services).
21
Statistics provided by Christine Krause, Director of Behavioral Health Services, Mary Greeley Medical
Center. According to information provided by Ms. Krause, Iowa had 239 public psychiatric beds in 2005,
when the State’s population was approximately 2,950,000.
22
CORRECTIONAL MENTAL HEALTH HANDBOOK 5 (Thomas J. Fagan & Robert K. Ax eds., 2003).
23
Id.
24
John G. Peters & Teri Himebaugh, Sudden Death, “Excited” Delirium, and Issues of Force: Jail
Suicide, 12 CORRECTIONAL MANAGERS’ REP. 91, 94 (2007).
25
DURRANT GROUP INC. ET AL, STATE OF IOWA SYSTEMIC STUDY FOR THE STATE CORRECTIONAL SYSTEM,
PHASE I 50 (2007). According to Phase I of the systemic report on the Iowa correctional system, the
number of inmates with mental illness increased by 9 percent from the prior year, to 40 percent of all
inmates. This was due, in part, by earlier and more accurate identification of inmates. Phase II, released
the following year, reported the number of seriously, persistently mentally ill offenders at 2,640,
representing 30.4 percent of the population. DURRANT GROUP INC. ET AL, STATE OF IOWA SYSTEMIC
STUDY FOR THE STATE CORRECTIONAL SYSTEM, PHASE II 68-69 (2008).
26
DURRANT GROUP, PHASE I at 214.
27
Id.

18

Getting Started:  Identifying Issues of Restraint Use

 
Compounding the effects of fewer psychiatric beds and underfunded community-based
mental health programs is the dearth of mental health professionals in Iowa. According
to a U.S. Department of Health and Human Services, Health Resources and Services
Administration report, Iowa ranked forty-seventh in the nation for psychiatrists per capita
and forty-sixth in psychologists.28 To make the matter even more dire, of the 24 major
health professions surveyed in Iowa in 2005, those servicing mental health represented
the highest percentage of licensees age 55 or older.29 “These percentages indicate the
probability that services to Iowa’s mental health consumers will decline substantially
during the next decade.”30
The U.S. District Court for the Northern District of Iowa did not address the issues of
underlying mental health for the individuals placed in the restraints in either Sanders or
Ogden. In Ogden, after learning of her husband’s arrest, the arrestee’s wife contacted the
county jail to inform staff her husband suffers from panic attacks and takes medication to
control the attacks. The court did not mention a need for medical or mental health staff to
review the status of an inmate to determine the potential medical basis of the aggressive
behavior and what medication, if any, should be prescribed to someone in restraints. In
Norris v. Engles, the Eighth Circuit Court of Appeals did not find handcuffing an inmate
with diagnosed manic bipolar disorder to a floor grate shocked the conscience.31
While no distinction has yet been made between those inmates with mental illness and
those without when placed in restraints, the Eighth Circuit has recognized that isolation
on inmates may have adverse effects on inmates with mental illness, where the same
techniques will not have any effect on an inmate with no mental illness. In Buckley v.
Rogerson, the Eighth Circuit cited the expert testimony regarding the effects of isolation
on someone with a mental illness similar to the plaintiff’s in that case.32 The court cited
Dr. Herbert Notch as testifying “while an average inmate might be isolated in a quiet
room and not suffer any harm, a person with [the plaintiff’s] illness would tend to suffer
exacerbation of his already serious symptoms.”33

28

MARY KELLY, IOWA’S MENTAL HEALTH WORKFORCE 5 (2006), available at
http://www.idph.state.ia.us/hpcdp/common/pdf/workforce/mentalhealth_0306.pdf
29
Id. at 4.
30
Id.
31
Norris v. Engles, 494 F.3d 634 (8th Cir. 2007). In Norris, an inmate diagnosed with manic bipolar
depression would self-mutilate as part of her symptoms. She was taken to jail under protective custody and
handcuffed to a floor grate after she threatened to pull a peripherally inserted central catheter out. Staff
determined being handcuffed behind the inmate’s back was not sufficient restraint to prevent the inmate
from pulling out the intravenous line. The court found that the length of time “while not insubstantial, was
not so lengthy as to warrant a finding that it was conscience-shocking.” Norris, 494 F.3d at 639.
32
Buckley v. Rogerson, 133 F.3d 1125 (8th Cir. 1998). Eddie O. Buckley, Jr. was an inmate at Iowa
Medical and Classification Center, under the direction of Dr. Paul Loeffelholz, and was diagnosed with
chronic schizophrenia or schizophrenia-like psychosis. Treatment plans for his mental illness included
isolation and restraints.
33
Id. at 1128.

19

Ombudsman Investigative Report
 
 
 
Publications authored by professionals with extensive experience in mental health and
corrections have been helpful with the Ombudsman’s investigation concerning mental
health in jails and the placement of mentally ill inmates in restraints. The Ombudsman
also relied on federal government findings and standards and certification policies from
the APA, the NCCHC, and the ACA as a guide for this report’s conclusions and
recommendations.

20

 
 

Current National Trends on Restraint Device Use
A. Inmate Deaths and Monetary Judgments
While restraint devices are still commonly used in Iowa jails, the Maricopa County
Sheriff in Arizona stopped using restraint chairs in 2006 after at least three inmate deaths
in ten years and replaced them with “safe beds.” The sheriff’s office had used a version
of the restraint chair since the late 1970s. One of the primary motivating factors for
discontinuing the restraint chair was a jury award for $9 million in March 2006. Prior to
the jury award, the county settled a lawsuit for $8.25 million stemming from an inmate’s
death in 1999. Though Sheriff Joe Arpaio cited drugs for triggering the inmate’s death,
he said it was “time to move in the direction of what many hospitals and psychiatric
wards do to restrain combative people.”34
According to a news story by CBS affiliate KPHO in Phoenix, Arizona, a consultant for
the Maricopa County Jail hired in 1997 wrote, “[t]he best recommendation I can
professionally make in respect to the restraint chair is to remove it from any use
associated with the Maricopa County Sheriff's Office jail.”35 According to the same
report, though the county’s insurance company covered $18 million in jury awards due to
the restraint chair, the county’s deductible after the last death rose from $1 million to $5
million per case for any subsequent deaths.
On May 7, 1998, Michael Oliver Lewis died after being placed on a restraint board for
three hours at El Paso County Jail in Colorado.36 The county coroner concluded Mr.
Lewis died from a combination of heart disease, medication, and the restraint board,
though he could not say which had a dominant role in the death.37 Mr. Lewis’ mother
later sued the county jail, who settled in 2001 for $116,000.38 The county also settled a
lawsuit the previous year brought by the ACLU concerning the county’s use of the
restraint board for $50,000.39 The county put a moratorium on the restraint board use,
and in its place began using a restraint chair.40
In March 1997 inmate Michael Valent died after spending 16 hours in a restraint chair in
a Utah state prison.41 The cause of death was determined by a medical examiner to be a
pulmonary embolism; bloods clots that traveled to his lungs caused by the extended use
34

Lindsay Collom, Jails Stop Restraint Chair Use, ARIZ. REPUBLIC, Aug. 22, 2006.
5 Investigates Jails’ Use of Restraint Chairs, available at http://www.kpho.com/iteam/9454105/
detail.html (last visited June 16, 2008).
36
Patricia Callahan, Restraining Inmates ‘Sadistic’ ACLU Sues El Paso Sheriff, DENVER POST, May 22,
1998, at B-07. According to the plaintiff’s complaint filed by the ACLU after the inmate’s death, the
restraint board was manufactured by Zeller Enterprises, based out of Iowa.
37
Id.
38
Pam Zubeck, County Settles Lawsuit/Family of Inmate Who Died After Restraint Will Get $116,000,
GAZETTE (Colorado Springs, Colo.), April 27, 2001, at Metro 1.
39
Id.
40
Id.
41
Sheila R. McCann, Utah Settles Lawsuit Over Inmate's Death; State Settles Inmate-Death Suit For
$200,000, SALT LAKE TRIBUNE (Utah), July 31, 1998, at A1.
35

21

Ombudsman Investigative Report
 
 
of the restraint chair. The county settled a lawsuit brought by the family against the Utah
state prison for $200,000 in 1998.42 The state ceased use of the restraint chair, even
though halting its use was not part of the settlement.
The circumstances involved in the Maricopa County, El Paso County, and Utah state
cases should sound alarms for Iowa county jails, if for no other reason than the financial
liability it raises. Liability may come in the form of failing to follow Iowa law, failing to
follow a jail’s own policy, or failing to follow national standards recommended by
professional organizations.43 At the time of this report, the Ombudsman knows of no
deaths caused by placement in a restraint chair in Iowa.

B. Restraint Devices as Torture
In addition to adverse financial verdicts handed down by courts, one federal court found
the punitive use of restraints equated to torture.44 The 2006 case involved a Michigan
state prisoner who was placed in “soft restraints” after disobeying custodial orders and
then placed on a restraint bed when he flooded his sink.45 The U.S. District Court for the
Western District of Michigan described the top of the bed restraint in the following
manner:
In practice, “top of the bed restraints” is a euphemism for chaining an
inmate’s hands and feet to a concrete slab. T.S.’s “bed” was composed
of a concrete slab with four metal, arc-shaped handles emanating from
the slab for the purpose of receiving the locking restraints . . . . A small
mattress pad was provided, but was not used for much of the restraint
because T.S. removed it and/or because he urinated on the bed.46
According to the district court, the inmate spent five days in two segregation cells, locked
in four-point restraints. He was seen by an outpatient social worker after the first day,
who determined T.S. exhibited symptoms consistent with his description of manic
episodes prior to incarceration.47 His documented mental health history included bipolar
disorder, depression, hyperactivity disorder, and suicide attempts. T.S. was referred for a
transfer to a prison psychiatric hospital, but while awaiting the transfer, he did not receive
any effective access to medical or psychiatric care.48 He was told by staff he would be
kept in the restraints until he was cooperative.

42

Id.
According to CLINICAL PRACTICE IN CORRECTIONAL MEDICINE, (Rolla Couchman ed., 2d ed. 2006), the
most widely referenced guidelines and standards are those published by the American Psychiatric
Association and the National Commission on Correctional Health Care.
44
Hadix v. Caruso, 461 F.Supp.2d 574 (W.D. Mich. 2006).
45
Id. at 577.
46
Id.
47
Id. at 578.
48
Id.
43

22

Current National Trends on Restraint Device Use
 

On the last day, T.S. was removed from restraints after prolonged sleeping and fell facefirst on the concrete floor.49 A nurse only reported T.S.’s vital sign readings as being
faint, but he heard them. Two hours later, T.S. was pronounced dead.50
The court spent the next five pages of the decision extensively reviewing the history of
torture as reviewed in judicial proceedings from pre-colonial English practice to presentday court interpretations of Eighth Amendment standards of review.51 The court then
reviewed the Michigan prison system’s punitive use of the restraint bed and concluded its
use violated the Eighth Amendment.52 The court relied on the expert testimony of a
medical monitor and the plaintiff’s expert witness, who testified restraints expose a
person to known risks of heart attack, dehydration, and asphyxiation.53 The court found
the use of punitive restraint constituted torture, and that its cessation was immediately
required “to prevent further loss of life, loss of dignity and damage to both inmates and
correctional officers.”54
The restraint chair has been referred by some organizations as a “devil’s chair” and a
“torture chair.”55 It has been at the center of controversy throughout the country, and
even for its use by U.S. officials outside the country. Media began reporting in 2006
accounts of the U.S. government using the restraint chair to force feed detainees at
Guantanamo Bay, Cuba, who had begun hunger strikes.56 The chairs were purchased by
the U.S. government from E.R.C. Inc, based in Denison, Iowa.57 This company is also
the primary source for restraint chairs used by Iowa county jails.

49

Id. at 579.
Id. at 580.
51
Id. at 590-95.
52
It must be noted the court reviewed the use of restraints under its stated purpose of punishment. The
court noted the defendants asserted the restraint was useful “(1) to discourage prisoners who are not overtly
mentally ill, but engaged in self-destructive behaviors such as cutting themselves or inserting foreign
objects into bodily cavities; and (2) to discourage disruptive prisoners who present a threat to others and/or
a threat of property damage.” Id. at 581. In Iowa county jails, the intended purpose is not to punish, but to
prevent harm to an inmate’s self or others, and destruction of property.
53
Id. at 595.
54
Id. at 596. Fred Cohen argues the court could have concluded the prison’s actions amounted to cruel and
unusual punishment without a finding of torture. Mr. Cohen recognized the situation involved T.S. as
being exceptional in its duration, inherent punitiveness, and unadulterated stupidity, but the actions should
have been analyzed under deliberate indifference, not torture. Fred Cohen, Restraints as Torture? A
Consent Decree Is Reopened, 18 CORRECTIONAL L. REP. 66, 77, 79 (2007).
55
Anne-Marie Cusac, The Devil’s Chair, THE PROGRESSIVE, April 1, 2000, available at
http://www.progressive.org/mag_cusacchair.
56
Tim Golden, Hunger Strike Breaks Out at Guantanamo, N.Y. TIMES, April 8, 2007, available at
http://www.nytimes.com/2007/04/08/us/08cnd-hunger.html?pagewanted=print.; Ben Fox, Guantanamo
Hunger Strikers Stay Defiant, USA TODAY, July 20, 2007, available at http://www.usatoday.com/news/
topstories/2007-07-20-558769473_x.htm.
57
Kevin Dobbs, Strapped in for Safety, DES MOINES REG., March 6, 2006, at 1A.
50

23

Ombudsman Investigative Report
 
 

C. Use of Restraints in MHIs and Nursing Homes
Along with jails and prisons, physical restraints such as chairs, beds, and boards have
long been used by mental health institutes (MHIs) and nursing homes on patients who are
exhibiting aggressive behavior to themselves and others. There is a movement in these
facilities, primarily due to federal law and the Centers for Medicare and Medicaid
Services (CMS) regulations, to limit the use of restraints that is not widely mirrored in the
jail setting. The federal requirements have shown a pattern of reduced restraint use while
maintaining a level number of assaults on staff working in these facilities.
1. Reduction of Restraint Use in MHIs
A report written by several administrators at Mary Greeley Medical Center (Mary
Greeley) in Ames, Iowa, discussed the implementation of CMS requirements that
restricted the use of restraint and seclusion on patients.58 It described how staff would
have to change from an environment of authorized discretion to one where restraint and
seclusion would only be used as a last resort after other interventions had been tried.59
One primary concern that administrators had was the potential increase in numbers and
severity of assaults on staff by patients.60
Mary Greeley implemented changes to its procedures to accommodate the new restraint
and seclusion standards that included mandatory de-escalations and violent patient
management training for staff, use of therapeutic interventions, and receiving input from
the local mental health advocate group. Mary Greeley reported restraint and seclusion
use declined over 50 percent between 2001 – when it implemented the process
improvements – and the article’s publication in 2007.61 “More remarkable is the near
elimination of restraint use.”62 At the same time, assaults and assaults with injuries had
not increased.63 The authors revealed:
What was clearly an assumption, that assaults would increase if restraint and
seclusion decreased, was proven wrong. If we had continued to embrace
this assumption we would not have made the changes that improved this
outcome for our patients.64

58

Judy Rabinowits et al, Maintaining Staff Safety While Reducing the Use of Seclusion and Restraints, in
TRANSFORMING NURSING DATA INTO QUALITY CARE: PROFILES OF QUALITY IMPROVEMENT IN U.S.
HEALTHCARE FACILITIES 23 (Isis Montalvo & Nancy Dunton eds., 2007).
59
Id. at 24.
60
Id.
61
Id.
62
Id.
63
Id. at 25.
64
Id. at 26.

24

Current National Trends on Restraint Device Use
 

The Nursing Spectrum published an article in 2007 about the successful reduction of
isolation and restraint in a Massachusetts MHI.65 The initiative to reduce restraints on
patients experiencing acute psychotic episodes at Anna Jaques Hospital came in response
to a Massachusetts state law mandating restraint reduction. According to the article, the
hospital incorporated practices to identify signs of impending crisis and practices to
diffuse situations, such as having patients “ride on exercise bicycles, work on puzzles, or
partake in warm footbaths.”66 The hospital conceded the efforts take more work, “but the
outcome is 100 times better.”67
2. Reduction of Restraint Use in Nursing Homes
Restraints were formerly a common practice in nursing homes and considered a necessity
to improve safety. However, according to an article published in the Globe Gazette
(Mason City), emphasis by federal and state governments and the nursing home industry
to eliminate the use of restraints resulted in a nearly 40 percent drop nationally in their
use in recent years.68 The article cited a decrease from 9.7 percent of the nation’s 1.5
million nursing home patients restrained in 2002, to 5.9 percent in 2006.69
One factor in the decrease was a 1987 change in federal law that made it illegal to
physically restrain patients for discipline or as a matter of convenience.70 Until the
change, restraints were common practice in nursing homes, but now can only be used for
medical purposes. According to Mary Jean Koren, Assistant Vice President of The
Common Wealth Fund, the typical effects of restraint use include depression, pressure
sores, and dehydration. At a nursing home in South Dakota, the need for restraints had
been curbed, in part, by hiring trained personnel to work with specific patients.
Anticipating patient needs is one process that acts as a substitute for restraints. The same
staff work with the same group of patients, allowing them to know the patients’ habits,
routines, and behaviors.71
The goal to reduce the use of restraints is aided by the efforts of the Advancing
Excellence in America’s Nursing Homes campaign, a coalition of long-term care
providers, caregivers, government agencies, and consumers.72 Compared to September
2006, the coalition wanted to reduce the number of restraints used on residents by 30,000

65

Heather World, Mental Health Care’s New Model Shuns Restraint and Seclusion, NURSING SPECTRUM,
Aug. 10, 2007, available at http://include.nurse.com/apps/pbcs.dll/article?AID=2007308100011.
66
Id.
67
Id.
68
Use of Physical Restraint on Patients in Nursing Homes Declines, GLOBE GAZETTE (Mason City, Iowa),
March 27, 2008, available at http://www.globegazette.com/articles/2008/03/27/news/latest/doc
47eb37e12a66e381245705.txt
69
Id.
70
Id. This provision of law is part of the Federal Nursing Home Reform Act, included in the Omnibus
Budget Reconciliation Act of 1987.
71
Id.
72
http://www.nhqualitycampaign.org/ (last visited Oct. 30, 2008).

25

Ombudsman Investigative Report
 
 
73

by September 2008.
goal was met.74

According to the organization’s data progress report, that national

73

ADVANCING EXCELLENCE IN AMERICA’S NURSING HOMES CAMPAIGN GOALS & OBJECTIVES, available at
http://www.nhqualitycampaign.org/files/NHQualityCampaignGoals-Technical.pdf (last visited Oct. 30,
2008).
74
http://www.nhqualitycampaign.org/files/reports/results/CampaignResultsSummary.pdf (last visited Oct.
30, 2008).

26

 
 

Law, Policies, Standards, and Guidelines
The Ombudsman reviewed several correctional resources to determine industry standards
for new inmate intake screening, mental health assessments and treatment, use of restraint
devices, and time limits for restraint device use. The Ombudsman relied heavily on the
American Correctional Association’s (ACA) jail standards, the National Commission on
Correctional Health Care (NCCHC) jail standards, the United States Department of
Justice’s investigations of correctional facilities under CRIPA, the Federal Bureau of
Prisons policies, and the Centers for Medicare and Medicaid Services rules and
regulations on restraint use in facilities under its jurisdiction.75 The ACA and NCCHC
are national organizations that provide accreditation to jails, but membership is voluntary
and the standards do not demand legal compliance from Iowa jails. However, these
sources, along with publications on correctional health care, provided a solid base upon
which the Ombudsman reached his conclusions.

A. Intake Screening for Mental Health
Iowa law requires jails to comply with emergency hospitalization procedures if an inmate
who is believed to be mentally ill is criminally charged with a simple misdemeanor, and
due to the mental illness, is likely to injure the person’s self or others.76 Regardless of the
underlying criminal charge, “[t]he jail shall have a written plan to provide prisoners
access to services for the detection, diagnosis and treatment of mental illness.”77
Recently, the Iowa Department of Corrections enacted an administrative rule that requires
a jail to initiate a mental health intake screening process upon admission: “The plan shall
include a mental health screening process at admission.”78 However, the new rule does
not provide guidelines on what the mental health screen must contain or what information
must be gathered.
The accuracy of the inmate’s responses to the questions and its usefulness to the jail
relies on the truthfulness and honesty of the inmate. Absent an admission by the
detainee, a medical condition or mental illness can go undiscovered by jail staff at intake.
This situation can arise particularly when someone is bipolar and experiencing a mania
cycle. A person in mania can experience a “high” and an increase in energy. Often, the
person will not want to seek treatment during this period because they feel good due to
their euphoric feelings, as opposed to the depression that often follows a session of
mania, and may not report the condition. An inmate can remain at a jail without staff
recognizing a specific mental illness.

75

See Appendix B for a comparison of policies between the organizations on each topic.
IOWA ADMIN. CODE r. 201—50.15(6)(d) (2008).
77
Id.
78
Id. The Iowa Department of Corrections is charged under Iowa law with making periodic inspections of
each jail and municipal holding facility. IOWA CODE § 356.43 (2008). The Department, in consultation
with the Iowa state sheriff's association, the Iowa association of chiefs of police and peace officers, the
Iowa league of cities, and the Iowa board of supervisors association, draws up minimum standards for the
regulation of jails. IOWA CODE § 356.36 (2008).
76

27

Ombudsman Investigative Report
 
 
 
1. Federal CRIPA Investigations
Beginning in 1998, the U.S. Department of Justice (DOJ), through its Civil Rights
Division, initiated an investigation of the Black Hawk County Jail’s conditions of
confinement, pursuant to their authority under the Civil Rights of Institutionalized
Persons Act (CRIPA), 42 U.S.C. § 1997.79 On January 4, 1999, the DOJ issued a letter of
written findings to the Black Hawk County Board of Supervisors, criticizing the jail’s
intake and screening of new detainees, its use of restraints and isolation, and postadmission health assessments for treatment of all inmates who stayed at the jail for
extended periods of time, including those with mental illness.80
The DOJ’s concerns about intake arose particularly from the possibility inmates were not
disclosing their medical conditions during the initial intake process.81 Relying on an
inmate to provide medical information was exacerbated by the lack of a thorough exam
by the jail’s medical staff. Nurses did not perform physical examinations or take vital
signs. Instead, an exam would consist of staff asking the inmate questions and calling
their physician or family members to obtain medications.82
These same deficiencies existed for intake and screening of mental health. Inmates at
Black Hawk County Jail were reluctant to relay medical and mental health information
due to the lack of privacy at the jail.83 This led to undocumented medical problems at the
jail, even in cases where the DOJ expert concluded some inmates showed signs of
obvious mental illness. There existed no routine mental health assessment of new
inmates who did not self-report or were identified by staff having mental illness. The
DOJ report described the case of one inmate whose mother notified the jail of her son’s
history of paranoid schizophrenia. The jail’s nurse reviewed the medical sheet, but the
inmate was never interviewed or evaluated by mental health personnel or the nurse and
received no treatment for mental illness. The report concluded the nursing staff lacked an
understanding of relevant psychiatric issues with the inmate.84
As part of its minimum remedial measures, the DOJ directed the jail to develop a
standard nursing form for nurses to take and record complete vital signs on all inmates
identified as having a medical problem.85 A complete health assessment by a physician
should be provided for all inmates within 14 days of admission. For mental illness, the
jail’s screening process should not rely on an inmate self-reporting his or her mental

79

Letter from Bill Lann Lee, Acting Assistant Att’y Gen., Civil Rights Div., to Brian S. Quirk, Chair,
Black Hawk County Bd. of Supervisors (Jan. 4, 1999), available at http://www.usdoj.gov/crt/spilt/
documents/bhfind.htm.
80
Id.
81
Id. at “Inadequate Medical Care, Intake/Screening”.
82
Id.
83
Id.
84
Id.
85
Id. at “Minimal Remedial Measures, Medical Care.”

28

Law, Policies, Standards, and Guidelines:  Intake Screening for Mental Health

illness in a group setting, but should instead “establish a system of collecting mental
health-related information that will ensure confidentiality.”86
A more recent investigation by the DOJ involved the Dallas County Jail in Texas. The
DOJ investigated and entered an “Agreed Order” settlement with Dallas County Jail on
November 6, 2007, that included a review of the intake screening process. The
settlement states the county shall implement and comply with policies to provide
adequate medical and mental health intake screening to all inmates.87 Newly admitted
inmates who present “current risk of acute mental health needs will be immediately
referred for a mental health evaluation by a mental health professional.”88
The DOJ also recently filed suit against Terrell County Jail, Georgia, where a federal
court granted the DOJ’s motion for summary judgment, finding no genuine issue of
material fact concerning whether the conditions at the jail were unconstitutional.89 On
December 21, 2007, the federal district court adopted the DOJ’s “Proposed Order,”
which required in part:
The defendants shall appropriately screen all inmates upon arrival at
the Jail to identify individuals with serious medical or mental health
conditions, including . . . mental illness, suicide risk, and drug and/or
alcohol withdrawal. Inmates who screen positively for any of these
items shall be referred for immediate or prioritized screening by
the HSA or other qualified health care staff.90 (emphasis added).
The initial screening would also record the inmate’s mental health history, including
mental health treatment, medication, and hospitalization.91 Terrell County Jail was also
required to ensure a qualified mental health professional provide timely, adequate, and
appropriate screening for inmates who enter the jail with serious mental health needs or
develop serious mental health needs while incarcerated.92
2. NCCHC Publications and Standards
The NCCHC is a not-for-profit organization that provides standards for health services in
prisons, juvenile facilities, and jails seeking accreditation as well as those institutions
only seeking to comply with national health care standards. “NCCHC also provides
86

Id. at “Minimal Remedial Measures, Mental Health Care.”
Agreed Order at 5, United States v. Dallas County, Texas, Civil No. 307 CV 1559-N (N.D. Tex. Nov. 6,
2007), http://www.usdoj.gov/crt/split/documents/dallas_county_order_11-06-07.pdf.
88
Id. at 5-6.
89
Order granting Summ. J., United States v. Terrell County, Georgia, 1:04-CV-76-WLS (M.D. Ga. Sept.
29, 2006).
90
Order accepting Pl.’s Proposed Order at 10, United States v. Terrell County, Georgia, 1:04-CV-76-WLS
(M.D. Ga. Dec. 21, 2007).
91
Id. at 11.
92
Id. at 15-16.
87

29

Ombudsman Investigative Report
 
 
 
technical assistance and quality improvement reviews on correctional health care
management and policy issues, and develops and publishes research on the correctional
health care field.”93 The NCCHC claims compliance with its standards can help reduce
the risk of adverse legal judgments. Black Hawk County Jail is the only jail in Iowa
accredited by the NCCHC.
According to the Clinical Practice in Correctional Medicine, Second Edition, published
by the NCCHC, the establishment of a functional and effective medical and mental health
intake screening process for inmates is vital and absolutely elemental to a correctional
facility’s health care system.94 “The NCCHC has formally stated that ‘receiving
screening’ is the most important of all standards in the NCCHC jail and prison
manuals.”95 Screening, to be done by a qualified health care professional or at least a
health-trained correctional staff member, ensures inmates are placed in appropriate
housing and identifies problems that need immediate attention.96 A physical examination
is used to establish a baseline health status so that further health care needs can be
identified and care can be provided.
The NCCHC’s Standards for Health Services in Jails requires “receiving screening” to
be performed on all inmates immediately upon arrival at the intake facility.97 Persons
who are mentally unstable are immediately referred for care. Reception personnel, using
a health-authority-approved form, must inquire about past and current mental illness,
including hospitalizations.98 The standards state inmates with mental disorders are often
unable to give complete or accurate information in response to health status inquiries.99
For this reason, it recommends in addition to the receiving screening, all inmates receive
a mental health screen and evaluation. The mental health screen should take place within
14 days of admission, conducted by qualified mental health professionals or mental
health staff.100
The purpose of the mental health screen is to prevent a suicidal inmate from causing self
harm and to provide psychiatric services to an inmate who requires it before a crisis
arises.101 The initial mental health screen includes inquiries into psychiatric
hospitalization and outpatient treatment, violent behavior, and the current status of
psychotropic medications.102 An inmate with a positive screen for mental health
93

STANDARDS FOR HEALTH SERVS. IN JAILS vii (Nat’l Comm’n on Corr. Health Care 2003).
John M. Raba, Intake Screenings and Periodic Health Evaluations, in CLINICAL PRACTICE IN
CORRECTIONAL MEDICINE. 41, 41 (Rolla Couchman ed., 2d ed. 2006).
95
Id. (citing Judith A. Stanley, The Most Important Standard: Receiving Screening, CORRECTCARE, Fall
2004, at 21).
96
Id.
97
STANDARDS FOR HEALTH SERVS. IN JAILS J-E-02, Compliance Indicators.
98
Id.
99
Id. at Recommendations.
100
Id. at J-E-05, Compliance Indicators.
101
Erin M. Spier et al, Psychiatric Intake Screening, in CLINICAL PRACTICE IN CORRECTIONAL MEDICINE
285, 286 (Rolla Couchman ed., 2d ed. 2006).
102
STANDARDS FOR HEALTH SERVS. IN JAILS J-E-05, Compliance Indicators.
94

30

Law, Policies, Standards, and Guidelines:  Intake Screening for Mental Health

problems should be referred to a qualified mental health professional for further
evaluation, and inmates who require acute mental health services beyond those available
at the facility are transferred to an appropriate facility.103 These standards intend to
ensure that the serious mental health needs are identified.104
According to Clinical Practice, many facilities face budgetary and staffing constraints
that preclude the use of mental health professionals for screening purposes.105 Both the
APA and the NCCHC allow for initial intake screening to be performed by correctional
or nursing personnel, as long as they have received adequate training on the intake
screening tools and where to refer inmates in need of service by mental health staff.106
Because inmates with mental illness may be unwilling or unable to provide complete or
accurate health history information, it is important that receiving staff are trained in
interviewing and observation.107
3. ACA Standards
The ACA’s Performance-Based Standards for Adult Local Detention Facilities provides
some guidelines on intake and screening, but does not go into great detail on policy
rationale for the requirements. The standards provide that the admission process for
newly admitted inmates includes medical, dental, and mental health screenings, and
inmates are assigned to holding settings according to their immediate security needs and
physical and mental conditions.108
All inmates also receive an initial mental health screening at the time of admission to the
facility by mental health-trained or qualified mental health care personnel.109 The
screening includes inquiries into the inmate’s present medications, current mental health
complaints, current treatment, and history of psychiatric treatment and substance abuse.
The screening also includes observations of general appearance and behavior, and current
symptoms of psychosis, depression, anxiety, and/or aggression.110 Based on the mental
health screen, the inmate will be (1) cleared for general population, (2) cleared for
general population with appropriate referral to mental-health care service, or (3) referred
to an appropriate mental-health care service for emergency treatment.111

103

Id.
Id. at Discussion.
105
Spier, supra note 101, at 286.
106
Id. See also STANDARDS FOR HEALTH SERVS. IN JAILS J-E-05, Discussion.
107
Id. at 287.
108
PERFORMANCE-BASED STANDARDS FOR ADULT LOCAL DET. FACILITIES 4-ALDF-2A-21, 4-ALDF-2A22 (Am. Corr. Ass’n, 4th ed. 2004) (amended 2007).
109
Id. at 4-ALDF-4C-29.
110
Id.
111
Id.
104

31

Ombudsman Investigative Report
 
 

B. Mental Health Assessment and Treatment
1. Federal CRIPA Investigations
During its investigation of Black Hawk County Jail, the DOJ found faults with the jail’s
mental health care staffing. While finding many of the systemic deficiencies that affected
the delivery of medical care also affect mental health care, the DOJ criticized the jail’s
contract with a private mental health provider. The private provider did not include a
psychiatrist, which inhibited the jail from providing a full range of mental health
services.112 This led the jail’s nursing staff to rely on outside psychiatrists or physicians
who had no formal relationship with the jail.113 This was usually done over the phone
with no face-to-face contact between the psychiatrist and the inmate. There would also
be few follow-up visits or monitoring by the psychiatrist.
The DOJ’s report cited one case in which an inmate requested to see mental health
personnel. A nurse responded that the jail did not routinely have mental health personnel
come out to the jail and advised the inmate to read, exercise, and talk to others.114 Other
than calling to determine if the inmate was on medication, the nurse ordered no further
follow-up or evaluation. Two days later, the inmate hung himself from the window bars
in his cell.115
The DOJ’s report recommended Black Hawk County Jail develop a quality assurance
plan to ensure the level of staffing provided sufficient mental health services to identify
and treat inmates suffering from serious mental disorders. It recommended the jail
provide an adequate and timely health evaluation by qualified and appropriately trained
health professionals of inmates who screen positive for possible mental illness at intake
and of inmates who exhibit symptoms of mental illness at any time during their
incarceration.116 The jail should ensure inmates who request mental health care are seen
and evaluated by a qualified and appropriately trained mental health professional, and
reviews of mental health-related sick calls should go to the jail’s psychiatrist.117
Similar deficiencies and requirements were set forth as a result of the DOJ’s review of
Dallas County Jail in Texas and Terrell County Jail in Georgia. With the enforcement of
a federal court, the DOJ provided recommendations for mental health assessment and
treatment. The “Agreed Order” for Dallas County Jail required, in part, the following:
•

Defendants shall ensure timely access to a qualified mental health professional
when presenting symptoms of mental illness require such care.

112

See Letter from Bill Lann Lee to Brian S. Quirk, supra note 79, at “Inadequate Mental Health Care,
Inadequate Mental Health Staffing.”
113
Id.
114
Id. at “Inadequate Mental Health Care, Sick Call/Treatment.”.
115
Id.
116
Id. at “Minimum Remedial Measures.”
117
Id.

32

 

Law, Policies, Standards and Guideline:  Mental Health Assessment and Treatment 
 
•

•
•

Defendants shall ensure adequate and timely treatment for inmates whose
assessment reveal serious mental illness, including timely and appropriate
referrals for specialty care and regularly scheduled visits with a qualified mental
health professional.
Defendant shall ensure that treatment plans adequately address inmates’ serious
mental health needs and that the plans contain interventions specifically tailored
to the inmates’ diagnoses.
Defendants shall provide adequate on-site psychiatric coverage for inmates’
serious mental health needs and ensure that psychiatrists see inmates in a timely
manner.118

The federal court in Terrell County adopted the DOJ’s “Proposed Order,” which
provided:
Mental Health Assessment and Referral. The Defendants shall develop and
implement adequate policies, procedures, and practices consistent with
generally accepted professional standards to ensure timely and appropriate
mental health assessments by a qualified mental health professional for any
inmate who becomes suicidal and those inmates with mental health
histories, whose responses to initial screening questions, or whose behavior
indicate a need for such an assessment.119
The “Proposed Order” also required Terrell County Jail to enter a written contractual
relationship with an individual with a minimum of a master-level education and training
in psychiatry, psychology, counseling, social work or psychiatric nursing, and licensed to
coordinate and deliver mental health services to jail inmates. Duties for this person
included providing on-call consultations and phone orders, obtaining prescriptions, and
evaluating and coordinating treatment for inmates in response to mental health
referrals.120
2. NCCHC Standards and Recommendations
The NCCHC standards state a jail’s written policy and procedures should address postadmission mental health screening and evaluation.121 Within 14 days of admission,
qualified mental health professionals or mental health staff should conduct initial mental
health screening with inquiries into a history of psychological hospitalization and
outpatient treatment, suicidal behavior and violent behavior, and the current status of

118

Agreed Order at 12-13, United States v. Dallas County, Texas, Civil No. 307 CV 1559-N (N.D. Tex.
Nov. 6, 2007), http://www.usdoj.gov/crt/split/documents/dallas_county_order_11-06-07.pdf.
119
Order accepting Pl.’s Proposed Order at 16, United States v. Terrell County, Georgia, 1:04-CV-76-WLS
(M.D. Ga. Dec. 21, 2007).
120
Id. at 9.
121
STANDARDS FOR HEALTH SERVS. IN JAILS J-E-05, Compliance Indicators (Nat’l Comm’n on Corr.
Health Care 2003).

33

Ombudsman Investigative Report
 
 
psychotropic medication. Inmates who screen positive for mental health problems are to
be referred to a qualified mental health professional for further evaluation.122
The purpose of identifying mentally-ill inmates during the post-admission screening is to
prevent deterioration of their functioning level and to receive necessary treatment. The
standards also require mental health services be available to inmates who require them.123
The immediate objective of mental health treatment in the correctional setting is to
alleviate symptoms of serious mental disorders and prevent relapses to enable the patient
to function safely in their environment.124 Patients who require acute mental health
services beyond those available at the facility are to be transferred to an appropriate
facility.125
3. ACA Standards
The ACA standards are similar to the NCCHC’s, though they give less detail or
explanation behind the policies. After the new inmate intake, the ACA standards require
those inmates who were referred to receive a mental health appraisal during the health
services screen receive the appraisal by a qualified mental health person within 14 days
of admission.126 A mental health examination includes, in part:
1)
2)
3)
4)
5)
6)
7)
8)

Assessment of current mental status and condition.
Assessment of current suicide potential.
Assessment of violence potential.
Review of historical records of psychiatric treatment.
Review of treatment with psychotropic medication.
Review of history of drug and alcohol addiction and treatment.
Referral to treatment.
Development and implementation of treatment plan.127

Inmates referred for mental health treatment receive a comprehensive evaluation by a
licensed mental health professional, which includes a review of the mental health screen,
direct observation of behavior, collection and review of individual diagnostic interviews
and tests, compilation of the individual’s mental health history, and development of an
overall treatment plan with referral to include transfer to mental health facility for
inmates whose psychiatric needs exceed the treatment capability of the facility.128
122

“Mental health staff” includes qualified health care professionals who have received instruction and
supervision in identifying and interacting with individuals in need of mental health services. “Qualified
mental health professionals” includes psychiatrists, psychologists, psychiatric social workers, psychiatric
nurses, and others who by virtue of their education, credentials, and experience are permitted by law to
evaluate and care for the mental health needs of patients.” Id. at Definitions.
123
Id. at J-G-04, Standard.
124
Id. at Discussion.
125
Id. at J-E-05, Compliance Indicators.
126
PERFORMANCE-BASED STANDARDS FOR ADULT LOCAL DET. FACILITIES 4-ALDF-4C-30 (Am. Corr.
Ass’n, 4th ed. 2004) (amended 2005).
127
Id.
128
Id. at 4-ALDF-4C-31.

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Law, Policies, Standards and Guideline:  Use of Restraints

C. Use of Restraints
1. Federal CRIPA Investigations
The Civil Rights DOJ’s review of Black Hawk County Jail concluded the lack of
psychiatric involvement at the jail contributed to deficiencies in medication management
for an inmate who was taking Haldol for his mental illness.129 The inmate claimed the
medication caused a heart attack, which the nurse dismissed with no thorough medical
examination or psychiatric input. The inmate thereafter refused to take the medication,
causing his mental health condition to deteriorate. This led to the inmate being placed in
restraints several times during the week. The investigation found “[h]is chart did not
contain an adequate treatment plan, and he was not receiving treatment for his serious
mental illness.”130
The DOJ focused on inmates who had been placed in the restraint chair due to symptoms
associated with their mental illnesses. Neither medical nor mental health personnel
appeared to be involved in the decision to place the inmates in the chair, or in monitoring
the inmates while they were restrained.131 The DOJ also reviewed two inmates with
serious mental illness in the “special housing unit,” (SHU) a maximum security area for
inmates in disciplinary or administrative segregation.132 A female inmate had been
placed in SHU because of actions associated with her mental illness, including assaultive
behavior. However, there was inadequate documentation in her chart regarding her
mental health history and treatment plan. A psychiatrist had given telephone orders to
administer psychotropic medication, but the inmate had not undergone a face-to-face
evaluation and was not receiving an adequate level of mental health care.133
The DOJ found the jail’s practice of placing inmates with mental illness in the restraint
chair created a serious risk for those inmates. The DOJ recommended the jail ensure its
on-call psychiatrist is consulted in the event of a mental health emergency.134 It also
recommended the jail develop a comprehensive policy on the use of restraints on inmates
with serious mental illnesses. When restraints must be used, the jail must ensure that
mental health personnel are involved in the decision to restrain mentally-ill inmates and
the monitoring of such inmates while restrained.135 The DOJ concluded, “[a]cutely
mentally ill persons who cannot function in the jail’s general population must be
transferred to a treatment facility as expeditiously as possible.”136

129

See Letter from Bill Lann Lee to Brian S. Quirk, supra note 79, at “Inadequate Mental Health Care,
Medication Management.”
130
Id.
131
Id. at “Inadequate Mental Health Care, Improper Restraint and Seclusion of Mentally Ill Inmates.”
132
Id.
133
Id.
134
Id. at “Minimal Remedial Measures, Mental Health Care.”
135
Id.
136
Id. at “Inadequate Mental Health Care, Improper Restraint and Seclusion of Mentally Ill Inmates.”

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Ombudsman Investigative Report
 
 
In the event any inmate is placed in restraints, regardless of mental health status, the DOJ
recommended a supervisor be present when the inmate is first placed in a restraint
chair.137 Inmates must be checked by appropriately trained personnel every 15 minutes
and by medical and mental health staff at “appropriate intervals.”138 Limb exercises
should be done to avoid circulation problems, and attention must be given to food,
hydration, and bodily functions.
In 2001 the DOJ issued a “Findings Letter” to Shelby County Jail in Tennessee, similar to
the one issued to Black Hawk County Jail.139 The Findings Letter was the precursor to a
Settlement Agreement entered between the United States and Shelby County in 2002,
which addressed issues relating to mental health and restraint chair use in its jail facility.
The Settlement Agreement required the county to revise its policies to ensure that
“mental health professionals are consulted before any planned use of force or non-routine
use of restraints on any inmate with a diagnosis of mental illness.”140 The county also
had to revise its policy on the use of its restraint chair to require pre-authorization and
supervision by mental health staff for any non-emergency use of the restraint chair
involving inmates with mental illness. The county must require all security staff to attend
annual in-service training on the use of force and de-escalation techniques.141
2. The Federal Bureau of Prisons Policies
The Federal Bureau of Prisons (Bureau), an agency of the U.S. Department of Justice, has
written policies governing the use of four-point restraints at its 114 institutions.
According to its website, the Bureau employs approximately 36,000 personnel and is
responsible for the custody and care of more than 201,000 federal offenders.142
a. Placement and use of four-point restraint
In federal institutions, four-point restraints are to be used when they are the only means
available to obtain and maintain control over an inmate.143 Prison staff is to use the
process of progressive restraints, where the least restrictive restraint method is used to
control the inmate based on the circumstances, and more restrictive restraints may be
used based on the inmate’s behavior.144 The Bureau’s policy states ambulatory restraints
should initially be used to restrain an inmate if deemed appropriate for the situation.145
137

Id. at “Minimal Remedial Measures, Use of Restraint.”
The DOJ Letter does not say what constitutes “appropriate intervals.”
139
Letter from William R. Yoemans, Acting Assistant Att’y Gen., Civil Rights Div., to Jim Rout, Mayor,
Shelby County, Tennessee (June 27, 2001), available at http://www.usdoj.gov/crt/split/
documents/shelbyfind.htm.
140
Settlement Agreement Between the United States and Shelby County, Tennessee (Aug. 15, 2002),
available at http://www.usdoj.gov/crt/split/documents/shelby_settleagmt.htm.
141
Id.
142
www.bop.gov/about/index.jsp (last visited Oct. 30, 2008).
143
FEDERAL BUREAU OF PRISONS, PROGRAM STATEMENT P5566.06(10) (2005), available at
http://www.bop.gov/policy /progstat/5566_006.pdf.
144
PROGRAM STATEMENT P5566.06(9).
145
Id.
138

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Law, Policies, Standards and Guideline:  Use of Restraints

Such situations include an assault that occurs and ends quickly, and the inmate is no
longer displaying signs of violence or aggression.146 The ambulatory restraints are those
which allow an inmate to eat, drink, and take care of basic human needs without staff
intervention.
When four-point restraints are necessary, the policy requires staff to check the inmate at
least every 15 minutes to ensure the restraints are not hampering circulation and for the
general welfare of the inmate.147 Every two hours, a lieutenant must review the inmate to
determine if the use of the restraints achieved the required calming effect, allowing staff
to remove the inmate from the restraints.148 During this two-hour review, the inmate will
be afforded the opportunity to use the toilet, unless the inmate is actively resisting or
becomes violent while being released.149 The lieutenant must determine how many staff
are needed for the bathroom break and what protective equipment is needed.
The goal of the two-hour review is to determine as soon as possible if the inmate has
regained self-control and can be placed in lesser restraints. If the inmate is temporarily
released from the four-point restraints for any reason, and there is no continued disruption
or aggression, the lieutenant must consider authorizing lesser restraints or removing the
restraints altogether. If the inmate is returned to the restraint after this non-disruptive
break, the lieutenant must document the reasons for this action.
b. Medical and mental health reviews
The policy states a qualified health personnel must initially assess the inmate when the
inmate is placed in four-point restraints to ensure appropriate breathing and physical and
verbal response.150 The health personnel should visit with the inmate at least twice
during each eight-hour shift, and if the inmate is to remain in the restraint longer than
eight hours, supervision must be conducted by the health personnel. In the event an
institution does not have 24-hour medical coverage, medical staff must report to the
institution twice during each eight-hour shift.151
Medical staff must examine and document the following:
•
•
•
•
•
•

Date and time of examination;
Examining staff member;
Body position;
Restraints (adequate circulation);
Vital signs (blood pressure, pulse, respiration, and temperature);
Medication;

146

Id.
PROGRAM STATEMENT P5566.06(10)(d).
148
PROGRAM STATEMENT P5566.06(10)(e).
149
Id.
150
PROGRAM STATEMENT P5566.06(10)(f).
151
Id.
147

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Ombudsman Investigative Report
 
•
•
•
•
•

 
Injuries;
The inmate’s intake, output, hydration, etc.;
Possible medical reasons for behavior;
Deterioration of inmate’s health; and
Any other significant findings and comments.152

After the inmate is removed from the restraints, medical staff must examine the inmate
and treat any noted injuries.153 Psychological services staff must examine an inmate who
is restrained once during every 24-hour period.
c. Documentation
Federal prison staff must document, in writing, the use of restraints on an inmate who
becomes violent or displays signs of immediate violence.154 The report must identify all
those who were involved in the incident and “must provide a vivid, detailed description
of the incident.”155 In addition, staff must document the 15-minute check, the two-hour
lieutenant check, the health services staff review, and the psychology check.156
Staff must immediately obtain a video camera to record any use of force incident, unless
a delay would endanger the inmate, staff, or others or would result in major disturbance
or serious property damage.157 The prison must maintain all documentation, including
the videotape, for a minimum of 2½ years.158 According to the policy requiring the
careful documentation of restraint applications, the incidents must be reported and
investigated to protect staff from unfounded allegations and eliminate the unwarranted
use of force.159
3. NCCHC Standards and Recommendations
According to the NCCHC standards, health services staff are to be notified immediately
when a restraint is used so that they can review the health record for any required
contraindications or accommodations and initiate health monitoring which continues as
long as the inmate is restrained.160 Health services staff are required to notify correctional
administration if they determine that an individual is being restrained in an unnatural
position or one that could jeopardize his or her health.161 If health services staff note
152

Id.
PROGRAM STATEMENT P5566.06(12)(b).
154
PROGRAM STATEMENT P5566.06(14).
155
PROGRAM STATEMENT P5566.06(14)(a).
156
PROGRAM STATEMENT P5566.06(14)(b).
157
PROGRAM STATEMENT P5566.06(14)(c).
158
PROGRAM STATEMENT P5566.06(14)(d).
159
PROGRAM STATEMENT P5566.06 (6)(j).
160
STANDARDS FOR HEALTH SERVS. IN JAILS J-I-01, Compliance Indicators (Nat’l Comm’n on Corr. Health
Care 2003).
161
B. Jay Anno & Steven S. Spencer, Medical Ethics and Correctional Health Care, in CLINICAL
PRACTICE IN CORRECTIONAL MEDICINE 19, 25 (Rolla Couchman ed., 2d ed. 2006) (referencing NCCHC
standards).
153

38

Law, Policies, Standards and Guideline:  Use of Restraints

improper use of restraint that is jeopardizing the inmate’s health, staff should
communicate their concerns as soon as possible to appropriate custody staff. The
standards state exercising each limb for at least ten minutes every two hours to prevent
blood clots is recommended.162
In the event an inmate has a medical or mental health condition, the physician is notified
immediately so that appropriate orders can be given.163 Except for monitoring an
inmate’s health status, health services staff does not participate in the restraint of inmates
ordered by custody staff.164
4. ACA Standards
Similar to its requirements for intake screening and assessment, the ACA standards do
not provide exhaustive detail on restraint use. However, they do state four- and fivepoint restraints are used only in extreme instances and only when other types of restraint
have proven ineffective.165 Advanced approval must be obtained from the jail
administrator or designee before placement, and the health authority must be notified to
assess the inmate’s medical and mental health condition. The health authority will also
determine if the inmate should be in a medical or mental health unit for emergency
involuntary treatment with sedation or medical management.
If the inmate remains in the facility, and four- and five-point restraints are used, the
following minimum procedures are to be used:
•
•
•
•

direct visual observation by staff is continuous prior to obtaining
approval from the health authority or designee;
subsequent visual observation is made at least every 15 minutes;
restraint procedures are in accordance with guidelines approved by
the designated health authority;
all decisions and actions are documented.166

These requirements closely resemble those incorporated by the ACA for adult detention
facilities housing convicted inmates, such as prisons. Advanced approval must be
obtained from the warden or designee, and the health authority must be notified to assess
the inmate’s medical and mental health condition to determine if the inmate must receive
emergency involuntary medical or mental health treatment.167

162

STANDARDS J-I-01, Recommendations.
Id. at Compliance Indicators.
164
Id. at Standard.
165
PERFORMANCE-BASED STANDARDS FOR ADULT LOCAL DET. FACILITIES 4-ALDF-2B-03 (Am. Corr.
Ass’n, 4th ed. 2004).
166
Id.
167
STANDARDS FOR ADULT CORR. INSTS. 4-4191 (Am. Corr. Ass’n, 4th ed. 2003).
163

39

Ombudsman Investigative Report
 
 
5. CMS Regulations
The Centers for Medicare & Medicaid Services (CMS) promulgates rules for institutions
that participate in the federal Medicare and Medicaid programs. Facilities that are
commonly affected by CMS rules include medical facilities such as hospitals and mental
health institutions. While county jails are not directly affected by the rules, according to
one corrections expert, “these rules may properly be looked at in the same fashion as
Standards or even Model rules; that is, persuasive but not binding authority.”168 This is
due in part to the similar circumstances that give rise to restraint use in hospitals and
county jails: patient is an immediate threat to themselves or others.
The CMS recently incorporated rules in the Code of Federal Regulations (Regulations)
that govern the use of restraints and seclusions in hospitals, including on patients who
pose a physical threat of harm to themselves or others.169 The Regulations allow for the
use of restraints and seclusion only when “less restrictive interventions have been
determined to be ineffective to protect the patient, a staff member, or others from
harm.”170 Also, the type or technique of restraint used must be the least restrictive
intervention that will effectively protect the patient, staff, and others.171
If restraints are required, the attending physician must be consulted “as soon as possible”
if the physician did not order the restraint.172 The patient’s condition must be monitored
by a physician, other licensed independent practitioner (LIP), or trained staff that have
completed training criteria required in the Regulations.173 These individuals must have a
working knowledge of hospital policy regarding the use of restraints and seclusion.
Patients must be seen face-to-face within one hour after placement by a physician or
other licensed independent practitioner, a registered nurse, or a physician’s assistant to
evaluate:

168

Patients’ Rights: CMS’s Rules on Seclusion and Restraints, 9 CORRECTIONAL MENTAL HEALTH REP. 51
(Fred Cohen ed., 2007).
169
Condition of Participation: Patients’ Rights, 42 C.F.R. § 482.13 (2007).
170
Id. at § 482.13(e)(2).
171
Id. at § 482.13(e)(3).
172
Id. at § 482.13(e)(7). According to the CMS, many facilities raised concerns during the public comment
period before the regulations were codified, arguing that physicians are not always available to order
restraints. The CMS responded,
[w]e understand that physicians are not always onsite when an emergency occurs. . . . We
do not expect staff to stand by and let the patient injure himself or others without
intervening simply because a physician is not present. The hospital may develop
emergency procedures that staff follow before obtaining the order for restraint or
seclusion; however, an order must be obtained as soon as possible.
Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients’ Rights, 71 Fed. Reg.
71,378, 71,396 (Dec. 8, 2006) (to be codified at 42 C.F.R. pt. 482).
173
The CMS defined “Licensed Independent Practitioner” as “any individual permitted by State law and
hospital policy to order restraints and seclusion for patients independently, with the scope of the
individual’s license and consistent with the individually granted clinical privileges.” Id. at 71,394.

40

Law, Policies, Standards and Guideline:  Use of Restraints
•
•
•
•

The patient’s immediate situation;
The patient’s reaction to the intervention;
The patient’s medical and behavioral condition; and
The need to continue or terminate the restraint or seclusion.174

If the evaluation is conducted by a registered nurse or physician’s assistant, the attending
physician or other LIP must be consulted as soon as possible after the completion of the
one-hour face-to-face evaluation. The Regulations allow orders for restraint and
seclusion to be written by a physician or LIP for a maximum of four-hour periods for
adults. Each four-hour order must be approved by a physician or LIP for a maximum of
24 hours total. At the 24-hour point, a physician or LIP must see and assess the patient
before a new order can be written.175 While an order may be written for up to four hours,
restraints must be discontinued at the earliest possible time “regardless of the length of
time identified in the order.”176
The Regulations do not provide for periodic reviews other than one for the first hour and
in conjunction with the order renewal every four hours. The Regulations leave additional
monitoring and checks to the hospital when it requires the patient’s condition to be
monitored “at an interval determined by hospital policy.”177 This is in part due to the
wide variety of restraints available to a hospital and the impracticality of the Regulations
to provide guidelines for each situation. As explained in the Federal Register, mental
health and vital sign checks are important, along with breaks for toileting, hydration, and
eating, even if not addressed in the Regulations:
We cannot provide an exhaustive list of the items to be monitored because
they will vary with the type of intervention used and the patient’s condition.
For example, the use of a restraint that keeps the patient immobilized would
require a check of the patient’s skin integrity and steps to prevent skin
breakdown. Depending on the duration of the intervention, range of motion
exercise might be necessary. The patient’s mental status, as well as vital
signs, should be assessed, particularly when the restraint is initiated to
manage self-destructive or violent behavior that jeopardizes the immediate
physical safety of the patient, a staff member, or others. The patient should
be provided the opportunity for toileting, hydration, and eating if the
interventions used impedes these activities.178
In addition, the CMS explained the absence of specific periodic checks codified in the
Regulations does not indicate staff should not attempt to address the underlying cause for
agitation:
174

42 C.F.R. § 482.13(e)(12)(ii).
Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients’ Rights, 71 Fed. Reg.
at 71,412.
176
42 C.F.R. § 482.13(e)(9).
177
Id. at §482.13(e)(10).
178
Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients’ Rights, 71 Fed. Reg.
at 71,400.
175

41

Ombudsman Investigative Report
 
 
The use of these interventions must not end efforts to treat the underlying
cause of the behavior; nor is it expected that treatment will come to a
complete halt. . . . Certainly, trained staff should work with the patient
toward release as quickly as possible and use other interventions to deescalate the crisis behavior.179
The Regulations also provide requirements for circumstances where hospital staff use
simultaneous seclusion and restraint. This is only permitted if the patient is continually
monitored (1) face-to-face by an assigned, trained staff member, or (2) by trained staff
using both video and audio equipment. The audio and video monitoring must be in close
proximity to the patient. The Federal Register explained these requirements as follows:
If restraint and seclusion are used simultaneously to manage self-destructive
or violent patient behavior that jeopardizes the immediate physical safety of
the patient, a staff member, or others, the patient must be continually
monitored, face-to-face, by an assigned, trained staff member; or continually
monitored by trained staff using both video and audio equipment . . .
“continually” means ongoing without interruption.180
When restraints or seclusion are used, staff must document each of the following:
1. The 1-hour face-to-face medical and behavioral evaluation if restraint or
seclusion is used to manage violent or self-destructive behavior;
2. A description of the patient’s behavior and the intervention used;
3. Alternatives or other less restrictive interventions attempted (as
applicable);
4. The patient’s condition or symptom(s) that warranted the use of the
restraint or seclusion; and
5. The patient’s response to the intervention(s) used, including the rationale
for continued use of the intervention.181
Commenters to the Regulations suggested requiring restraints logs and elements that
should be included in the log such as time initiated and discontinued, time physician was
contacted, and documentation of physical exams. The CMS replied that it agreed with
such practices and believed tracking and monitoring would be appropriate for the
hospital, but declined to require such documentation because it would be unnecessarily
burdensome.182

179

Id. at 71,413.
Id. at 71,400.
181
42 C.F.R. § 482.13(e)(16).
182
Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients’ Rights, 71 Fed. Reg.
at 71,415.
180

42

Law, Policies, Standards and Guideline:  Use of Restraints

6. Other Resources
In The Mentally Disordered Inmate and the Law, Fred Cohen provides a list of essential
points that every facility must cover in its policy and procedures governing restraint
device placement, monitoring, and duration. Those points include:
1) Clarity on the rationale (or criteria) for the intervention. There are
always emergencies that will require the prevention or reduction of harm
and damage. The nature of emergencies that trigger therapeutic restraint
or seclusion must be spelled out.
2) Authorization. In an emergency (and these situations always are
emergencies) it may not always be possible to have a doctor or a
psychiatrist perform an initial authorization. However, the regulations
should clarify (1) who may then authorize [restraint application], (2) how
soon thereafter clinical authorization is required, and (3) whether or when
personal observation must precede clinical authorization.
3) Monitoring. The policy should specify who will do the monitoring, at
what intervals monitoring shall occur, and whether it is for medical,
psychiatric, or comfort purposes.
4) Bodily function factors. The policy should provide for details on provision
of food, relief of bodily wastes and fluids, water intake, nonimpairment of
blood circulation, and the like.
5) Duration. The policy must state how long a single restraining episode will
last and the time frames for monitoring, recordkeeping, and the like.183
Kenneth L. Faiver, in his book, Health Care Management Issues in Corrections,
published by the ACA, states that in the case of a person with a diagnosed or suspected
mental illness, “the officer should notify mental health personnel as soon as possible and
be guided by competent clinical advice as to the continuation of any form of restraint.”184
The warden or jail administrator delegates authority for the use of restraints on mentally
ill inmates, but correctional personnel should only employ them while consulting with
mental health staff.185
Mr. Faiver sets proposed requirements that should accompany policies governing
restraints used by mental health professional on mentally ill prisoners. A policy should
address:
•
•
•
•

who may order the restraints,
what type of restraints should be used,
the length of time for which an order for restraint is valid,
alternative measures which must be considered prior to employment of
restraints,

183

FRED COHEN, THE MENTALLY DISORDERED INMATE AND THE LAW ¶ 12-5[2] (1998).
KENNETH L. FAIVER, HEALTH CARE MANAGEMENT ISSUES IN CORRECTIONS 152 (1998).
185
Id. at 153.
184

43

Ombudsman Investigative Report
 
•
•
•

 
a requirement for periodic inspection of the restraint patient by a qualified
mental health and/or medical staff,
a requirement for visitation of the restrained patient by a mental health
professional who is qualified to order restraints, and
adequate documentation.186

Mr. Faiver states that the principle of “least restrictive environment” should be observed
in all cases of restraint use. This means restraints should be applied only when less
restrictive devices are judged to be insufficient, and the type of restraint used must be the
least restrictive restraint that is effective.187 Mr. Faiver also describes in his book the
restraint chair that is now popularly incorporated in small jails was used in the early
1900s in mental hospitals, “but was long ago discarded as an inappropriate and
unacceptable treatment for mentally ill persons.”188
The American Psychiatric Association’s Resource Document, addressing the use of
seclusion and restraint in the correctional health care system, states when four-point
restraints are used, observation should be continuous and documentation of the
observations should be contemporaneous.189 A nurse should check each extremity every
15 minutes for at least the first 2 hours of restraint.190 “Every two hours, nursing staff
should perform an assessment of the patient, including condition of the skin and
circulation, need for toileting, personal hygiene procedures, and proper application of the
restraint.”191 Evaluations should summarize the patient’s overall physical condition,
general behavior, and response to counseling/interviews. Vital signs should be taken
every eight hours.
The Resource Document suggests range of motion exercises should be performed every
two hours unless the patient is too agitated or assaultive to safely remove the restraints.
For exercise, restraints on each extremity shall be removed one at a time.192 Toileting
should be provided at least every four hours, and if security concerns do not allow the
inmate to exit a room for these facilities, a urinal or bed pan should be used. Fluids and
nourishment should also be provided every two hours except during hours of sleep.193

186

Id.
Id.
188
Id. at 154. The Ombudsman recognizes, however, that the restraint chair is not being used to treat
mentally ill inmates, but to prevent injury by the inmates. Correctional officers are not trained mental
health professionals, and their primary functions lies with maintaining security.
189
JEFFERY L. METZNER ET AL., COUNCIL ON PSYCHIATRY AND LAW, THE USE OF RESTRAINT AND
SECLUSION IN CORRECTIONAL MENTAL HEALTH CARE 5 (2006).
190
Id. at 6.
191
Id.
192
Id.
193
Id.
187

44

 
  
 

 

Law, Policies, Standards and Guideline:  Time Limits

D. Time Limits
1. E.R.C. Inc. Policy
Over the past several years, E.R.C. Inc. has changed the language and substance of its
policy manual; some of which appears to be contradictory. According to an older version
of E.R.C. Inc.’s Instructions, whose publication date is unknown, “detainees should not
be left in the Emergency Restraint Chair for more than two hours at a time.”194 This
policy is echoed on the E.R.C. Inc. website.195 A letter from President Tom Hogan to
customers, (Customer Letter), dated January 17, 2001, states:
We recommend that detainees not remain in the Emergency Restraint
Chair for more than two hours at a time. This time limit was
established to allow for the detainee to calm down or sober up, and if
needed it allows for the correctional officer to seek medical or
physchological (sic) help for the detainee. This two-hour limit may be
extended, but only under direct MEDICAL SUPERVISION
(Doctor/Nurses) while performing range of motion exercises. This
extended time period should not exceed eight hours; therefore we
do not recommend anyone be left in the Emergency Restraint
Chair for more than ten hours total.196 (bold emphasis added).
The Customer Letter states the company understands some customers are keeping
detainees in the restraint chair longer than the manufacturer intended. The company
cautioned that the guidelines listed above should be followed carefully.
A version of the Instructions that followed the Customer Letter, published February 10,
2001, contains similar language.197 It provides for the option of extending the two-hour
time limit, but only under direct medical supervision of a doctor or a nurse.198 It does not
recommend anyone be left in the restraint chair more than ten hours.199 During this
investigation, the Ombudsman learned several jails relied on the older version of the
Instructions.
The Ombudsman contacted E.R.C. Inc. President Tom Hogan about the time limit
language. According to Mr. Hogan, the two-hour and ten-hour language is “arbitrary.”200
He stated a time limit needed to be set, and two hours was a reasonable amount of time to
194

E.R.C. Inc., EMERGENCY RESTRAINT CHAIR INSTRUCTIONS 11 (Feb. 10, 2001). The Ombudsman
obtained two versions of the ERC Instructions during the course of his investigation. One instruction
manual appears to be an older version when taking into consideration the “Patent in Progress” language on
the manual and the black and white photos. Another manual, dated “February 10, 2001,” states “Patented
in 1998” and is printed in color.
195
http://www.restraintchair.com/diagram.htm (last visited Oct. 30, 2008).
196
Letter from Thomas Hogan, President , E.R.C. Inc., to Customer (Jan. 17, 2001).
197
E.R.C. Inc., EMERGENCY RESTRAINT CHAIR INSTRUCTIONS (Feb. 10, 2001).
198
Id. at 12.
199
Id.
200
Telephone Interview with Tom Hogan, President, Emergency Restraint Chair, Inc. (June 11, 2008).

45

Ombudsman Investigative Report
 
 
 
determine if the inmate is exhibiting unusual behavior that requires medical personnel
involvement, and allows time for the jail to incorporate medical supervision of the
inmate. This was based on his experience as a county sheriff and running his own jail
where he used the restraint chair. The initial two hours is meant to seek medical
attention.
The E.R.C. Inc. Customer Letter also revealed an additional policy basis for the two-hour
limitation. According to the Customer Letter, two hours should be enough time to allow
an inmate to calm down or sober up. This sentiment has been repeated by other
correctional officers the Ombudsman contacted, who have stated an inmate will rarely
need to be in a restraint chair longer than two hours. The Customer Letter states those
two hours allow a correctional officer to seek medical or psychological help for the
detainee. In addition, the letter reflects language used by the Jefferson County Jail’s
policy that extended use of the restraint chair beyond the two-hour limit may only be
done under direct medical supervision.201
2. Iowa Law and Case Law
Iowa law does not provide requirements for specific maximum limits for restraint device
use or when medical staff should be consulted. It does state the restraint device “shall be
used only when a prisoner is a threat to self or others or jeopardizes jail security.”202 It
further requires personal visual observations of the inmate and the restraint device
application every 15 minutes.203
Iowa case law has not provided a maximum time limit, but courts have criticized jails for
not providing documentation to support continued use of restraints. In Ogden v. Johnson,
the Northern District of Iowa upheld a jury verdict that found the arrestee’s five-hour
placement on a “restraint board” by Linn County Jail staff was unreasonable.204 The
arrestee showed he was held on the board long after the need for restraint had ended, and
the jury found this constituted excessive force. In approving the jury award, the court
determined the board was “more than just uncomfortable. It is a restraint that should be
used only for the amount of time necessary to restore order.”205 Further, the court found
the officer who approved the continued use beyond the reasonable time was not entitled
to qualified immunity. The court upheld the $11,500 jury award against the officer in his
individual capacity for punitive damages and also awarded $43,502.50 in attorney fees.206
In another similar case against the Linn County Jail, the same court found the jail could
not justify the continued restraint of an inmate that lasted for eight hours and concluded

201

Id.
IOWA ADMIN. CODE r. 201—50.13(2)(f) (2008).
203
Id.
204
Ogden v. Johnson, No. C00-0034, WL 32172301 (N.D. Iowa Sept. 5, 2002).
205
Id. at *3.
206
Id. at *5, *7.
202

46

Law, Policies, Standards and Guideline:  Time Limits

the restraint violated the inmate’s Eighth Amendment rights.207 The court found the
inmate’s initial placement was not excessive under the circumstances, where the inmate
prevented an officer from closing a door and physically resisted the officer. However,
the court found the record could not support the inmate’s continued restraint in response
to his verbal abuse:
No evidence was offered that indicated Rogers presented a physical
threat to inmates or staff or that jail security was jeopardized in any
way. Mere verbal abuse by an inmate does not justify eight hours of
immobility on “the board.”208
The court found the actions of the officer, who was also one of the defendants in Ogden,
were taken for no other purpose than to punish the inmate and inflict pain, humiliation,
and suffering on him for the verbal abuse.209 The court described the officer’s action as
“cruel” when the defendant was denied bathroom provisions and had no choice but to
urinate on himself. The court further criticized the lack of periodic reviews and
documentation:
While Sergeant Johnson checked on Rogers once in awhile, no
documentation of reviews and evaluations were offered evidencing any
justification for the excessive eight hours Rogers spent immobilized on the
board.210
The court held the inmate’s Eighth Amendment rights were violated by the continued use
of the restraint board. The court again denied the defendant officer qualified immunity
for his actions, and awarded the former inmate $1,500 in compensatory damages plus
attorney fees.211
The requirement that a correctional facility provide evidence that continued restraint is
necessary to defend against constitutional rights allegations has been upheld by other
federal district courts outside Iowa. In 2004 a federal district court in Virginia concluded
a state prison could not substantiate the need to restrain an inmate in four-point restraints
longer than the initial three hours after his placement.212 The inmate showed no further
signs of aggression after this time and was released periodically for meal and bathroom
breaks with no violence. However, the prison kept him restrained to a bed for 47 hours
and 20 minutes, a regular practice by the prison when it determined an inmate needed to

207

Rogers v. Dunn, No. 00-0188-PAZ, 2001 U.S. Dist. LEXIS 22710, at *14 (N.D. Iowa Nov. 27, 2001).
Id. at *10.
209
Id.
210
Id. at *10-11.
211
Id. at *14-15.
212
Sadler v. Young, 325 F.Supp.2d 689, 704 (W.D. Va. 2004), rev’d on other grounds, 118 Fed. Appx. 762
(4th Cir. 2005).
208

47

Ombudsman Investigative Report
 
 
 
213

be restrained.
found:

While substantiating the initial placement, the court in Sadler v. Young

Neither the testimony nor the reports suggest any reason for keeping
Sadler restrained for nearly two days . . . . The absence of evidence of a
need to restrain Sadler for nearly two days indicates that the defendants
were executing a forty-eight hour punishment of Sadler as opposed to
responding to an immediate disturbance . . . . I hold as a matter of law
that the remaining defendant did not act in good faith in restraining
Sadler for forty-seven hours and twenty minutes because there is no
reasonably sufficient evidentiary basis showing that the defendants
perceived Sadler to be a threat after . . . three hours after he was first
restrained.214
The court found that no reasonable jury could find the defendant’s conduct required the
application of force for nearly 48 hours.215
3. Other Sources for Length of Time
Correctional, medical, or mental health articles, standards, and court cases reviewed by
the Ombudsman do not designate a specific maximum time limit like the one proposed by
the E.R.C. Inc. Customer Letter. Rather, many of the referenced sources require staff and
medical monitoring and reviews of the inmate who is placed in the restraints. Many
county jails set either a two- or four-hour maximum time limit, unless approval for
additional time is given by a jail administrator or designee.
As mentioned earlier, the DOJ recommended a supervisor be present when the inmate is
first placed in the chair, and medical and mental health staff should check the inmate at
“appropriate intervals,” though it is not known what specific time interval was intended.
The NCCHC standards require health services staff be notified immediately, and in the
event the inmate has a medical or mental heath condition, a physician is notified
immediately. The ACA standards require the jail’s health authority be notified when
restraints are used and require 15-minute visual checks of the inmate.

213

Id. at 694-95.
Id. at 702-704.
215
Id. at 702.
214

48

 
  

 

Analysis
A. Review of Restraint Devices Used in Iowa County Jails
1. Manufacturer Testing and Research
According to E.R.C. Inc. President Tom Hogan, the policies drafted by the company were
based on his experience as an EMT and county sheriff. Little or no medical research
designates specific time period for medical checks, which he set at two hours, or
maximum amount of time an inmate can be left in the restraint chair, which he set at ten
hours. He also based the design of the chair on his experience in medical treatment and
law enforcement. The slightly-reclined chair provides comfort that is not available with
the restraint board, which straps the inmate face down on a piece of plywood. If the
circumstance allows for it, when an inmate calms down or falls asleep, jail staff can
loosen the straps for the inmate’s comfort and may easily re-tighten the straps if the
inmate suddenly becomes violent again.
Mr. Hogan emphasized the need for jail staff to observe the inmate and note any unusual
behavior that may indicate an underlying medical or mental health cause for the
aggressive actions. The initial two hours should be used to seek medical treatment if the
inmate does not calm down after that time, and should follow medical advice on whether
medical intervention is required.
A previous report issued by the Ombudsman on restraint chair use involved the Scott
County Jail. The restraint chair used by the Scott County Jail on that occasion was
manufactured by AEDEC International, Inc.216 A report published in The Progressive
reviewed the use of restraint chairs and provided deposition responses from Dan
Concoran, President of AEDEC International, Inc.217 The deposition was conducted as
part of a civil lawsuit against Sacramento County, California, and its use of the restraint
chair.
According to the deposition excerpt reprinted in the article, the only testing conducted on
the restraint chair was done by Dan Concoran himself, who tested the chair on various
friends while pulling the straps as hard as he could. It was his opinion the chair was less
psychologically traumatizing than four-point restraints, being chained to a bench, or
being strapped to a bed. However, that opinion was not based on any medical or
psychological expert. While the manufacturer’s “Statement of Purpose” said the chair
was especially useful for restraining drug or alcohol-affected prisoners, a claim asserted
in the “Manufacturer’s Warning” during the Ombudsman’s investigation of Scott County
Jail, this conclusion was not based on scientific literature or on testing of individuals
under the influence of alcohol, drugs, or narcotics.218 The deposition also revealed no
216

William P. Angrick II, Citizens’ Aide/Ombudsman, INVESTIGATION OF SCOTT COUNTY JAIL’S USE OF
FORCE 5 (2007), http://www4.legis.state.ia.us/caodocs/Invstgtv_Reports/2007/CIWPA010.PDF
217
Anne-Marie Cusac, The Devil’s Chair, THE PROGRESSIVE, April 1, 2000, available at
http://www.progressive.org/mag_cusacchair.
218
Id.

49

Ombudsman Investigative Report
 
 
 
literature was relied on, and no studies or research were conducted, to determine the
maximum amount of time a person could be restrained without causing injury.
2. Adverse Medical Effects of Restraint Use
In 2003 a psychiatric journal published a research article that analyzed the adverse effects
of restraint use.219 The research article included in its review of “restraints” the use of
four- and five-point beds, restraint chairs, ambulatory restraints, and straight jackets.220
The article cited a report that reviewed 20 restraint-related deaths. It found 40 percent of
the deaths were caused by asphyxiation. Asphyxiation can be caused by putting
excessive weight on a patient’s back while in a prone (face down) position, placing a
towel or sheet over the patient’s head to protect staff from spitting or biting, or
obstructing the airway when pulling the patient’s arms across the neck area.221
“Positional asphyxia,” where asphyxiation results when the body’s position interferes
with respiration, had been found to occur when an individual is placed in a position that
does not allow adequate breathing.222 This was most often found when a person was
placed in a prone position, including when law enforcement officers would transport
individuals in this position. Included in the article was a study conducted on healthy
adults to determine the physiological effects of restraint. The study found nine of ten
healthy adults experienced prolonged recovery from exercise performed in the prone
position, though the specific cause for the prolonged recovery was unknown.223
The National Institute of Corrections (NIC) provided an explanation of the mechanics of
breathing and asphyxiation during a teleconference in 2000. During the process of
breathing in, a person raises the ribs and contracts the diaphragm. When a person is in
the prone position, the person has to lift the weight of his body to breath, and if the
abdomen is compressed, the abdominal content is raised making it more difficult to
contract. The presenter explained the typical reaction of the restrained person who is
having difficulty breathing:
The natural reaction to that is to struggle more violently. The perception of
those trying to subdue the individuals is that he needs more compression to
be subdued. You then enter a vicious cycle in which compression makes air
hunger, air hunger makes a greater struggle, and greater struggle demands

219

Wanda K. Mohr et al, Adverse Effects Associated with Physical Restraint, 48 CAN. J. PSYCHIATRY 330
(2003).
220
Id. at 330, 331.
221
Id. at 331, citing JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS, Preventing
Restraint Deaths, SENTINEL EVENT ALERT (Nov. 18, 1998).
222
Id. at 332.
223
Id. at 331. The article states potential causes included “restriction of thoracic respiratory movements,
airway compromise, and the release of catecholamines during physical exertion.” Id.

50

Analysis:  Review of Restraint Devices Used in Iowa County Jails

greater compression. Unfortunately, in some of these circumstances, the
price of tranquility is death.224
The research article also noted restraint in a supine (face-up) position could predispose a
patient to aspiration. Aspiration in this position can result when an individual has a
decreased level of consciousness. Death can result from asphyxia, acute pulmonary
edema, or pneumonitis.
While no literature was available on the subject when the research article was published,
the authors reviewed blunt trauma to the chest (BTC) as another cause of sudden death.225
It is important to mention the article’s review of BTC since a case reviewed by the
Ombudsman, and included in this report, involved an officer striking an inmate in the
chest while partially restrained in a restraint chair. BTC can lead to death as a result of
commotio cordis.226 While this occurs most often in athletes, the article referenced a case
where a child was struck in the chest during restraint, causing his death.227
Other adverse medical conditions discussed in the research article included
catecholamine rush, rhabdomyolosis, and thrombosis – the latter condition arising when
individuals are held immobile for long periods of time in the same position.228
Thrombosis, the formation of a blood clot in a blood vessel,229 led to the pulmonary
embolism that killed a Utah state prison inmate mentioned earlier in this report who was
held in a restraint chair for 16 hours.230 The article concludes that psychiatric literature
has provided little information on the cause of death and injury due to physical restraints,
and additional research is needed to provide additional data on the risk factor and adverse
effects of restraint use.231
3. Preferred Attributes of a Restraint Device
The Ombudsman reviewed several types of restraint devices used in Iowa jails. The
primary differences in the types of restraint chairs are strap placement and how these
straps restrain the inmate.
One type of restraint chair has two straps attached to the chair from the shoulders to the
opposite waist areas, crossing the individual’s torso. The exact place the straps cross the
224

Videotape: Application and Use of Restraints in Custody: Reducing the Risks (Nat’l Inst. of Corr.
Teleconference, Apr. 19, 2000).
225
Mohr, supra note 220, at 332.
226
Id. The article defines commotion cordis as “a cardiac arrhythmia secondary to myocardial concussion
during the vulnerable phase of cardiac electrical repolarization (just prior to T-wave peak) resulting from
BTC.” Id.
227
Id.
228
Id. at 332-33.
229
http://www.medterms.com/script/main/art.asp?articlekey=25023 (last visited Oct. 30, 2008).
230
Sheila R. McCann, Utah Settles Lawsuit Over Inmate's Death; State Settles Inmate-Death Suit For
$200,000, SALT LAKE TRIBUNE (Utah), July 31, 1998, at A1.
231
Mohr, supra note 220, at 335.

51

Ombudsman Investigative Report
 
 
 
torso depends on the height and size of the individual being placed in the restraint chair.
The Ombudsman’s concern arises from these straps and their potential for interfering
with the mechanics of breathing. Asphyxiation may result if the straps are tightened to
the point where the restrained person cannot fully raise the ribs and contract the
diaphragm, simulating the complications that arise when a person is placed in a prone
position. The Ombudsman must concede that this concern is not based on scientific
research of this specific restraint device, but the lack of any scientific research conducted
by the manufacturer is also the basis of the Ombudsman’s concern.
The other type of restraint chair has straps that restrain the shoulders of the individual,
going from a point above the shoulders to under the armpit. Though it has a strap for the
waist, the device does not have straps crossing the individual’s chest or torso that could
restrict breathing.
The Ombudsman also has concerns about the restraint board. The restraint board
reviewed by the Ombudsman shows the individual face-down on a piece of plywood.
The restraint board is a ten-point restraint device, including an individual’s ankles, thighs,
wrists, upper-arms, waist, and head. The device used on the individual’s head has one
strap across the forehead and another close to the neck. The prone position used by the
restraint board is the same prone position that creates the positional asphyxia risk.
Further concerns arise regarding the restrictive head straps that force the individuals head
to be turned perpendicular to the individual’s shoulders, as well as the straps that cross
the neck. The restraint board was found to be a contributing factor in a death of a
Colorado inmate in 1998, though the medical condition caused by the board that
purportedly contributed to his death is unknown.232
The Ombudsman does not endorse the use of any particular device or manufacturer, since
many different devices exist on the market that restrain individuals in different ways.
While not endorsing any specific device, the Ombudsman places emphasis on the
construction of the device, taking into consideration adverse medical conditions that are
more likely to arise in some devices than others. As mentioned above, the two restraint
devices the Ombudsman has concerns about involve those that can restrict breathing.
Though not reviewed in the cases addressed in this report, the Ombudsman has seen a
variety of restraint beds and boards advertised on correctional websites that restrain an
individual in the supine position.233 Problems can arise with inmates who are under the
influence – as is common in inmates requiring restraint – if the inmate vomits but cannot
clear the material due to their position. As mentioned in the psychiatric research article
on the adverse effects of restraint use, above, aspiration in the supine position can also
occur due to the individual’s decreased level of consciousness.234

232

Patricia Callahan, Restraining Inmate ‘Sadistic’ ACLU Sues El Paso Sheriff, DENVER POST, May 22,
1998 at B-07.
233
http://www.pxdirect.com/restraints.htm (last visited Oct. 30, 2008).
234
Mohr, supra note 220, at 332.

52

Analysis:  Standards for All Jails

B. Standards for All Jails
1. New Detainee Intake Screening
Iowa law requires a medical history intake form be completed on each person admitted to
the jail, which includes screening for potential self-injury or suicide.235 While no specific
screen is required, an accurate medical and mental health screen can identify potential
problems before they reach a crisis level. Identifying this potential problem may in turn
reduce the need for physical restraint and risk of injury to either the inmate or jail staff. It
can also protect a jail from potential federal or civil tort claims by inmates or a federal
agency alleging a facility failed to recognize and treat a specific medical condition.236
The Ombudsman reviewed several intake forms used by Iowa jails and researched others
that accurately identify potential mental health issues, including one endorsed by the
National Institute of Corrections, Jail Division.237 The “Brief Jail Mental Health Screen”
(BJMHS) was developed by researchers funded by the National Institute of Justice (NIJ),
a research arm of the U.S. Department of Justice.238 The screen is an eight-question,
“yes/no”-answer form that takes about two to three minute to complete.239 The screen is
comprised of six questions inquiring about current mental health symptoms, and two
questions about whether the inmate has ever taken medication or been hospitalized for
emotional or mental health problems. If the inmate answers “yes” to two or more of the
first six questions, or answers positively to either question seven or eight, the screening
form recommends the jail refer the inmate for further mental health evaluation.
Based on the extensive research conducted using this test, and its endorsement by the
National Institute of Justice, National Institute of Corrections, and the National GAINS
Center, the Ombudsman believes Iowa jails would benefit by incorporating the test
235

IOWA ADMIN. CODE r. 201—50.15(6)(c) (2008).
The DOJ, Civil Rights Division has brought numerous claims against jails across the country under
CRIPA. A list of settlements and court decisions involving jails and prisons can be found at
http://www.usdoj.gov/crt/split/findsettle.htm#Settlements.
237
See Appendix C for a sample of the BJMHS. The National Institute of Corrections is an agency within
the Department of Justice, Federal Bureau of Prisons. According to its website, the NIC provides training,
technical assistance, information services, and policy/program development assistance to federal, state, and
local corrections agencies. It also provides leadership to influence correctional policies, practices, and
operations nationwide in areas of emerging interest and concern to correctional executives and practitioners
as well as public policymakers. http://www.nicic.org.
238
JULIAN FORD ET AL., MENTAL HEALTH SCREENS FOR CORRECTIONS (2007). The Research for Practice
discusses two research reports, (Evidence-based Enhancement of the Detection, Prevention, and Treatment
of Mental Illness in the Correction Systems and Validating a Brief Jail Mental Health Screen), whose
purpose was to create and validate a mental health instrument that corrections staff can use during intake.
The reports developed the Correctional Mental Health Screen (CMHS) and the Brief Jail Mental Health
Screen (BJMHS). The Research for Practice states the BJMHS takes less time to fill out and requires
minimal training to administer. The researchers found both tests acceptable, compared to “longer, more
cumbersome, and training-intensive tools currently used in clinical settings.” Id. at 10.
239
Henry J. Steadman et al., Validation of the Brief Jail Mental Health Screen, 56 PSYCHIATRIC SERVICES
816 (2005).
236

53

Ombudsman Investigative Report
 
 
 
during the screening process.240 The test is free to download from a federal government
website, and is found in the Appendix of this report.241 The BJMHS, or other healthauthority-approved mental health screen, should not replace other intake screening forms
used to obtain non-mental health or current medication information from an inmate since
the BJMHS does not screen for this information.
Ideally, intake screening is done by a licensed medical professional. However, budgetary
constraints often limit a jail’s ability to employ such individuals in this position. When
such limitations are present, the Ombudsman shares the view of the APA and the
NCCHC, which allows initial inmate screenings be performed by correctional staff as
long as they are trained to identify potential medical and mental health issues in
inmates.242 Another reason the Ombudsman supports the incorporation of the BJMHS
form is because, according to the NIJ’s Mental Health Screens for Corrections,
corrections classification officers, intake staff, or nursing staff can administer the BJMHS
without specialized health training.243 The NIJ report states personnel can receive brief
informal training before administration, relieving the need for the jail to cover extensive
or specialized training in mental health for staff.
2. Assessment of Screened Inmates
It is imperative that inmates who screen positive for potential mental illness are assessed
by a mental health professional. This was a critical failing the DOJ identified in its
investigation of the Black Hawk County Jail. A review by a mental health professional
can determine the detainee’s mental health needs, whether those needs can be served by
the jail, or if those needs can only be satisfied by an outside source, such as a mental
health facility.
A mental health assessment is a follow-up process after the initial intake screen. It is
required by the NCCHC and the ACA standards and is recommended in the DOJ Civil
Rights Division’s CRIPA investigations and other correctional and medical publications
reviewed by the Ombudsman. Iowa law only requires a jail to have a written “plan” to
provide prisoners access to services for the detection, diagnosis, and treatment of mental
illness.244 However, it does not require a jail to take any action in the event an inmate
responds he has a mental illness or may be suicidal.
Despite the absence of a state law requiring a jail to follow-up on an inmate’s possible
mental health condition, jails are required under the Eighth Amendment to seek treatment
for an inmate’s mental illness. Ignoring an inmate’s mental health needs exposes a jail to
the same liability as if it were to ignore an inmate’s physical medical needs. Federal law,
240

http://gainscenter.samhsa.gov/html/resources/MHscreen.asp (last visited Oct. 30, 2008).
http://gainscenter.samhsa.gov/pdfs/disorders/bjmhsform.pdf (last visited Oct. 30, 2008).
242
STANDARDS FOR HEALTH SERVS. IN JAILS J-E-02, Discussion (Nat’l Comm’n on Corr. Health Care
2003).
243
FORD, supra note 239, at 2-3.
244
IOWA ADMIN CODE r. 201-50.15(6)(d) (2008).
241

54

Analysis:  Standards for All Jails

under 42 U.S.C. § 1983, provides an avenue for pretrial detainees to file a legal action
against jails for the deliberate indifference to their serious medical needs.245 This liability
extends to an inmate’s mental health care needs.246
The Ombudsman believes seeking treatment from a mental health professional for those
inmates who screen positive for mental illness is a constitutional requirement under the
Eighth Amendment. It is also consistent with standards and recommendations set forth
by correctional organizations. Jails need to use the mental health professional with whom
they currently contract or work with the county CPC on locating mental health
professionals that can provide services to the jail.
3. Decision to Place Inmate in Restraint Device: When to Use
Restraint devices have been the subject of multiple litigations following inmate deaths
and have cost jails and state governments millions of dollars in judgments and
settlements, let alone the lives of the detainees placed in the chair. Despite disputes over
the actual cause of an inmate’s death and to what extent the restraint device’s
involvement played a role, lawsuits and settlements have led some law enforcement
departments to abandon their use of the restraint devices in an effort to avoid liability.
This caveat should not be interpreted as a position against the use of restraint devices.
Rather, it should be read that use of restraints must be accompanied by policies and
procedures that are carefully written and closely followed to avoid restraint misuse and
abuse by staff, which can lead to serious consequences for the correctional facility, staff,
and the inmate. Litigation has led to the abandonment of specific restraint devices in
some jurisdictions. However, the importance of having restraints available as an option
in the correctional mental health setting was stressed in the American Psychiatric
Association’s Resource Document:
The efforts in recent years to minimize the use of seclusion and restraint of
persons with mental illness have been a positive development. However,
the nature of severe mental illness is such that seclusion and restraint cannot
be eliminated as a necessary part of treatment and management. Therefore,
it is crucial that there not be an expectation that seclusion and restraint be
abolished in correctional mental health. Staff must feel that they are
permitted to use seclusion and restraint when it is clinically necessary for the
welfare and safety of the patient, other patients and the staff. . . . The

245

Hartsfield v. Colburn, 491 F.3d 394, 396 (8th Cir. 2007) ("[I]t is now settled 'that deliberate indifference
is the appropriate standard of culpability for all claims that prison officials failed to provide pretrial
detainees with adequate food, clothing, shelter, medical care, and reasonable safety.'" (quoting Butler v.
Fletcher, 465 F.3d 340, 345 (8th Cir. 2006))).
246
Vaughn v. Lacey, 49 F.3d 1344 (8th Cir. 1995); Smith v. Jenkins, 919 F.2d 90 (8th Cir. 1990).

55

Ombudsman Investigative Report
 
 
 
unintended consequences may include unnecessary injuries to the patient, to
other patients and to the staff.247
Use of restraint devices must be restricted to those circumstances when an inmate is an
imminent risk of harm to themselves or others, or is jeopardizing jail security. It is
important to stress the risk of harm must be immediate and ongoing. The Ombudsman
reviewed one Iowa county complaint, not included in this report, where the jail placed an
inmate in a restraint chair for 35 minutes after he triggered a fire alarm and fire
suppression sprinklers. There was no indication the inmate was still causing problems at
the time he was placed in the restraint chair. Regarding use of a restraint device after the
occurrence of an incident, Fred Cohen surmised:
It must be made clear by administrators and policy and procedure that
mechanical restraints are not about what has occurred, they are about
what is occurring now. When they are about the past, it is punishment .
. . .248
In a Washington University law journal, Fred Cohen explained that restraint use “is to be
purely preventative (for example, to prevent escape, self-harm, or injury to others) and
applied for no more time than is absolutely necessary.”249 When their use is upheld by
judicial review, it is because their use was to prevent harm to the inmates self or others,
not as a form of punishment.250
Use of a restraint device in response to verbal abuse from an inmate towards officers has
also been considered punitive. An Iowa federal district court has indicated verbal abuse
is not sufficient reason to place an inmate in a restraint device, nor is it sufficient reason
to keep an inmate restrained.251 This was also stated in the U.S. Department of Justice,
Civil Rights Division’s investigation of Black Hawk County Jail:
We find . . .that the Jail at times uses the chair for punitive purposes
when inmate control is not an issue. For example, the chair has been
used to punish inmates who are verbally disrespectful to officers and
inmates who inappropriately call out to other inmates from their cells.
Use of the chair in this manner constitutes excessive force.252
(emphasis added)
247

JEFFERY L. METZNER ET AL., COUNCIL ON PSYCHIATRY AND LAW, THE USE OF RESTRAINT AND
SECLUSION IN CORRECTIONAL MENTAL HEALTH CARE 1 (2006).
248
Fred Cohen, Restraints as Torture? A Consent Decree Is Reopened, 18 CORRECTIONAL L. REP. 65, 78
(2007).
249
Fred Cohen, Isolation in Penal Settings: The Isolation-Restraint Paradigm, 22 WASH. U. J.L. & POL’Y
295, 307 (2006).
250
Id. at 309.
251
Rogers v. Dunn, No. C00-0188-PAZ, 2001 U.S. Dist. LEXIS 22710 (N.D. Iowa Nov. 27, 2001).
252
Letter from Bill Lann Lee, Acting Assistant Att’y General, Civil Rights Div., to Brian S. Quirk, Chair,
Black Hawk County Bd. of Supervisors (Jan. 4, 1999), available at http://www.usdoj.gov/crt/spilt/
documents/bhfind.htm.

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Analysis:  Standards for All Jails

The Federal Bureau of Prisons’ policy governing federal correctional institutions
provides five situations when a prisoner may be placed in restraint, including when the
inmate (1) assaults another individual, (2) destroys government property, (3) attempts
suicide, (4) inflicts injury upon self, or (5) becomes violent or displays signs of imminent
violence.253 The policy provides for the use of four-point restraints, but states the least
restrictive restraint method must be used to control the inmate. Ambulatory restraints,
which allow the inmate to eat, drink, and take care of basic human needs, should be
initially used to restrain the inmate.254
Use of a less restrictive alternative is also implied by Iowa law. The Iowa Administrative
Code states “[f]our/five-point restraints shall be used only when other types of restraints
have proven ineffective.”255 The Ombudsman interprets this language to mean jails are
obligated to consider or employ less restrictive restraints before restraint chairs, beds, and
boards are used on an inmate. This may include placing an inmate in a strip cell,
handcuffs, or ambulatory restraints as an initial step, and only use a restraint chair, bed,
or board when the other restraints have proven ineffective. Further, the Ombudsman
believes the decision to place an inmate in a chair, bed, or board should document how
the less restrictive restraints failed to properly control the inmate.
4. Continuous Monitoring, 15-Minute Checks, and Periodic Reviews
Continuous monitoring of the inmate placed in a restraint chair, board, or bed is essential
and required under Iowa law.256 Monitoring may be done either in-person or via CCTV.
In several cases reviewed by the Ombudsman, monitoring was not apparent, and in at
least one case, did not occur at all. Situations leading to injury or death, such as a
restraint chair tipping over, an inmate choking on vomit, or an inmate suffering from
excited delirium, can occur within minutes.
If video monitoring is going to be used in place of in-person monitoring, the video should
be able to view the inmate’s body and face. Federal regulations on the use of restraints
and seclusion of hospital patients require video and audio monitoring to be in close
proximity to the patient.257 The rationale for this requirement is to ensure staff can
immediately intervene to meet the patient’s needs.258 Preferably, the CCTV camera
would be located in the room where the inmate is held in the restraint device. This would
allow the staff member monitoring the video to be alerted if the inmate begins to have an
obvious physical emergency, such as gagging, seizing, or becomes limp and
253

FEDERAL BUREAU OF PRISONS, PROGRAM STATEMENT P5566.06(1) (2005), http://www.bop.gov/policy/
progstat/5566_06.pdf.
254
PROGRAM STATEMENT P5566.06(9).
255
IOWA ADMIN. CODE r. 201—50.13(2)(f)(2008).
256
Id.
257
Condition of Participation: Patients Rights, 42 C.F.R. §482.13(e)(15)(ii) (2007).
258
Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients’ Rights, 71 Fed. Reg.
71,378, 71,415 (Dec. 8, 2006) (to be codified at 42 C.F.R. pt. 482).

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Ombudsman Investigative Report
 
 
 
unresponsive. An unacceptable camera angle would include viewing the back of a
restraint chair that prevents viewing the inmate’s face and extremities, viewing from a
distance where a monitoring staff member would not be able to observe the details of the
face and extremities, or viewing into a dark room. The Ombudsman has reviewed video
where each of these elements were present.
The Ombudsman reviewed the Federal Bureau of Prisons’ policy on inmate checks,
which states “[s]taff shall check the inmate at least every fifteen minutes, both to ensure
that the restraints are not hampering circulation and for the general welfare of the
inmate.”259 Requiring staff to ensure the restraints are not hampering circulation and
checking the general welfare of the inmate would imply more is expected than only
making sure the inmate is “alive and breathing.”
Iowa law requires personal visual observation of the inmate and the restraint device
application be made at least every 15 minutes. While the law is vague on what “personal
visual observation” requires, the Ombudsman believes logic dictates that jail staff must
check the well-being of the inmate. This would include checking whether the application
of the restraint device is causing adverse medical conditions, such as cutting off
circulation or restricting breathing. Such checks would require up-close, face-to-face
observation of the inmate and each point of the restraint device’s use on each extremity.
This interpretation seems consistent with statements provided by Linn County Sheriff
Don Zeller during an Administrative Rules Review Committee hearing on April 4, 2008.
Sheriff Zeller, as co-chair of the Iowa State Sheriffs and Deputies Association’s Jail
Committee, gave testimony to the legislative committee regarding proposed changes to
the administrative rules governing jail operations. Regarding the 15-minute checks, the
following exchange occurred:
Representative Dave Heaton: “I see that then when you talk about
camera surveillance, you go on to say every 15-minutes that person has
to be observed physically, I mean, face-to-face observation by
personnel in the jail. Is that correct?”
Sheriff Don Zeller: “Let me give you an example. In Linn County Jail,
before anybody would be placed in these types of restraints, that has to
be approved by the shift supervisor who was on duty there. And,
fortunately in our case we have nursing personnel on duty probably
about 16-18 hours a day out of 24 hours a day. So not only is there
things you talk about on camera, but exactly what you said, the
physical – actually going in to look at the individual and checking the

259

PROGRAM STATEMENT P5566.06(10)(d).

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Analysis:  Standards for All Jails

restraints that are placed on there which are the hook and fastener type
apparatus that helps restrain the person.”260
Sheriff Zeller’s testimony to the committee seems consistent with the Iowa
Administrative Code requiring 15-minute visual checks of the prisoner and the restraint
device application, as opposed to only reviewing whether the inmate is alive and
breathing.261 The Ombudsman believes blood circulation checks of the inmate
accompanying the visual checks every 15 minutes are consistent with Iowa law
requirements. While these checks would be best handled by medical personnel,
budgetary constraints may demand such checks be done by correctional staff.
Though jails may only restrain an inmate for the amount of time it takes to alleviate the
condition causing the restraint, Iowa law does not provide for periodic reviews of inmates
after placement to determine if the inmate can be released.262 The Ombudsman has
reviewed several cases where periodic reviews were not done – or were not properly
documented if they were done – though the inmate was left in the restraint device for
several hours. When a jail is not able to provide documentation the inmate needed to
remain in the device, it raises the question whether the restraint device was used for an
excessive amount of time. If this is the case, the jail would violate Iowa law and the
inmate’s constitutional rights against using the restraint as punishment. Failing to
provide evidence showing the continued need for restraint use has lead to adverse court
judgments against jails.263
The Federal Bureau of Prisons requires a review every two hours for inmates placed in
four-point restraints. “The goal of the two-hour reviews is to determine, as soon as
possible, that the inmate has regained self-control and may be placed in lesser
restraints.”264 In addition, removal of the restraints must be considered when the inmate
is temporarily released from the four-point restraints for any reason and the inmate does
not display any disruptive or aggressive behavior.265
Periodic reviews of the inmate are required to determine if the need for the restraint is
necessary. The review should determine if the inmate is still a threat to themselves,
others, or property. Verbal abuse from an inmate alone is not sufficient reason to place

260

Proposed Amendments to Ch. 50 Update Jail Inspection Standards: Hearing on ARC 6641B Before the
Admin. Rules Review Comm., 2008 Leg., 82nd Gen. Assem., 2nd Sess. (Iowa 2008) (Statements of Rep.
Dave Heaton, Member, Admin. Rules Review Comm. and Don Zeller, Linn County Sheriff). Under Iowa
Code § 356.36, the Iowa Department of Corrections must consult with the Iowa State Sheriff’s Association
when drawing up minimum standards for jails.
261
IOWA ADMIN. CODE r. 201—50.13(2)(f)(2) (2008).
262
IOWA ADMIN. CODE r. 201—50.13(2)(f) (2008).
263
See Ogden v. Johnson, No. C00-0034, WL 32172301 (N.D. Iowa Sept. 5, 2002); Rogers v. Dunn, No.
C00-0188-PAZ, 2001 U.S. Dist. LEXIS 22710 (N.D. Iowa Nov. 27, 2001); Sadler v. Young, 325 F.Supp.2d
689, 704 (W.D. Va. 2004).
264
FEDERAL BUREAU OF PRISONS, PROGRAM STATEMENT P5566.06(10)(e) (2005).
265
Id.

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Ombudsman Investigative Report
 
 
 
an inmate in a restraint device and not sufficient reason for its continued use. Periodic
reviews of an inmate should be included in any policy and practice on restraint chair use.
5. Medical Reviews During Restraint Device Use
Iowa law does not require medical reviews of inmates placed in a restraint device, either
during or after its use. The ACA Standards require the health authority be notified to
assess the inmate’s medical and mental health condition.266 The NCCHC requires health
services staff be notified immediately to review the inmate’s health record and initiate
health monitoring.267 The Federal Bureau of Prisons’ policy requires qualified health
personnel to initially assess the inmate when the inmate is placed in four-point
restraints.268
A restraint device can be an effective temporary tool for dealing with violent inmates,
regardless of the underlying cause of their behavior. However, it must be emphasized a
restraint device, whether a chair, board, or bed, is to be used as a temporary means of
preventing the inmate from harming him/herself or others, or from creating a security
threat to the jail. This restricted use is recognized by at least one manufacturer of a
restraint device commonly used in Iowa jails. The five cases reviewed in this report used
a restraint chair manufactured by E.R.C. Inc. The company’s instruction manual, which a
purchaser receives with the chair, provides two warnings on the possible cause of an
inmate’s aggressive behavior and the need for medical review of the chair’s use.269 After
the last instructional “step,” the manual reads:
Caution, violent behavior may mask dangerous medical conditions.
Detainees must be monitored continuously and provided medical
treatment if needed.270 (emphasis found in original).
On the last page of the instruction manual under “Caution,” it states:
Detainees should not be left in the Emergency Restraint Chair for more
than two hours.
This time limit was established to allow for the detainee to calm down
or sober up, and if needed it allows for the correctional office to seek
medical or psychological help for the detainee. This two-hour time

266

PERFORMANCE-BASED STANDARDS FOR ADULT LOCAL DET. FACILITIES 4-ADLF-2B-03 (Am. Corr.
Ass’n, 4th ed. 2004).
267
STANDARDS FOR HEALTH SERVS. IN JAILS, J-I-01, Compliance Indicators (Nat’l Comm’n on Corr.
Health Care 2003).
268
FEDERAL BUREAU OF PRISONS, PROGRAM STATEMENT P5566.06(10)(f).
269
The Ombudsman reviewed two written policy manuals from E.R.C. Inc. The language relies on the
most recent published manual.
270
E.R.C. Inc., EMERGENCY RESTRAINT CHAIR INSTRUCTIONS 11 (Feb. 10, 2001).

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Analysis:  Standards for All Jails

limit may be extended, but only under direct medical supervision
(Doctor/Nurse).271 (emphasis found in original).
The E.R.C. Inc.’s instructional video also mentions the need for medical supervision
three times in the first two minutes of the video, (“This chair is designed to restrain
people comfortably so you can keep them under control and get them medical attention if
they need it.”), and again as a caution at the end:
At this point they need to be monitored continuously in the event they
would have a medical problem. Obviously if the person is out of
control, they might have taken an overdose of alcohol or drugs. They
might be, with this overdose, having heart trouble. They may have
been maced during the arrest process and if so you need to get them
medical treatment.272
In a letter to its customers, dated January 17, 2001, E.R.C. Inc. acknowledged that some
of its customers keep detainees in the chair longer than the company intended, and
stressed its customer should follow the following guideline:
We recommend that detainees not remain in the Emergency Restraint
Chair for more than two hours at a time. This time limit was established to
allow for the detainee to calm down or sober up, and if needed it allows
for the correctional officer to seek medical or physchological (sic) help
for the detainee. This two hour time limit may be extended but only under
direct MEDICAL SUPERVISION (Doctors\Nurses) while performing
range of motion exercises.273 (bold emphasis added).
Tom Hogan, President of E.R.C. Inc. and former Sheriff of Crawford County, Iowa,
provided insight during a media interview behind the policy of the restraint chair he
designs, manufactures, and markets. In response to a news report that his chair was being
used to forcibly feed inmates in Guantanamo Bay, Cuba, Mr. Hogan stated, “[t]he reason
we want them comfortable is because a lot of people who are violent or acting out are not
doing it because of something they’ve done. They have a medical problem, they need to
get medical help, but they need to be restrained while that happens.”274 Mr. Hogan
repeated these sentiments during an interview with the Ombudsman, when he stated the
initial two hours should be used to determine if the inmate’s behavior is caused by a
medical or mental health condition, and to obtain medical services to review the
inmate.275

271

Id. at 12.
Videotape: Emergency Restraint Chair Instructions (E.R.C., Inc.).
273
Letter from Thomas Hogan, President, E.R.C. Inc., to Customer (Jan. 17, 2001).
274
Carol Kloss, Sheriff Designed Chair Now Reportedly Used on Gitmo Inmates, KETV (Omaha, Neb.),
Feb. 12, 2006, available at http://www.ketv.com/news/6986646/detail.html
275
Telephone Interview with Tom Hogan, President, Emergency Restraint Chair, Inc. (June 11, 2008).
272

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Ombudsman Investigative Report
 
 
 
Absent a provision that is contrary to state or federal law, it is important a jail facility
follows the guidelines provided by the manufacturer. Dr. Robert D. Jones, the Medical
and Mental Health Director for the Montana Department of Corrections, stressed the need
to follow a restraint device manufacturer’s guidelines:
It’s very important that the staff understand how to apply the devices. But
also, I think they should be trained with guidelines from the manufacturer.
[Correctional staff] really can be ingenious, but unfortunately that
ingenuity can lead to modifications which can be deadly. So, I think it is
very, very important that the restraint device, whatever it is, is used as
recommended by the manufacturer and that there is training.276
The Ombudsman believes failing to follow a manufacturer’s recommended use can create
liability for the jail as well. With the absence of a comprehensive state or federal law on
restraint device use, a court could use manufacturer guidelines to determine if a jail’s
actions were reasonable in the event an inmate is injured. As discussed earlier in this
report regarding Maricopa County, Arizona, damages from restraint chair injuries can
range up to the tens of millions of dollars.
As part of an NIC teleconference, Michael Thurber, Corrections Director for Lancaster
County, Nebraska, addressed the liability concern as it relates to medical staff being
involved with restraint use. Along with close observation, “the medical protocol from
nurses or physician assistants that might be on duty, EMTs, to be able to help provide the
medical need for that person, you’re going to reduce the liability as much as you can.”277
Dr. Robert D. Jones stated during this teleconference:
In situations where there’s time and there is a planned event, I think it
behooves the medical staff to pull the medical records to review the
individual’s medical history; to look for medication, to anticipate some
of the problems that are there.278
The NIC teleconference provided a “Medical Action Plan” detailing the role of medical
staff in the correctional setting. Medical staff involved in the use of restraints need to:
•
•
•
•

Participate in the review of use of force,
Be prepared,
Know the risks involved, and
Expect the unexpected.279

276

Videotape: Application and Use of Restraints in Custody: Reducing the Risks (Nat’l Inst. of Corr.
Teleconference, Apr. 19, 2000) (on file with author).
277
Id.
278
Id.
279
Id.

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Analysis:  Standards for All Jails

Regardless of jail size or financial constraints, the Ombudsman believes a jail should
follow the recommended standard set forth by several accrediting institutions reviewed in
this report to notify a health authority of the inmate’s placement in a restraint device.
Further, jails should follow the manufacturer’s instructions to seek direct medical
supervision from a doctor or nurse – or other appropriate licensed medical professional –
whenever it uses the restraint chair for extended periods of time lasting over two hours.
The question remains on what is required for “direct medical supervision.” A medical
staff member would need to take vital signs of the inmate, indicating that the supervision
and monitoring needs to be done in-person. The Ombudsman has considered the use of
telemedicine, but does not believe that would be practical in the event medical personnel
needs to conduct physical tests on the inmate. The Ombudsman believes reviews may be
conducted by a doctor, nurse, physician’s assistant, or other appropriate licensed medical
professional.
6. Consultation with A Mental Health Professional
The state of Iowa has faced a dearth of psychiatric personnel, including psychiatrists,
psychologists, and psychiatric nurses and counselors. This can compound the effects on
an inmate and jail staff when an inmate has a possible psychotic episode, and a jail does
not have the medical or mental health expertise to respond to the inmate’s specific needs.
However, an inmate’s mental health needs cannot be ignored, and the potential adverse
effects of placing an inmate with a mental illness in a restraint device carries a greater
risk of physical and psychological repercussions than an inmate with no mental illness.
This is in large part due to the amount of time an inmate with a mental illness spends in
the restraint device compared to other inmates.
The Ombudsman heard repeatedly from corrections personnel that inmates will typically
need to be restrained for between 45 minutes to 1½ hours. However, the restraint device
cases reviewed in this report include incidents lasting 6, 7, 10, 11, and 12 hours. In each
of the extensive use cases, the inmate had a history of mental illness. In some cases, the
jail had no specific documentation or knowledge of the inmate’s mental illness, nor are
most correctional officers licensed to identify a specific mental illness.
A licensed mental health professional is able to identify the signs and symptoms of a
mental illness, the needs of an inmate with the mental illness, and whether the jail facility
can accommodate those needs. While recognizing the need for a mental health
professional’s services, actually contracting with such a person raises further problems,
such as who qualifies as a “mental health professional,” when should the jail contact a
mental health professional, and how would a jail obtain those services.
The Ombudsman borrows the definition of “mental health professional” from the
NCCHC, which includes psychiatrists, psychologists, psychiatric social workers,
psychiatric nurses, “and others who by virtue of their education, credentials, and
experience are permitted by law to evaluate and care for the mental health needs of
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Ombudsman Investigative Report
 
 
 
patients.”280 If the jail does not currently have a contact for mental health services, it
should work with the county Central Point of Coordination (CPC) in its jurisdiction to
locate potential sources that can offer such services, which may require looking outside
the county.
The second issue relates to when a jail should contact a mental health professional. The
Ombudsman believes any time an inmate who needs to be placed in restraints has a
suspected or known mental illness, jail staff should contact a mental health professional.
Staff’s awareness of a known or suspected mental illness can arise from the intake
screening form, subsequent statements from the inmate regarding mental health history,
and observations of the inmate that shows signs of mental illness. This identification
would not require staff to diagnose a specific mental illness.
Staff may also suspect a mental illness, where other signs do not exist, in the event an
inmate needs to be held in a restraint device for excessive periods of time. According to
Management and Supervision of Jail Inmates with Mental Disorders, mental health
examinations should be required for any inmate remaining in restraints longer than a few
hours. “If in that time the inmate has not calmed down enough to be released to a normal
cell situation, questions may arise as to whether mental illness lies at the root of the
inmate’s continuing recalcitrant behavior.”281 Consistent with this assertion, the
Ombudsman believes the cases reviewed in this report that required restraints for six or
more hours should have triggered concerns about the mental health of the inmate in
restraints.
The third issue involves the manner of services the mental health professional must
provide for an inmate placed in restraints. Unlike a medical staff member, the
Ombudsman does not believe the mental health professional needs to provide in-person
physical examination of the inmate. Such reviews of the inmate can be done remotely.
The Ombudsman spoke to Christine Krause, Director of Behavioral Health Services at
280

STANDARDS FOR HEALTH SERVS. IN JAILS J-E-05, Definitions (Nat’l Comm’n on Corr. Health Care
2003). The Settlement Agreement entered into by Shelby County, Tennessee, as a result of a CRIPA
investigation provided definitions for medical and mental health personnel. It defined a “Qualified Mental
Health Professional” as a) an individual with a minimum of masters-level education and training in
psychiatry, psychology, counseling, social work or psychiatric nursing licensed in the state to deliver those
services, or b) a registered nurse with a bachelor’s degree in nursing with a minimum of two years
psychiatric experience, or a registered nurse with a minimum of five years psychiatric experience.
Settlement Agreement Between the United States and Shelby County, Tennessee (Aug. 15, 2002),
available at http://www.usdoj.gov/ crt/split/documents/shelby_settleagmt.htm. A mental health
professional must be consulted before any non-routine use of restraints on an inmate with a diagnosis of
mental illness.
The Settlement Agreement defined “Mental Health Staff,” who must authorize and supervise use of the
restraint chair involving inmates with mental illnesses, as “individuals with a minimum of a bachelor’s
degree and two years of experience providing mental health services.” Id.
281
MARIN DRAPKIN ET AL., MANAGEMENT AND SUPERVISION OF JAIL INMATES WITH MENTAL DISORDERS
2-38 (2003). According to the publication, author Marin Drapkin has been involved with jail issues and jail
officer training for 23 years. He is also the director of the Jail division of the Gallagher-Westfall Group,
Inc., a private consulting group specializing in liability risk management for law enforcement agencies.

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Analysis:  Standards for All Jails

Mary Greeley Hospital in Ames, Iowa, who said her department relies on telemedicine
technology that allows a psychiatrist 60 miles away to evaluate a patient at the
hospital.282 She quoted her cost to install the telemedicine equipment at between $500 to
$750.
7. Written and Video Documentation
Iowa law directs that “[a]ll decisions and actions shall be documented” when a jail inmate
is placed in four- and five-point restraints.283 This would include jail staff decisions to
initially place an inmate in such restraints, observations by medical personnel,
observations from the mandatory 15-minutes checks, and decisions whether to release the
inmate or continue the restraint use based on the inmate’s behavior and actions. The
documentation should contain sufficient information to inform a supervisor or other
reviewer what the staff member observed and the basis for any decisions made regarding
restraint use.
While not required under Iowa law, many county jails videotape use of force incidents,
including restraint device placement and use. However, this was not done in each case
reviewed by the Ombudsman, and one jail stated it recorded over the video documenting
the restraint chair before it knew of the Ombudsman’s interest in the incident. The
Federal Bureau of Prisons requires video documentation of each use of force incident,
including the use of a restraint device, which is reviewed by the warden and the regional
director.284 Similarly, Iowa Department of Corrections requires audio-visual recording of
all facets of the use of force incident and the recording must be clearly marked and stored
as evidence.285
The issue of videotaping use of force incidents was addressed during the NIC
teleconference on reducing the risks of restraint application and use. The teleconference
provided a compelling rationale for videotaping which included administrative review
and liability reasons. The following is an excerpt from the teleconference, presented by
Larry Fischer, Jail Administrator at Binghamton, N.Y.:
Videotaping demonstrates a good faith interest on the part of the
agency or organization, especially in the event of a planned force
situation. You’re documenting the restraint. You’re documenting the
position of the individual both before and during the time they’re being
restrained and subsequently. You’re documenting the actions you have
taken to prevent further injury to that individual.

282

Telephone interview with Christine Krause, Dir. of Behavioral Health Servs., Mary Greeley Med.
Clinic, (Apr. 18, 2008).
283
IOWA ADMIN. CODE r. 201—50.13(2)(f)(4) (2008).
284
FEDERAL BUREAU OF PRISONS, PROGRAM STATEMENT P5566.06(14)(c) (2005).
285
STATE OF IOWA DEP’T. OF CORR. POLICY AND PROCEDURES IO-SC-08(IV)(E) (2008).

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Ombudsman Investigative Report
 
 
 
Videotaping is also a useful tool for review, that you can look back
through the history of your organization, history of incidents in the
organization, and see that you have consistently managed the restraint
issue properly. That you’re consistently managed the planned uses of
force properly. You can also highlight areas of training that you need
additional scope or that you need additional concentration on.
Our experience has been that the videotaping of uses of force reduce
lawsuits from the inmates. It is very, very hard for an inmate to claim
they were beaten when the videotape clearly shows that they were
not.286
Videotaping use of force incidents should document all circumstances demanding
restraint device use. This includes initial placement, duration of use, and removal of the
inmate. Such documentation allows for jail supervisors to review the procedures used by
staff to place, monitor, and release the inmate and review any missed procedures with
staff. Close video monitoring allows staff who are not utilizing direct continuous
monitoring to view the inmate from a remote location, and respond immediately if the
inmate shows signs of an emergency or injury.287 Most importantly for the jail, video
monitoring and documentation can rebut accusations of physical abuse or procedural
misconduct raised by an inmate, and may provide evidence the restraint was required due
to the inmate’s behavior.
The Ombudsman believes Iowa jails should retain copies of each restraint device use
videos for at least two years, which is the statute of limitations for tort actions in Iowa.288
8. Time Limits
The Ombudsman has considered what, if any, time limits should be imposed on restraint
device use. State and federal courts have refused to designate specific time limits, and
Iowa law states only, “[t]he inmate will be restrained only for the amount of time it takes

286

Videotape: Application and Use of Restraints in Custody: Reducing the Risks (Nat’l Inst. of Corr.
Teleconference, Apr. 19, 2000).
287
“Many systems require that a cell extraction leading to restraint, as well as the actual application, be
videotaped. Such videos (and I have seen hundreds) are invaluable monitoring and training resources.”
Cohen, supra, note 250, at 307.
288
There seems to be some dispute whether a state’s statute of limitations applies to § 1983 federal actions,
or whether a four-year statute of limitations applies as a result of Congress passing 28 U.S.C. § 1658. Prior
to § 1658 being passed in 1991, the U.S. Supreme Court held a state’s statute of limitations for torts applied
to § 1983 actions since the original 1871 federal law did not provide its own statute of limitation. Wilson v.
Garcia, 471 U.S. 261, 275-76 (1985). The Eighth Circuit Court of Appeals previously held Iowa’s two
year statute of limitations for torts applies for § 1983 actions arising in Iowa. Wycoff v. Menke, 773 F.2d
983, 984 (8th Cir. 1985). However, an Iowa federal district court case pointed out the Eighth Circuit has
not reviewed this issue since Congress passed § 1685, and the issue may still be unsettled. Williams v.
Hawkeye Comm. Coll., 494 F.Supp.2d 1032, 1039 (N.D. Iowa 2007).

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Analysis:  Standards for All Jails

to alleviate the condition causing the restraint.”289 The Ombudsman also could not locate
any guidelines on time limits in correctional guidelines or medical and mental health
treatises. The only source for time limits the Ombudsman could locate was E.R.C. Inc.’s
policy instructing restraint chair use no longer than ten hours total, though this does not
appear to be based on any medical or scientific research. As such, the Ombudsman
declines to recommend any finite or static time limit on restraint chair use. Time limits
must be determined on a case-by-case basis using the inmate’s immediate threat to self or
others as the determining factor. This is a process required by Iowa law and enforced by
federal case law within and outside of Iowa. As mentioned in a previous section dealing
with periodic reviews, this report reviewed several federal court cases that have held an
inmate’s continued restraint must be accompanied by evidence the inmate continued to be
a threat to himself or others and provide documentation of reviews and evaluations.290
With no set time limits, the Ombudsman places greater emphasis on the need to have
timely medical and mental health reviews of inmates placed in restraints. It is important
to have at least direct, in-person medical reviews of inmates placed in a restraint chair
and held longer than two hours, and repeat the in-person medical review every two hours
thereafter. Extended periods of restraint device use can lead to circumstances similar to
those that arose in the Utah prison, where an inmate died from blood clots after a
prolonged stay in the restraint chair. That inmate was restrained for 16 hours. Several
detainees who contacted the Ombudsman were kept in restraint chairs for at least ten
hours with no in-person physical assessment of the inmate.

289

IOWA ADMIN. CODE r. 321—50.13(2)(f) (2008).
Ogden v. Johnson, No. C00-0034, WL 32172301 (N.D. Iowa Sept. 5, 2002); Rogers v. Dunn, No. C000188-PAZ, 2001 U.S. Dist. LEXIS 22710 (N.D. Iowa Nov. 27, 2001); Sadler v. Young, 325 F.Supp.2d 689,
704 (W.D. Va. 2004).
290

67

 
  

 

General Recommendations for Jails
The Ombudsman makes the following recommendations regarding inmate
screening and restraint device use for all jail facilities:
1. A jail should incorporate a health-authority-approved mental health screen
to be used on all newly admitted inmates soon after entering the jail. A
screen should possess the following qualities:
•
•
•
•

The screen has been vetted and approved by a mental health
organization for its accuracy in identifying mental health
conditions;
The screen is brief and easy to administer;
Limited training is needed for a screening officer to use the form;
The screen notifies an officer when to refer an inmate for further
mental health assessment based on the responses of the inmate.

2. Inmates who screen positive for a mental illness must receive further
assessment by a mental health professional. Assessments for referred
inmates may require a jail to enter a formal relationship with a mental
health professional who can become knowledgeable of the jail’s services and
limitations, and can accurately determine if the inmate needs to be
transferred to another facility.
3. Restraint devices must only be used when an inmate is an imminent risk to
the inmate’s self or others, or is jeopardizing jail security. Verbal abuse
alone is not sufficient reason to place an inmate in a restraint device. Use of
a restraint device should cease immediately when the condition causing the
need for the restraint is no longer present. Jail policy should detail the
conditions when an inmate may be restrained and when an inmate should be
released.
4. When the circumstances allow for it, jail staff must consider using less
restrictive alternatives to restraint devices, which ensures the safety of the
inmate and others. When a less restrictive alternative is not used, jail policy
should require staff to report what alternatives were considered and the
reason for not employing them.
5. When a jail uses video for continuous monitoring, the video must provide a
clear and accurate view of the inmate’s body, including torso, extremities,
and face. Staff must be able to identify emergency conditions on the video
immediately when they arise.
6. Personal, visual observation of the inmate and the restraint application every
15 minutes is required under Iowa law. This should include checking the
inmate up-close and face-to-face for adverse medical conditions.

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General Recommendations for Jails

7. Jails should conduct periodic reviews of the inmate for the purpose of
determining whether the inmate can be released from the restraint device.
After each review, staff should document whether the inmate was released
and if not, the reason for keeping the inmate in the restraint device. Periodic
reviews should be conducted at least every hour.
8. A jail’s restraint chair policy should, as a minimum standard, incorporate
the recommended procedures for use found in the manufacturer’s
instruction manual. That policy should also include recommended medical
reviews of the inmate placed in the restraint device.
9. Absent specific manufacturer recommendations, a jail should incorporate
medical review procedures in its policy that require direct, in-person medical
reviews of a restrained inmate by a physician, nurse, physician’s assistant,
nurse practitioner, or other appropriate licensed medical professional.
10. The person conducting the medical reviews should be a medical professional
who is employed or contracted by the jail for the purpose of conducting
medical reviews and assessments of the inmates. Medical reviews of an
inmate should not be conducted by a person employed as an officer or
administrator of the jail, even if the officer or administrator is a licensed
medical professional.
11. A jail should incorporate in its policy a requirement to contact a mental
health professional whenever an inmate with a known or suspected mental
health condition is placed in a restraint device. In the event any inmate is
required to be held for longer than a few hours, a mental health professional
should be contacted. To accommodate facilities that may not have a mental
health professional in their immediate area, mental health reviews of an
inmate may be conducted by telemedicine, enabling the mental health
professional to view and talk to the inmate through video from an offgrounds location.
12. Jail staff must document all decisions and actions when an inmate is placed
in four- and five-point restraints. This includes the reason the inmate was
placed in restraints, who ordered the inmate to be placed in the restraints,
observations during 15-minute checks, observations of medical reviews
conducted on the inmate, and the decision to release the inmate or keep the
inmate in restraints after periodic reviews. Such documentation should be as
detailed as possible.
13. All facets of restraint device use should be videotaped, including placement,
duration of use, and release. Jails should retain video copies of restraint
device use for a period of at least two years.
69

 
  

 

Jefferson County Jail – Findings, Conclusions, and Recommendations
A. Findings of Fact
Sheriff Jerry R. Droz and Jail Administrator Mike Simons operate the Jefferson County
Jail. It is a 32-bed jail, housing an average of 20 inmates daily. The jail purchased the
Emergency Restraint Chair in December 1996 from E.R.C. Inc., an Iowa company based
in Denison.291 The jail operates from one of the more detailed written policies on the
maintenance and use of the restraint chair reviewed by the Ombudsman. Gordan Plepla,
a jail consultant with whom the jail contracted for services, drafted the restraint chair
policy. It is not known by Administrator Simons what sources the drafter relied on for
the restraint chair policy language or whether he consulted with any medical or mental
health professionals.292
According to Administrator Simons, the restraint chair is rarely used by the jail.
However, during 2007, the jail used the restraint chair on five separate occasions on
inmate T.H.293 T.H. was housed at the jail for pending criminal charges that arose from a
bank robbery. He was first placed in the restraint chair approximately two months after
his admittance to the jail when he took aggressive actions against jail staff and became a
threat to himself or others, though he had been argumentative with staff since his arrival.
The Ombudsman requested and received the security tapes relating to T.H.’s behavior
prior to his placement in the restraint chair and his conduct while in the chair. The
Ombudsman also reviewed the jail’s medical sheets on T.H., incident reports, and facility
logs for each occasion the restraint chair was used in April 2007.
1. Intake Screening and Medication
T.H. stated in his initial contact with this office that he suffered from bipolar disorder.
During early conversations with Sheriff Droz and Administrator Simons, these officials
indicated to the Ombudsman they were aware of some mental health issues with T.H.,
based on their extensive history dealing with him, but did not know his specific diagnosis
or what treatment he was receiving. Intake screening forms also show T.H. reported he
was under a doctor’s care for mental health issues. Sheriff Droz told the Ombudsman it
was his experience dealing with T.H. that when T.H. was on medication, he was very
easy to deal with and talk to, but when he was off medication he turned into a different
person.
While at the jail, T.H. was listed as receiving five different medications. After reviewing
T.H.’s medical sheets, the Ombudsman noted a pattern of T.H. refusing to accept a
medication called carbamazepine, which the jail’s medical log noted as being for
291

The President of E.R.C. Inc. is Tom Hogan, Sheriff of Crawford County, Iowa.
Mr. Plepla drafted Jefferson County Jail’s policy from his out-of-state based consulting firm and has
since retired from jail consultation.
293
For purposes of this report, the Ombudsman is reviewing placement in the restraint chair on the four
occasions before our office was contacted by T.H.
292

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Jefferson County Jail:  Findings of Fact

“seizures.” Based on his own research, the Ombudsman learned this drug had a lesserknown role of acting as a mood stabilizer for the purpose of treating bipolar disorder.
When asked about the purpose of the medication, Administrator Simons did not know
who prescribed it or whether its intended purpose was for seizure control or for mental
health issues. Citing Sheriff Droz’s experience with T.H. as being difficult when off his
medication, coupled with T.H.’s refusal to take carbamazepine in the days and weeks
leading up to his placement in the restraint chair, the Ombudsman requested that
Administrator Simons find out who prescribed the medications and why. The
Ombudsman expressed his concern about the different reaction the jail could expect when
T.H. refused to take his medication. He could either be expected to suffer a physical
seizure or a psychotic episode.
The jail located the prescribing doctor at University of Iowa Hospitals and Clinics
(UIHC), and with help from the Ombudsman, was able to obtain a medication report
from the hospital.294 The medication report stated T.H. has “a history of bipolar disorder,
antisocial and paranoid personality disorder.” T.H. was prescribed the carbamazepine
and Haldol for these disorders. The Ombudsman also learned T.H. had been hospitalized
at UIHC for three weeks in December 2006 for a manic episode, two months prior to his
arrest in February 2007.
According to a National Institute of Mental Health article published in the periodical
Mental Health News, “bipolar disorder” is a brain disorder that causes unusual shifts in a
person’s mood, energy, and ability to function.295 Approximately 5.7 million Americans
18 and older have bipolar disorder. It causes dramatic mood swings – from overly “high”
and/or irritable to sad and hopeless. The periods of highs and lows are referred to as
episodes of mania and depression. The signs and symptoms of mania (or a manic
episode) include:
•
•
•
•
•
•

increased energy, activity, and restlessness;
excessively high, overly good, euphoric mood;
extreme irritability, racing thoughts and talking very fast, jumping on one idea
to another;
little sleep needed;
unrealistic beliefs in one’s abilities and powers;
poor judgment;

294

Administrator Simons reported the UIHC refused to provide the records due to HIPAA concerns. The
Ombudsman contacted the hospital’s legal counsel, who identified a statutory provision allowing permitted
disclosures from a covered entity to a correctional institution that has lawful custody of an individual and
that institution represents the information is needed for the health care of the individual. Public Welfare &
Human Services, 45 C.F.R. §164.512(k)(5)(2007).
295
The National Institute of Mental Health, Understanding and Treating Bipolar Disorder, MENTAL
HEALTH NEWS, Fall 2007, at 1.

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Ombudsman Investigative Report
 
 
 
• provocative, intrusive, or aggressive behavior, and denial that anything is
wrong.296
According to an article by Dr. Richard H. McCarthy, mania causes highs of elevated
energy mood and extreme pleasure seeking. This stands in sharp contrast to the lows and
misery of depression and its complete lack of energy, which is part of the cycle with
bipolar disorder. One problem with mania patients is they typically feel good when they
are ill and, therefore, it is hard to get someone in a mania episode help if they will feel
less good after treatment.297
Administrator Simons provided the Ombudsman with the medical questionnaire T.H.
completed upon his arrival at the jail and the booking questions contained on the jail’s
computer. The questionnaire is a 27-question sheet asking about medical and mental
health history, to which an inmate answers “yes” or “no.” On this hard-copy
questionnaire, T.H. answered “yes” to whether he was recently hospitalized, “yes” to
whether he was under a doctor’s care, and “yes” to whether he was on medications. The
computer’s follow-up booking questions and responses contained the following
information:
Question: Have you recently been hospitalized?
Answer: Yes, in December.
Question: Are you under a Drs (sic) Care?
Answer: Yes, for mental health.
Question: Are you on any prescription medications?
Answer: Yes, but doesn't know the names of them.298
The questionnaire and follow-up questions encompass the intake and screening process at
Jefferson County Jail. The jail has no system in place where an inmate that answers
positively about being recently hospitalized, reports a mental illness, or shows signs or
symptoms of mental illness is referred to a mental health professional. As such, after
reporting he had been recently hospitalized and was under a doctor’s care for mental
health, T.H. was not referred to or assessed by a mental health professional. A mental
health professional did not have an opportunity to determine T.H.’s condition or whether
the jail had the facilities or expertise to care for his mental health needs.
The Ombudsman noticed on the UIHC medication sheet obtained from the hospital that
the prescribing physician ordered a prescription of Haldol, along with the carbamazepine.
The Ombudsman found no mention of a Haldol dosage in the materials previously
296

Id.
Richard H. McCarthy, Working with Medication: So Many Medications for Bipolar Disorder – A Good
Problem to Have, MENTAL HEALTH NEWS, Fall 2007, at 1, 34.
298
E-mail from Capt. Michael S. Simons, Jail Adm’r, Jefferson County Jail, to Andy Teas, Assistant
Ombudsman, Iowa Citizens’ Aide/Ombudsman (Aug. 3, 2007, 11:09 CST) (on file with author).
297

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Jefferson County Jail:  Findings of Fact

provided by the jail. Haldol is an antipsychotic drug commonly prescribed to treat
acutely agitated patients.299 The Ombudsman contacted Martin’s Pharmacy where the
prescription was ordered. According to the pharmacist, the Haldol was ordered by the
UIHC doctor, but was never filled by the jail. In fact, when the Ombudsman contacted
the pharmacy in January 2008, the Haldol prescription was still on hold, eight months
after it was ordered by the doctor. According to the pharmacist, the jail will occasionally
not fill a prescription if an inmate is expected to be released soon, such as on bail.
When the Ombudsman contacted Administrator Simons about the Haldol, Mr. Simons
had no prior knowledge of a Haldol prescription and was not able to respond why the
prescription was not filled by the jail. The Ombudsman noted to Mr. Simons the Haldol
prescription was ordered one month before T.H. was required to be placed in restraints.
After consulting with his staff, Mr. Simons reported that T.H. had been refusing to take
Haldol before the doctor reordered the prescription, so it was never requested from the
pharmacy.
Pursuant to an earlier request for T.H.’s medical records, the jail provided its medical
sheets which list the dates, times, and medications offered to T.H., as well as whether he
accepted or refused the medication. These sheets indicated when T.H. was offered
carbamazepine and when he refused to accept it. However, there is no reference to
Haldol or its generic in any of the materials the jail provided. As a result, the
Ombudsman cannot substantiate whether there was even an offer of Haldol for T.H. to
refuse.
2. Treatment Received Prior to Restraint Chair Use
During his entire incarceration at Jefferson County Jail, T.H. never saw a psychiatrist or
other mental health professional until his civil commitment that occurred more than seven
months after entering the jail. As mentioned above, Jefferson County Jail currently has
no contract for psychiatric or mental health services. In cases where an inmate
specifically requests mental health treatment, the inmate will first see a local medical
doctor. This is true also for inmates who exhibit “unusual behavior,”300 or attempt to hurt
themselves or others. Only in cases when a medical doctor makes a referral will the jail
contact the local psychiatrist to set up an appointment.301 Otherwise, the jail will only
contact a psychiatrist if the inmate has a standing appointment.

299

http://www.rxlist.com/cgi/generic/haloper.htm (last visited Oct. 30, 2008). Haldol is the brand name for
haloperidol.
300
In response to the Ombudsman’s question under what circumstances the jail contact the psychiatrist,
Administrator Simons replied, in part, “if an inmate exhibits unusual behavior, attempts to hurt themselves
or others.” Responses to Ombudsman Questions (Feb. 26, 2008).
301
The Ombudsman spoke to Clinical Director Marjorie Gerber from the Community Mental Health Center
in Fairfield. Ms. Gerber stated she saw inmates a couple of times each month in the office, but was not
aware whether the jail initiated contact, or if it was based on medical doctors making a referral.

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Ombudsman Investigative Report
 
 
 
While T.H. was incarcerated, the jail received a series of warning signs that T.H. had a
potential mental illness. He informed the jail during admission that he was under a
doctor’s care for mental health issues and was recently hospitalized, he was placed in
restraints on five separate occasions for violent behavior, he started numerous food and
water strikes that resulted in the jail consulting with medical doctors, he incurred 13
criminal charges for assaults on correctional officers, and, according to Mr. Simons, T.H.
was “highly agitated most of a 24-hour period.”302 A review of the jail’s records do not
indicate T.H. was ever referred to a medical doctor due to an existing threat of harm to
himself or others, or for any “unusual behavior.”
3. Immediate Facts and Circumstances of Restraint Chair Use
The Ombudsman reviewed security tapes and staff reports on each of the incidents in
which T.H. was placed in the restraint chair during the April 2007 timeframe. While
there were some issues regarding the poor quality of the tapes, and not being able to
locate some of them immediately upon request, the jail generally executed a good policy
of documentation during the restraint chair use.
a. April 17, 2007
T.H. was first placed in the restraint chair on April 17, 2007. Prior to his placement, T.H.
was allegedly disobeying orders to return his food tray for meals that were provided an
hour earlier. According to incident reports, a female officer entered T.H.’s cell to retrieve
the tray that T.H. refused to give her. T.H. took an aggressive stance when the officer
took the tray and said “[c]ome on bitch, take it away from me.”303 Another officer
entered the cell and physically forced T.H. to his bed, face down. Four officers were
used to place T.H. in the restraint chair within the cell. According to the reports, T.H.
continued to resist and spat pieces of apple while officers struggled to place the 63-year
old, 160-pound inmate in the restraint chair.
After T.H. was restrained, officers set the mobile restraint chair, advertised by its
manufacturer as a “padded cell on wheels,” in the jail’s day room.304 The day room
contained a closed-circuit camera that enabled officers to monitor T.H. from the jail’s
control room. The security tape from the control room on this occasion was in such bad
condition it provided no relevant information to this investigation, though officer reports
indicate the CCTV monitor was working properly during this time. T.H. remained in the
restraint chair on this occasion for two hours before he was released.

302

Letter from Capt. Michael S. Simons, Jail Adm’r, Jefferson County Jail, to Andy Teas, Assistant
Ombudsman, Iowa Citizens’ Aide/Ombudsman (Feb. 26, 2008) (on file with author).
303
Resistance Report from Sgt. Phil Stocks (Apr. 17, 2007).
304
http://www.restraintchair.com/ (last visited Oct. 30, 2008).

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Jefferson County Jail:  Findings of Fact

b. April 23, 2007
On April 23, 2007, T.H. placed wet paper on the window of his cell, blocking the security
camera’s view and causing what the jail considered a safety and security issue. When
asked over the intercom to remove the paper from the window, T.H. refused. A
correctional officer contacted Administrator Simons about how to handle the situation.
Administrator Simons interpreted the situation as threatening safety and security and
directed T.H. to be placed in the restraint chair. T.H. previously charged at an officer
earlier in the evening, so additional officers were called to assist. Before a cell entry was
accomplished, T.H. removed the paper from the window, but when an officer directed
him to hand the papers through a meal slot, he refused. Three officers then entered
T.H.’s cell and placed him in the restraint chair.
During his placement in the restraint chair at approximately 5:00 a.m., T.H. cursed and
threatened the officers and tried to grab officers’ hands during the 15-minute circulation
checks. Even after an hour in the chair, T.H. threatened to one officer that he was going
to “knock your teeth out, kick you in the nuts, and chop you in the throat.”305 T.H.
remained hostile for the next six hours.
After the first two hours, officers contacted the Jefferson County Hospital and spoke to
“Mr. Harl.” The officers reported T.H.’s disposition as still being hostile. Mr. Harl
approved two more hours in the restraint chair. At 9:02 a.m., officers spoke to Dr. Buck
and explained T.H. was still threatening staff and still very angry.306 Dr. Buck said it
would be all right to keep T.H. in the restraint chair for another two hours. T.H. was
eventually removed from the restraint chair at 11:08 a.m., approximately six hours after
the initial placement.
c. April 24, 2007
The day after being released from the restraint chair, T.H. instigated events that, again,
would lead to his placement in the restraints. At 7:16 p.m., T.H. refused to give his meal
tray to a correctional officer. Earlier in the evening, he made threats against a female
correctional officer, saying “you want to f--k with me, you’re going to get it girl.”307
When T.H. refused to hand over his meal tray, three correctional officers entered the cell,
and T.H. immediately laid on the ground. When the tray was picked up, an officer told
T.H. he would not be placed in the restraint chair. After saying this, T.H. jumped to his
feet and took an aggressive stance against the officers, making a fist. The three officers
then secured T.H. and placed him in the restraint chair.

305

Incident Report from C.O. Gabe Tramel (Apr. 23, 2007).
This information was provided on a non-descript printout provided by the jail, listing the dates and times
officer contacted medical doctors while T.H. was restrained. This document states “I called JCH ER and
spoke to Dr. Buck. The Ombudsman learned Dr. Buck works in the Fairfield Clinic, not the Jefferson
County Hospital’s emergency room.
307
Incident Report from C.O. Kayleen S. Martin (Apr. 24, 2007).
306

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Ombudsman Investigative Report
 
 
 
T.H. remained in the restraint chair for the next 12 hours. Jail logs show officers checked
T.H.’s circulation every 15 minutes. During his stay in the restraint chair, T.H. remained
hostile, making threats against officers and trying to grab their hands when they checked
on him. At approximate 3:00 a.m., eight hours after being placed in the restraint chair,
T.H. yelled at officers,
“I’m going to hurt you motherf----rs. I’m in here because I wanted to
be in here, you didn’t put me in this chair, don’t f--king touch me. I’m
gonna hurt you motherf----r.”308
Soon after, when a female officer checked his circulation, T.H. said, “If you touch me
whore I’m going to f--king hurt you.”309
Jail staff contacted the Jefferson County Hospital every two hours and spoke to the
emergency room doctor on call to seek approval for extended use of the restraint chair.
Staff would describe T.H.’s disposition over the phone, and approval for extended use
was granted each time. Throughout the jail’s use of the restraint chair, staff spoke to Dr.
Pool, Dr. Trigger, and Dr. Pandit. When T.H. stated at 7:00 a.m. he would fight the
correctional officers if he was released, staff contacted Dr. Pandit to approve extended
use for the restraint chair. T.H. had been in the restraint chair for 12 hours by this time.
Dr. Pandit approved an additional two hours, but said she had concerns if he were
restrained any longer than that.
Despite Dr. Pandit’s approval for an additional two hours, Administrator Simons directed
staff to remove T.H. from the restraints. T.H. was removed without incident.
d. April 30, 2007
On April 30, at approximately 12:30 a.m., T.H. began beating his cell window with his
suicide smock. Three correctional officers entered his cell to retrieve the suicide smock
and blanket and transferred him to a detox cell. During this transfer, T.H. spat on officers
and attempted to head-butt them. Officers handcuffed T.H. behind his back and placed a
foam helmet on his head. T.H. was first placed in an isolation room, where he was free to
move around with the restriction of his hands being cuffed. After 2½ hours, T.H. was
able to pry off his foam helmet. T.H. was placed in the restraint chair at 4:30 a.m. when
he threatened, spat on, and attempted to kick officers who were adjusting the foam
helmet.
T.H. remained in the restraint chair for 11 hours. Jail staff contacted the Jefferson
County Hospital every two hours and spoke to Dr. Larson and Dr. Studer on separate
occasions. Jail staff checked T.H.’s circulation every 15 minutes and documented T.H.’s
aggressive behavior while in the restraint chair, including using profanity, making verbal
308
309

Incident Report from C.O. Sandi Ropp (Apr. 25, 2007).
Id.

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Jefferson County Jail:  Findings of Fact

threats against the officers, and trying to grab their hands. Though there was no
documentation of T.H.’s state of agitation when he was let out at 3:15 p.m., Mr. Simons
reported he took this into consideration, along with safety concerns for T.H. and staff,
when he approved the release.
4. Doctor Approval for Continued Use
After reviewing Jefferson County Jail’s incident reports, security tapes, and medical
sheets, the Ombudsman contacted the medical facilities involved in approving the
extended use of the restraint chair on T.H. The jail has a contract with the Fairfield
Clinic, P.C. (Clinic) for medical services. When the Clinic was not available for approval
of the chair’s use, the jail’s telephone calls were transferred to the Jefferson County
Hospital (Hospital) emergency room. During the course of T.H.’s various restraints, four
of the medical staff the jail contacted were with the Clinic – doctors Buck, Poole, and
Larson, and PA Harl – while three were from the Hospital – doctors Larson, Studer, and
Pandit.
Each time the jail contacted the Hospital, the jail was not consulting with doctors directly
employed by the Hospital. The Hospital contracts with Acute Care, Inc. (Acute Care) for
its emergency room doctors. Acute Care is a private corporation based out of Ankeny,
Iowa. According to its website, Acute Care provides emergency medical physicians to
60 hospitals throughout the United States.310 The Ombudsman contacted and received
permission from the Acute Care and the Clinic administrators to question the doctors
involved in approving extended use of the restraint chair.
The Ombudsman sent each medical professional the same set of questions regarding:
•
•
•
•
•

the doctor’s experience with restraint devices,
the doctor’s knowledge of the restraint chair used by Jefferson County,
general medical concerns the doctor had about restraint chairs,
whether an inmate’s mental health history would have any effect on restraint
approval, and
whether the doctor believed over-the-phone consultation was the best way to
evaluate an inmate for possible medical concerns.

The Ombudsman received a variety of responses. Though the Ombudsman sent each
medical personnel an individually addressed letter, he received from the Clinic a single
response signed by Doctors Buck, Poole, and Larson, but written in the first person. In
response to what experience the doctors had with restraint devices, the Clinic replied it
has a “papoose board” it occasionally uses when repairing a young child’s laceration.
The Clinic did not have a working knowledge of the restraint chair used by the jail. The
only information the Clinic requested from the jail was whether the restraint was needed
for the inmate’s safety or those around him. The Clinic did not indicate to the
310

http://www.acutecare.com/aboutus.php (last visited Oct. 30, 2008).

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Ombudsman Investigative Report
 
 
 
Ombudsman it had any medical concerns for T.H. while in the restraint chair or whether
those concerns could be addressed over the phone.
The Ombudsman received individual responses from the three Acute Care physicians
contracted by the Hospital. No doctor was familiar with the restraint chair used by
Jefferson County Jail. One physician replied he felt comfortable giving approval over the
phone, while a second felt it was “never ideal,” stating face-to-face evaluations by a
trained health care provider who is responsible for the well-being of the inmates is the
ideal.311 During a phone conversation, a third physician told the Ombudsman she did not
feel comfortable giving approval over the phone compared to in-person observation, but
she later refused to respond in writing to any of the Ombudsman’s questions, stating
“[m]y knowledge of use of restraint devices in correctional facilities is by no means
expert opinion. Hence, I refrain from commenting on the issue as my experience is based
more in ED than elsewhere.”312
Due to the variety and inconclusiveness of responses received, the Ombudsman contacted
the Iowa Board of Medicine (IBOM) as the professional licensing and disciplinary
agency in the state to determine to what extent physicians can and should be used for
restraint chair approval. The Ombudsman presented the facts as they pertained to
Jefferson County, absent any names or locations involved. The Ombudsman sought the
opinion of the IBOM on the following areas:
•

Whether evaluating adverse medical symptoms associated with extended
restraint chair use could be effectively identified and evaluated by a medical
professional over the phone.

•

Whether a medical professional could accurately identify a potential mental
illness over the phone.

•

Whether medical professional should be placed in the position of granting
extended use of the restraint chair that is used in a correctional setting.

The IBOM replied that it “does not possess the necessary medical expertise regarding
proper procedures for medical approval of the use of restraint devices in the jail setting,”
and declined to provide any guidance on the matter.313

311

Letter from Dr. Studer to Andy Teas, Assistant Ombudsman, Iowa Citizens’ Aide/Ombudsman
(received Nov. 14, 2007) (on file with author); Letter from Dr. Brandon Trigger to Andy Teas, Assistant
Ombudsman, Iowa Citizens’ Aide/Ombudsman (Nov. 18, 2007) (on file with author).
312
Letter from Dr. Kalpana Pandit to Andy Teas, Assistant Ombudsman, Iowa Citizens’ Aide/Ombudsman
(Dec. 1, 2007) (on file with author).
313
E-mail from Kent M. Nebel, Dir. of Legal Affairs, Iowa Bd. of Med., to Andy Teas, Assistant
Ombudsman, Iowa Citizens’ Aide/Ombudsman (Jan. 7, 2008, 16:00 CST) (on file with author).

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Jefferson County Jail:  Findings of Fact

5. Civil Commitment
During his incarceration, T.H. incurred an additional 13 charges for assaults on officers
between April 9 and September 4, 2007, in addition to the criminal charge of robbery that
placed him in jail. Soon after T.H.’s last assault, the Ombudsman contacted the county
attorney on September 20, 2007, about a possible civil commitment. The Ombudsman
previously spoke to the jail administrator and sheriff, who indicated an application for
civil commitment would not be successful for an inmate in jail because the magistrate
considers the person to already be in a secure environment. The Jefferson County
Attorney, Tim Dille, expressed the same apprehension, saying the magistrate views
persons in jail as not being a harm to themselves or others. However, Mr. Dille agreed he
would work with the jail staff to file a civil commitment petition with the court.
Within four days, the civil commitment order was granted by the magistrate. By
September 25, 2007, T.H. was admitted into the UIHC. T.H. remained at UIHC for
approximately 18 days. Medical notes stated he was threatening, spitting, throwing food,
and irritable during admission. Medications were adjusted during his stay at UIHC, and
he was released back to the jail with instruction to have the local ER administer an
antipsychotic medication shot.
During the time between T.H.’s return from UIHC and his acceptance at Iowa Medical
and Classification Center for a competency evaluation, Mr. Simons reported T.H.’s
agitation level “was near none upon his arrival back to us from UIHC.”

B. Analysis, Conclusions, and Recommendations
The Ombudsman identified several areas that need attention by Jefferson County Jail.
Jail staff were aware immediately of T.H.’s mental health needs as early as the booking
process, and since law enforcement and the jail had a history of encounters with T.H., it
can be argued they were aware of his needs even before booking. This section will detail
the identified problems and recommendations concerning intake screening and
assessments. This section will also review restraint chair procedures, with focus on how
and when to consult with medical staff.
1. Mental Health Screen and Assessment
According to the NCCHC, new-detainee intake screening is one of the most important
functions of the jail.314 This process can identify an inmate’s immediate and long-term
needs, and help determine early whether the jail is able to accommodate those needs. In
response to questions asked by the intake officer, T.H. informed the jail he was recently
hospitalized, he was under a doctor’s care for mental health, and he was on medication.
Despite these answers, the jail did not seek a mental health assessment to determine what
314

Judith A. Stanley, The Most Important Standard: Receiving Screening, CORRECTCARE, Fall 2004, at 20,
available at http://www.ncchc.org/pubs/CC/archive/18-3.pdf.

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Ombudsman Investigative Report
 
 
 
mental health services the jail needed to provide T.H., and whether it could in fact
provide for those needs.
A review of its policy shows the jail is primarily concerned with a detainee’s mental
health as it relates to suicide.315 The policy is not centered on how to respond to a
detainee with mental health needs who may not have suicidal tendencies, as T.H. reported
he did not. The policies provided by the jail do not instruct an intake officer on what
steps to take if an inmate reports a mental illness, but who otherwise provides no
indication of a suicide threat. Questioning a detainee’s mental health history at intake
should be aimed at determining whether a detainee needs to be referred to a mental health
professional for further review.
The Ombudsman supports the use of the Brief Jail Mental Health Screen (BJMHS)
during new-detainee intake screening. This form not only alerts intake officers of a
potential mental illness, but also clearly directs when to refer a detainee for further
mental health evaluation. This does not act as a supplement for an officer’s observations
of the detainee, particularly if the detainee does not answer the form’s questions
truthfully. However, it can make the decision of when to refer a detainee more clear for
the officer. In the case of T.H., the Ombudsman believes the BJMHS, or other healthauthority-approved mental health form, would have led T.H. to services much more
quickly, as there was no apparent effort on his part to “hide” his mental health history.
The BJMHS would have limitations in Jefferson County Jail, however, since the jail does
not currently have a provider for mental health services. The Ombudsman believes the
need for the jail to enter a formal relationship with a mental health professional is
essential as part of its intake process. At the same time, the Ombudsman recognizes the
difficulty in contracting for services due to the shortage of professionals in the
psychological field. Marjorie Gerber, the Clinical Director for Life Solutions Behavioral
Health, located in Fairfield, can provide a list of possible contacts for the jail. In
addition, the Ombudsman encourages the jail to contact its county central point of
coordination (CPC) official who can locate potential service providers.
The Ombudsman does not believe services for intake screening referrals need to be made
by a licensed psychiatrist. Mental health professionals can include psychiatrists,
psychologists, psychiatric nurses, and even social workers or others who, based on their
education and experience, are permitted to evaluate a person’s mental health needs. A
formal relationship between the mental health staff person and the jail is important so the
mental health professional can gain detailed knowledge of the resources and staff the jail
is able to provide, and accurately determine whether the jail can adequately provide for
315

Jefferson County Jail’s admission policy states “[a]ll staff involved in the booking process or the
supervision of inmate shall be trained in suicide prevention.” The admission policy also includes a section
specifically for suicide screening during the intake procedure. JEFFERSON COUNTY JAIL POLICY AND
PROCEDURE III-1 (2007). The Jail has a separate policy devoted to suicide prevention, which includes
procedures for screening and classification of suicidal inmates. JEFFERSON COUNTY JAIL POLICY AND
PROCEDURE III-1A (2007).

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Jefferson County Jail:  Analysis, Conclusions, and Recommendations
 
 
 
 
the detainee’s mental health care needs or if steps need to be taken to relocate the
detainee to another facility.
Having a designated mental health professional may also reduce the jail’s liability for not
providing mental health treatment to an inmate. The Eighth Circuit has recognized a
correctional facility’s liability under the Eighth Amendment for failing to provide mental
health services to inmates who require them.316 Providing mental health care serves the
interests of the jail, its employees, and the detainee.
Conclusion: Jefferson County Jail does not currently have a mental health screen in place
that identifies a potential mental illness in newly admitted inmates and instructs the
screening officer when to contact a mental health professional for further assessment.
Jail policy is primarily centered around suicide detection and prevention only. The jail
should incorporate a questionnaire covering an inmate’s mental health history for the
purpose of determining treatment needs of the inmate.
The Ombudsman makes the following recommendations:
1. Jefferson County Jail should incorporate a health-authority-approved mental
health screen, such as the Brief Jail Mental Health Screen, that identifies an
inmate’s past and current mental health information. This form would preferably
notify the officer performing the screen when an inmate should be referred to a
mental health professional for further assessment.
2. The jail should take immediate steps to review entering a formal relationship
with a mental health professional that can provide initial assessment services for the
jail on a regular basis. This may include contacting the local mental health facility
in Fairfield, Life Solutions Behavioral Health, as a resource for a mental health
professional referral.
Entering into a contract for mental health services with a mental health professional
will ensure timely treatment and intervention for inmates in need of mental health
services. If necessary, the mental health professional can inform the jail when a
detainee’s required care is beyond the jail’s capabilities and needs to be transferred
to another facility.
2. Mental Health Services After Intake
According to Administrator Simons, inmates will only see a psychiatrist if referred by a
local medical doctor. This applies whether an inmate specifically requests mental health
treatment or exhibits unusual behavior. Direct contact with a psychiatrist for mental
316

Vaughan v. Lacey, 49 F.3d 1344, 1346 (8th Cir. 1995) (“Prison staff violate the Eighth Amendment if
they are deliberately indifferent to an inmate’s serious mental-health-care needs.” (citing Smith v. Jenkins,
919 F.2d 90, 92-93 (8th Cir. 1990))).

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Ombudsman Investigative Report
 
 
 
health issues is never the first step unless the inmate is already seeing the local
psychiatrist.317 Despite T.H.’s growing agitation while at the jail, there is no indication,
based on conversations with Administrator Simons or review of T.H.’s medical records,
that the jail consulted with a medical doctor about his aggressive behavior. Even after
T.H. needed to be placed in the restraint chair on four separate occasions, the jail did not
consult with a local medical doctor about a referral for mental health.
Nor was a local medical doctor consulted about T.H.’s aggressive behavior after he
committed assaults on correctional officers that lead to 13 additional criminal charges
during his jail stay. When T.H. refused to take his prescribed Haldol for bipolar disorder
and routinely spat out or flushed his other medication, there was no consultation with a
local medical doctor. There was also no record of a medical consultation after he became
verbally abusive with a cardiologist during a medical appointment, who terminated the
visit.318
T.H.’s continuous aggressive behavior, his refusal to take medication, and his jail
admission statement that he was under a doctor’s care for mental health should have been
sufficient notice to the jail to follow its own practice of consulting a local medical doctor
for a referral. Moreover, the Ombudsman believes the jail should have contacted a
mental health professional for advice on what avenues to take with T.H. Relying solely
on a local medical doctor for a referral is not sufficient to identify when an inmate needs
to see a mental health professional. No local medical doctor referred T.H. to a mental
health professional on February 21, 2007, when the Fairfield Clinic refused to treat him
due to his past behavior and said they would never see him again.319 None of the local
medical doctors that were consulted during the four restraint chair placements referred
T.H. for mental health services at any time.
As mentioned in the previous section, Jefferson County Jail needs to establish a
relationship with a mental health professional to address issues relating to where it can
directly refer concerns about an inmate’s ongoing mental health condition and needs.
Inmate’s mental health can quickly deteriorate after intake for a variety of reasons,
whether stress from incarceration, not receiving proper medication, or a delay in the
manifestations of mental illness. For these reasons, jail staff need a mental health
professional to contact to report growing signs and symptoms from an inmate.
Though staff reported agitation early in his reception to the jail, T.H.’s behavior and
actions became worse as time passed, to the point where he was regularly assaulting
correctional officers. In reference to this period of time, Administrator Simons described
T.H’s behavior as “highly agitated most of a 24-hour period.”320 It is likely a mental
health professional could have identified the connection between T.H’s aggressive
317

Letter from Capt. Michael S. Simons, Jail Adm’r, Jefferson County Jail, to Andy Teas, Assistant
Ombudsman, Iowa Citizens’ Aide/Ombudsman (Feb. 26, 2008) (on file with author).
318
Jefferson County Jail, Inmate Incarceration Report 14 (Feb. 22, 2008) (on file with author).
319
Id. at 16.
320
See Letter from Capt. Michael S. Simons to Andy Teas, supra note 318.

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Jefferson County Jail:  Analysis, Conclusions, and Recommendations
 
 
 
 
 
behavior, his ongoing mental health treatment, and his refusal to take medication
prescribed for his mental illness. Further, a mental health professional may have been
able to recognize that the carbemazapine was not prescribed for “seizures,” as was listed
on the jail medication sheets, but was intended for the purpose of treating T.H. for bipolar
disorder. Recognizing the signs and symptoms of mental illness and responding to them
appropriately is important for providing the medical attention the inmate needs,
protecting staff from assault and injury, and protecting the jail from liability. If the
inmate’s medical or mental health needs are beyond those the jail can provide, a mental
health professional would be able to advise the jail when to transfer the inmate to another
facility or initiate civil commitment proceedings.
Conclusions: The jail did not follow its own practice of referring an inmate who displays
signs of mental illness to a medical doctor as a result of the potential mental illness. The
jail was provided with multiple signs of T.H.’s mental illness, the most apparent being
him stating he was under a doctor’s care for mental health. However, the Ombudsman
believes T.H.’s highly aggressive behavior and refusal to take his medication should have
also alerted staff of a potential mental illness.
The Ombudsman believes medical professionals with no formal training in mental health
are not the appropriate referrals for a person with a suspected mental illness. The jail
relies on medical professionals to make mental health referrals, but in T.H.’s case, at no
point was a mental health referral made. The Ombudsman stresses the need for the jail to
enter a formal relationship with a mental health professional who can assess an inmate
with a suspected mental health condition.
The Ombudsman makes the following recommendations:
3. Jefferson County Jail should establish a formal relationship with a mental health
professional for consultation and to evaluate inmates whenever they show signs of a
potential mental illness. It should not rely on local medical doctors to refer inmates
to a mental health professional. The jail should use the local contact provided in the
previous section and the county central point of coordination for recommendations
to mental health professionals that may provide services.
3. Use of the Restraint Chair
a. When to use
Jefferson County Jail’s restraint chair is supported by an eight-page policy and procedure
manual detailing when and how to use the restraint chair. Its policy states the purpose of
the restraint chair “is to protect corrections personnel from bodily harm in the
performance of their duties when inmates become aggressive, violent or combative, and

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Ombudsman Investigative Report
 
 
 
to bring these individuals under situational control without serious injury to themselves or
others.”321
The policy details maintenance, inspection, and storage of the restraint chair, and requires
that only those Jefferson County Sheriff’s Office and Correctional Facility employees
who have received training on the restraint chair be involved in its use. It further
instructs officers to never treat the restraint chair as a toy. Emphasis is placed throughout
the written policy in bold capitalized letters on issues relating to not provoking inmates,
not using the restraint chair as a means of punishment, restricted placement of straps, and
warnings that misuse can lead to death.
The policy bullet-points when the restraint chair may be used, including:
•
•
•
•
•
•
•

To prevent an inmate from self-injury.
To prevent an inmate from injuring others.
To prevent property damage.
Situational control of aggressive, violent or combative mentally disturbed
individuals when peaceful attempts to regain situational control have
failed.
Situational control of extremely alcohol intoxicated individuals who are
aggressive, violent or combative when peaceful attempts to regain
situational control have failed.
Situational control of individuals under the influence of narcotics, drugs or
vapors; who are aggressive, violent, or combative when peaceful attempts
to regain situational control have failed.
Situational control of all other aggressive, violent, or combative inmates
when peaceful attempts to regain situational control have failed.322

In four of the seven points, the words “when peaceful attempts to regain situational
control have failed.” This implies an obligation by correctional staff to attempt other
resolutions before concluding a restraint chair must be used to control the inmate.
The Ombudsman believes a determination that peaceful attempts will fail can be implied
by the circumstances of a situation. During the events of April 17, 2007, T.H. refused to
hand over his meal tray, and when a female officer entered the cell to retrieve the tray,
T.H. stood and threatened, “Come on bitch, take it away from me.”323 Another officer
entered the cell and forced T.H. to the bed before he was placed in the restraint chair.
Such action by the inmate may indicate seeking a peaceful resolution would not have
been successful, and if the inmate is not physically controlled while displaying an intent
to assault an officer, a delay could lead to serious injury on the officer. The Ombudsman

321

JEFFERSON COUNTY JAIL POLICY AND PROCEDURE I-10A at 1, Purpose (2007).
Id. at 3, Policy.
323
Resistance Report from Sgt. Phil Stocks (Apr. 17, 2007).
322

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Jefferson County Jail:  Analysis, Conclusions, and Recommendations
 
 
 
 
 
does not believe further steps to seek a peaceful resolution were required during the April
17 incident.
The Ombudsman has some concerns regarding T.H.’s placement on April 23, 2007. On
this date, T.H. placed wet paper on his window, blocking the view of the security camera.
He refused orders to remove the papers, though he eventually did so approximately five
minutes after ordered. However, T.H. ignored instructions to hand the paper to officers
through the meal slot. As a result, officers entered the cell and placed him in the restraint
chair.
Refusing verbal commands is not contemplated in the jail’s policy as a basis for placing
an inmate in the restraint chair. The officers’ actions by themselves appear excessive.
While T.H. may have created a safety and security concern by placing the wet paper on
the window, this was remedied by T.H. later removing the paper. Further safety concerns
could have been resolved by having officers enter the cell and remove all paper products.
When T.H. was refusing orders, Officer Gabe Tramel’s report stated that T.H. looked at
him during the order, “but would not respond.”324 At that point, T.H. was sitting on the
floor with his mattress. Based on the written reports provided by the jail, there is no
indication T.H. was aggressive, making threats, or destroying the cell. In fact, Officer
Tramel’s report stated “I then discussed with Ropp and Richardson that we would not
need to use the cell entry pad due to him lying on the floor.”325 The incident report does
not indicate T.H. resisted or fought with officers when they entered the cell, and the only
indication he began fighting was when he was placed in the restraint chair. At the time
staff determined T.H. would be placed in the restraint chair, his violation was refusing to
hand over the paper.
Iowa law states a restraint device is not to be used as punishment. This restriction is
echoed in the jail’s written policy, the restraint chair manufacturer’s instructions, court
cases, and correctional publications. When an inmate is placed in a restraint chair in
response to his past action, the decision begins to take on the appearance of punitive
measures.326 At the time officers entered the cell, T.H. was not showing aggressive
action or actively causing a security problem for the jail. He was refusing to hand over
paper as directed. Officers could have entered the cell, secured T.H., and removed the
paper themselves without using the restraint chair.
This suggested approach is the one used the next time officers had to enter T.H.’s cell on
April 24. Three officers entered his cell when T.H. refused to hand over his meal tray.
One officer had a cell entry pad. According to Sgt. Rick Smith report, the officers had no
intent to place T.H. in the restraint chair after retrieving the tray:

324

Incident Report from C.O. Gabe Tramel (Apr. 23, 2007).
Id.
326
Fred Cohen, Restraints as Torture? A Consent Decree Is Reopened, 18 CORRECTIONAL L. REP. 65, 78
(2007).
325

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Ombudsman Investigative Report
 
 
 
We determined we would back out of [T.H’s] cell one by one, so I took the
pad off Inmate [T.H’s] back and stood up myself. Up to this point we had
no resistance from Inmate. I then said to [T.H.], “I am not going to put you
in the chair since you did comply without becoming hostile.”327
It was only after T.H. took an aggressive stance against the officers and made a fist when
let up that the decision was made to place him in the restraint chair. The different
responses from the officers between the April 23 and April 24 incidents are apparent.
They are similar in that T.H. refused direct orders, and a cell entry was accomplished.
The two situations are also similar in that there was no hostility from T.H. during cell
entry. The only apparent difference is the officers’ decision to place T.H. in the restraint
chair. On April 24, that decision was made only after T.H. took aggressive action against
the officers when they were leaving the cell. At that point, officer safety was an issue,
and restraint chair use can be justified. This argument is difficult to make for the April
23 incident, when the security threat subsided and T.H. refused to follow a directive but
showed no signs of aggression.
On April 30 T.H. was placed in the special status cell after he spat in a C.O.’s face. He
was then taken to the detox cell after he kept hitting the cell door with his clothes and
blanket. When T.H. was able to pry his “soft-helmet” off while handcuffed, officers
entered his cell to adjust it, at which time T.H. spat directly in an officer’s face. He then
attempted to kick an officer when they left the cell. Shortly after, Administrator Simons
gave approval to place T.H. in the restraint chair.328 This incident represents the jail’s
attempt to respond to T.H.’s aggression with incremental steps of restraint, instead of
immediate placement in the restraint chair. T.H. displayed immediate and ongoing
aggression toward the officers, and after exhausting less restrictive alternatives, the jail
placed T.H. in the restraint chair.
A pattern becomes clear while reviewing the four April incidents. On April 17 and 23,
officers immediately placed T.H. in the restraint chair with little warning or attempt to
resolve the conflict before its use. By April 24 and 30, officers took multiple steps in
trying to resolve the situation, such as removing a meal tray with no intent to use the
restraint chair and using less restrictive alternatives to the restraint chair use. The
Ombudsman believes these steps were consistent with the jail’s written policy of using
the restraint chair “when peaceful attempts to regain situational control have failed.”
Conclusion: The Ombudsman believes the jail was justified in its use of the restraint
chair under Iowa law. However, the Ombudsman questions its use under jail policy on
April 23 when the circumstance appears to offer an alternative to the restraint chair use,
and the immediate threat to the security of the jail had subsided. The Ombudsman
borrows analogies from Management and Supervision of Jail Inmates with Mental
Disorders, addressing alternatives to the use of restraints:
327
328

Incident Report from Sgt. Rick Smith (Apr. 24, 2007).
Incident Report from Sgt. John Wayne Cornelius (Apr. 30, 2007).

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Jefferson County Jail:  Analysis, Conclusions, and Recommendations
 
 
 

 
Consistent with the notion of using the least restrictive alternative,
officials should consider whether an inmate simply can be placed in a
cell out of earshot of other inmates prior to gagging. Similarly, if an
inmate is tearing up a cell, is placing him in a strip cell, which contains
nothing he can destroy, a less restrictive response than putting him in
restraints?329

It must be noted that jail practices seemed to have changed after this incident to explore
less restrictive alternatives to restraint chair placement, and it was employed only after
those efforts were not successful. The Ombudsman encourages the continued practice of
using the restraint chair only “when peaceful attempts to regain situational control have
failed.”
The Ombudsman makes the following recommendations:
4. Jefferson County Jail should review its policy and training to explore steps jail
staff can take to use less-restrictive alternatives to a restraint device, especially if the
inmate can be secured to no longer pose an immediate threat to others or jail
security.
b. Documentation
Jefferson County Jail’s restraint chair policy states:
All officers involved will accomplish a report of the circumstances
surrounding the use of the E.R.C. prior to the end of that shift.
These reports are to be submitted to the Jail Administrator. These
reports will include the noting of time in and out of the E.R.C.
These reports must be very detailed.
Resistance reports will be completed by each officer involved city
or county. NO EXCEPTIONS.330 (emphasis found in original).
In each of the cases when T.H. was placed in the restraint chair, correctional officers
drafted reports of the incident, as required under jail policy. The Ombudsman obtained
six typed officer reports for the April 17 placement, two typed reports and a third handwritten “resistance report” from April 23, eight typed reports for the April 24-25
placement, and three typed reports and several hand-written “resistance reports” for April

329

MARIN DRAPKIN ET AL., MANAGEMENT AND SUPERVISION OF JAIL INMATES WITH MENTAL DISORDERS
2-37 (2003).
330
JEFFERSON COUNTY JAIL POLICY AND PROCEDURE I-10A at 7, Reporting use of the Emergency Restraint
Chair (2007).

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Ombudsman Investigative Report
 
 
 
30. There were no reports detailing T.H.’s removal from the restraint chair or his
disposition at the time of removal.
The officers’ reports were detailed and provided a vivid picture of what occurred in the
time before and during each placement. Included with the reports were activity logs for
each of the dates detailing when T.H. was checked for circulation every 15 minutes.
Each date included an “Activity Report by Location” that stated only T.H.’s location, the
time he was checked, and the officer who checked in on him. During T.H.’s placement
on April 23 and 30, the jail provided a “Facility Log” that included much more detail of
the restraint, including the date, time, offender, and brief notes documenting T.H.’s
placement in the restraint chair; visual or physical checks; statements made by T.H.;
when officers contacted medical doctors; and his removal. The system, developed by
Professional Computer Solution in Ottumwa, Iowa, is not currently required by the jail to
document restraint chair placement and use. According to Administrator Simons, it is
used at the discretion of the officer on shift.
The Ombudsman also reviewed videos of T.H.’s placement during each of the incidents.
The videos did not provide as consistent information as the written reports. Many of the
security videos were so poor they provided little or no relevant information to the
investigation. The videos from April 17, 23, 24, and 25 were not discernable.331 The jail
also could not provide all of the tapes immediately when requested; some taking several
weeks to locate. However, all requested recordings were eventually made available.
Conclusions: Jefferson County Jail has included excellent language on documentation
requirements in its restraint chair policy. The jail should ensure the inmate’s release is
documented and include the reason for the release and the inmate’s disposition upon
release. Administrator Simons reported he made the decision to release T.H. based on his
agitation level and consideration of the inmate’s and staff’s safety. Administrator Simons
or any other official who is involved in the release should document these observations in
a report soon after release.
The Facility Log provides sufficient detail to comply with Iowa law requiring
documentation of all decisions and actions. In contrast, the “Activity Report by
Location” does not provide nearly as much information. The jail should incorporate the
Facility Log during each restraint chair use due to its capacity to detail what action took
place at what time and its convenience in providing a quick review of the events.
It is not clear why some of the security tape quality was so poor. Based on the incident
reports, there were no reported problems from the control desk while monitoring T.H. on
the CCTV. Possible causes could be the age of the tapes or because of wear and tear
from their recycled use. Visual recording of restraint chair placement and use is an
excellent tool for the jail to combat allegations of physical abuse by an inmate, to identify
331

The Ombudsman was able to review videos of restraint chair placement and use on these dates that
recorded different times or locations in the jail.

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Jefferson County Jail:  Analysis, Conclusions, and Recommendations
 
 
 
 
problems the jail needs to address if policy is not followed, and to use as a training tool
for officers. The jail should ensure the tapes can accurately record the events taking
place.
The Ombudsman makes the following recommendations:
5. Jefferson County Jail should incorporate and consistently execute an event log
that provides sufficient information for an accurate review at a later time. The jail
should record in writing all decisions and actions taken towards an inmate who is
placed in a restraint device, including the reason for release.
6. The jail should ensure its video recording equipment is functional and portrays
an accurate account of the events it is supposed to record. Copies of recordings
should be filed separately from other security tapes, and copies should be retained
for at least two years.
c. Consultation with medical and mental health staff
During each of T.H.’s restraint sessions that lasted over two hours, the jail contacted
medical doctors to receive approval for additional time. On each occasion, the doctors
gave approval, even when the restraint chair had already been used for 12 hours. On each
occasion, the doctor giving approval did not review T.H.’s condition in person. On each
occasion, the doctor did not have personal knowledge of the restraint device used by the
jail. Some doctors had no personal knowledge of T.H. himself, or his medical or mental
health history. On each occasion, the jail did not follow its own written policy requiring
inmates to be held in the restraint chair for “NO MORE THAN 2 HOURS WITHOUT
DIRECT MEDICAL SUPERVISON.”332 (emphasis found in original).
The Ombudsman has concerns over using telephonic medical consultation, especially
when the medical professional has no working knowledge of the restraint device in use or
the inmate on whom it is being used. The Ombudsman inquired from each of the medical
doctors involved in approving extended use of the restraint chair what their familiarity
was with the device. Of the six doctors who replied to the written question, none had
knowledge of the specific device used by the jail.
The Ombudsman believes the need for direct medical supervision beyond the initial two
hours is essential for restraint chair use. This position is based on the Ombudsman’s
review of the ACA Standards for Adult Local Detention Facilities, the NCCHC
Standards for Health Services in Jail, the APA Resource Document on the Use of
Restraint and Seclusion in Correctional Mental Health Care, the DOJ’s investigation and
recommendation to Black Hawk County Jail, and the E.R.C. Inc. Instruction Manual.
None of these sources make an exception for medical reviews when an inmate is placed
in a restraint device, generally, and none provide that an inmate can remain in a restraint
332

Id. at 6, Supervision.

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Ombudsman Investigative Report
 
 
 
device for extended periods of time without direct medical supervision. On the contrary,
each of these sources recommend contacting medical services in the event an inmate is
placed in restraints.
When asked whether the doctor could find resolution for his or her medical concern by
telephone only, the Ombudsman received a variety of responses from the doctors
involved in T.H.’s case. One doctor’s entire response was “possibly,” with no further
explanation. Another said medical concerns typically could be broached over the phone,
but it is never the ideal method, while a third doctor explained feeling uncomfortable
with it, and a face-to-face evaluation would have been better. The single response this
office received from The Fairfield Clinic, signed by three doctors, did not address this
written question at all. When this specific issue of telephone consultation was posed to
the Iowa Board of Medicine, its Director of Legal Affairs replied that it lacked the
expertise to respond.333
If the restraint involves an inmate with a suspected mental illness, a mental health
professional should be contacted. The DOJ concluded mental health personnel must be
involved in decisions to restrain inmates and the monitoring while restrained. The
NCCHC requires a physician be notified immediately if the restraint involved an inmate
with a mental health condition so appropriate orders can be given. The ACA requires the
health authority to be notified to assess the inmate’s medical and mental health condition,
and determine if there is an emergency related to these conditions that requires attention.
E.R.C. Inc. states violent behavior can mask a medical condition, and its two-hour time
limit recommendation allows its customers to seek medical or psychological help for the
detainee. The two-hour time limitation can be extended only under direct medical
supervision. The Ombudsman does not believe an inmate’s medical and mental health
conditions can be fully evaluated by a phone conversation with medical staff who have
little or no knowledge of the inmate or jail procedures.
Conclusions: Considering the language in the Jefferson County Jail policy, the restraint
chair manufacturer instructions, and correctional associations’ policies, the Ombudsman
believes direct medical supervision is required for any inmate placed in the restraint chair
for longer than two hours. This would mean face-to-face supervision by a doctor, nurse,
physician’s assistant, or other licensed medical professional. The Ombudsman believes
the answers provided by the doctors involved in T.H.’s restraint and the response by Iowa
Board of Medicine highlights the problems and potential harm if jail staff rely on
consultation with medical personnel over the phone.
Pursuant to this report’s prior conclusion that the jail should establish a formal
relationship with a mental heath professional for new inmate intake and assessment
services, the Ombudsman believes such a relationship would provide an invaluable
service for restraint chair use when the inmate has a suspected mental illness. A mental
333

E-mail from Kent M. Nebel, Dir. of Legal Affairs, Iowa Bd. of Med., to Andy Teas, Assistant
Ombudsman, Iowa Citizens’ Aide/Ombudsman (Jan. 7, 2008, 16:00 CST) (On file with author).

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Jefferson County Jail:  Analysis, Conclusions, and Recommendations
 
 
 
 
health point person should be familiar with the jail’s facilities, the staff involved, and
potentially the inmate subject to restraints. A mental health professional would be in a
better position to evaluate an inmate’s condition to determine if the inmate’s behavior
and aggression is the result of a mental illness that needs to be treated by other means
than prolonged placement in restraints, and relay this information to jail staff. The
mental health point person should be contacted as soon as the decision is made to place
the inmate in restraints.
The Ombudsman makes the following recommendations:
7. Jefferson County Jail should enter a formal relationship with a mental health
professional, whether the same or different resource for assessment, to provide
reviews of inmates placed in the jail’s restraint device. The jail should ensure the
review involves a visual review by the mental health professional, and not rely on
phone consultation alone. If a mental health professional cannot conduct reviews in
person, an alternative could involve telemedicine, where the mental health
professional can observe the inmate by video.
d. When to release
The Ombudsman is not taking a position on maximum time limits for restraint device
use. Instead, extended use of restraints will depend on the disposition of the inmate and
whether the inmate remains an immediate threat to himself or others. T.H.’s
circumstances represented the longest use of a restraint device investigated by this office.
Fortunately, his disposition and actions were documented through activity logs and
incident reports by the jail. During even the 11- and 12-hour time periods, the jail was
able to demonstrate the continued threat T.H. posed to staff. This is important
considering at least two U.S. districts court cases in Iowa have found against jail facilities
that could not justify extended use of the restraint device on inmates.334
As discussed previously, the lack of time limits means greater emphasis must be placed
on medical and mental health services, especially when an inmate is restrained for
extended periods of time. Several county law enforcement and corrections officers the
Ombudsman spoke with stated restraint chair and board use often does not last longer
than two hours. The restraint chair manufacturer states the initial two-hour time limit
allows officers to seek medical or psychological health, and any use beyond this time
must be accompanied by direct medical supervision by a doctor or nurse.335
Clearly, the restraint chair sessions that lasted six or more hours in this case constituted
exceptional periods of restraint chair use. However, such lengthy stays may not occur if

334

Ogden v. Johnson, No. C00-0034, 2002 WL 32172301 (N.D. Iowa Sept. 5, 2002); Rogers v. Dunn, No.
C00-0188-PAZ, 2001 U.S. Dist. LEXIS 22710 (N.D. Iowa Nov. 27, 2001).
335
Letter from Thomas Hogan, President, E.R.C. Inc., to Customer (Jan. 17, 2001).

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Ombudsman Investigative Report
 
 
 
the inmate is seen by medical and mental health personnel, mentioned in the previous
section, who can provide or recommend emergency medical and mental health care.
Conclusion: The Jefferson County Jail documented the need for the continued use of
restraints on each occasion, and the Ombudsman does not find the jail held T.H. longer
than required under Iowa law. However, the jail should have taken the opportunity to
seek the services of a mental health professional. At the least, after T.H. was placed in
the restraint chair on the first occasion, the jail should have recognized the need for such
services existed. The jail should have also followed its own written policy to have direct
medical supervision of the inmate in the restraint chair every two hours. Such resources
may have offered intervening medical or mental health services to reduce the length of
time T.H. spent in the restraint chair.
The Ombudsman makes the following recommendations:
8. Jefferson County Jail should enter a formal relationship with a mental health
professional, whether the same or different resource for assessment, to provide
reviews of inmates placed in the jail’s restraint device. The jail should ensure the
review involves a visual review by the mental health professional, and not rely on
phone consultation alone. If a mental health professional cannot conduct reviews in
person, an alternative could involve telemedicine, where the mental health
professional can observe the inmate by video.

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Woodbury County Jail – Findings, Conclusions, and Recommendations
A. Findings of Fact
G.A. contacted the Ombudsman on November 13, 2006, complaining about being placed
in a “detoxification cell” for 18 days with no access to showers or hygiene. After
reviewing jail records, the Ombudsman determined the allegations were unsubstantiated.
However, during the investigation, the Ombudsman discovered G.A. was placed in a
restraint chair on two occasions: one lasting seven hours with no review by medical staff.
This action, coupled with G.A.’s documented mental health history, raised concerns with
the Ombudsman.
1. Intake Screening and Treatment Before Restraint Device
Assistant Chief Deputy Robert Aspleaf explained to the Ombudsman that G.A. had a
history of mental illness before he entered the jail. In 2004 G.A. was arrested for assault
and spent time at Woodbury County Jail. During his incarceration at that time, G.A. was
prescribed Paxil, Risperdal, and Depokote while at the jail for “psychosis” and
“depression.” The jail’s medical records from his 2006 incarceration revealed G.A. was
diagnosed with adjustment disorder with anxiety, depression, and anti-social personality
disorder. The Ombudsman requested, but never received, medical or mental health
intake sheets from G.A.’s 2006 admission into the jail, so it is unknown what information
G.A. reported to intake staff regarding medical or mental health history.336 However,
four days after his June 25, 2006, admission into the jail, G.A. filed a medical request to
see a mental health professional. He reported depression and anxiety. Despite the jail
having in its possession the 2004 medical sheets listing G.A.’s previous diagnosis and
medications, G.A. was not seen by the physician’s assistant until September 1, 2006.
The day G.A. saw the physician’s assistant, he was prescribed Seroquel, a drug
commonly prescribed for bipolar disorder and schizophrenia. Medical sheets drafted at
this time stated he was diagnosed with adjustment disorder with anxiety, depressive
disorder, and anti-social personality disorder. Before this date, jail staff reported several
incidents of aggressive behavior and specific threats against officers.
2. Immediate Facts and Circumstances of Restraint Devices Use
On September 2, the day after he was evaluated by the physician’s assistant, G.A. was
directed out of his cell when he tore the cell light from the wall. When he walked out of
the cell, G.A. was carrying a sharpened toothbrush in his hand, which he dropped when
an officer yelled at him. However, he tried to strike the officer whom he previously made
threats against, and a struggle resulted in injuries to the officer. Officers took G.A. to a
padded cell, where he continued to make threats. When officers observed him peeling
336

E-mail from Linda Brundies, Assistant Ombudsman, Iowa Citizens’ Aide/Ombudsman, to Robert
Aspleaf, Assistant Chief Deputy, Woodbury County Sheriff’s Office (Feb. 22, 2008, 7:29 CST) (on file
with author); e-mail from Robert Aspleaf to Linda Brundies (Feb. 25, 2008, 13:49 CST) (on file with
author).

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the padded wall off the cell window, they placed him on a restraint board. G.A. was able
to loosen the straps and get his head free, and officers then transferred him in a restraint
chair, where he remained for three hours.337
The next day, a dispute arose between G.A. and the officer regarding peanut butter. That
dispute accelerated when officers noticed G.A. had pulled wall padding from the cell
window as he had done the previous day. Officers immediately called for the restraint
chair. While waiting for officers to arrive, G.A. continued to make threats toward
officers. He held pieces of the padded wall in his hands and wrapped his head with a tshirt, which he later described was intended to protect himself from pepper spray. When
officers entered the cell, G.A. threw the pieces of wall at the officers. Shortly after, G.A.
was placed on a restraint board, but when the straps did not hold, was transferred to the
restraint chair at 4:52 a.m.
The jail was able to provide limited documentation of G.A.’s stay in the restraint chair.
A log periodically states “CKING STRAPS ON [G.A.],” or similar words, followed by
the initials of the officers who checked the straps. However, while the jail recorded the
cell entry and initial placement in the restraint board and restraint chair, the jail did not
document on video the duration of the restraint chair use. The jail could not provide any
documentation showing staff periodically reviewed G.A.’s behavior to determine if he
should be removed from the restraint chair or provide reports supporting the staff’s
decision to release G.A. from the restraints.
The Ombudsman received written documentation showing the staff nurse, Dan Nettleton,
conducted a physical check on G.A. during the September 2 restraint use, but did not
receive documentation indicating he reviewed the inmate during the seven-hour restraint
on September 3. Mr. Nettleton told the Ombudsman a nurse would normally assess an
inmate, the restraint device, the inmate’s mental status, and his need to use the bathroom.
According to Mr. Nettleton, he was on-call on September 3, but could not recall a
notification to check on G.A. He further stated if he was called in, documentation should
exist showing he was called in. The Ombudsman found no such documentation.
In the months following his placement in the restraint devices, G.A.’s Seroquel
medication was adjusted on four additional occasions. After these adjustments were
made and administered on a regular basis, Chief Robert Aspleaf reported to the
Ombudsman that the jail had no further problems with G.A.’s behavior.

337

Jail documents refer to their restraining device as a “restrainer chair.” For purposes of consistency, this
report refers to the device by the general term “restraint chair.”

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B. Analysis, Conclusions, and Recommendations
The Ombudsman reviewed Woodbury County Jail’s incident reports, security videos,
activity logs, and restraint chair policies. The Ombudsman identified several areas of
concern in G.A.’s case including intake screening and response to medical requests,
medical review of the inmate during restraint chair use, notification of a mental health
professional of restraint chair use, and documentation of periodic review to determine the
continued need for the restraint chair.
1. Intake Screening and Response to Medical Requests
The Ombudsman cannot fully determine to what extent the jail had notice of G.A.’s
mental health history. In reply to our requests for the 2006 jail intake screen, the jail
asserted the Ombudsman’s office had everything in the file. Iowa law requires certain
procedures to be followed during a jail’s booking process, including separating certain
classes of detainees and identifying detainees that may be suicidal.338 Iowa law also
requires during admission that jails determine if a detainee has a communicable disease,
determine whether a detainee needs to see medical personnel, and provide a medical
history intake form.339
According to Woodbury County Jail’s policy and procedure, the jail has a formal
relationship with Siouxland Mental Health (Siouxland) to see and treat inmates twice
weekly.340 When an inmate requests mental health treatment during booking, the
booking officer will notify nursing staff and refer an inmate to Siouxland if appropriate.
In addition, Siouxland, through a program called “Project Compass,” reviews the booking
files each morning to evaluate new detainees for mental health problems.341
Woodbury County Jail stated this office had “tapped the well” in response to its request
for mental health intake sheets during G.A.’s booking.342 Based on the record in the
Ombudsman’s possession, there was no medical or mental health history information
dated the day of G.A.’s admission, June 25, 2006. If the Ombudsman received all the
information in the jail’s possession regarding G.A.’s screening, it appears no medical or
mental health screen was done for G.A.
Aside from the implications that the jail violated Iowa law by not being able to locate or
provide the intake documents this office requested, further concerns arise regarding the
consequences of the jail’s failure to administer a medical history for G.A. The jail
338

IOWA ADMIN. CODE r. 201—50.13(1) (2008).
IOWA ADMIN. CODE r. 201—50.15(6) (2008).
340
WOODBURY COUNTY JAIL POLICIES & PROCEDURES FOR HEALTH SERVS.: MENTAL HEALTH SITUATIONS,
NURSING ASSESSMENT AND TREATMENT JSOG 118 (2007).
341
Id.
342
E-mail from Linda Brundies, Assistant Ombudsman, Iowa Citizens’ Aide/Ombudsman, to Robert
Aspleaf, Assistant Chief Deputy, Woodbury County Sheriff’s Office (Feb. 22, 2008, 7:29 CST); E-mail
from Robert Aspleaf to Linda Brundies (Feb. 25, 2008, 13:49 CST).
339

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Ombudsman Investigative Report 
 
 
 
provided documentation and medical sheets from G.A.’s previous stay at the jail in 2004.
These sheets show G.A. was receiving three separate medications for his diagnosed
psychosis and depression. However, no psychotropic medication was administered upon
his admission in 2006. Nor was he prescribed medication for depression and anxiety
until over two months had passed since he submitted a medical request. The
Ombudsman believes the jail’s apparent failure to conduct a medical history screen for
G.A. upon his admission to the jail in 2006 contributed, in part, to the jail’s failure to
identify any previously diagnosed or new mental health condition.
Conclusion: Iowa law requires a medical history screen for all inmates admitted into a
jail. The medical screen should identify physical medical conditions as well as mental
health history that may require attention for purposes beyond only identifying whether an
inmate is suicidal. This was not done when G.A. was admitted to the jail. Further, it
took over two months for the jail to respond to G.A.’s request for medical attention for
his depression and anxiety, a condition the jail was previously aware of during his
incarceration two years earlier. The Ombudsman believes this was an unreasonable delay
in obtaining necessary medical attention.
The Ombudsman makes the following recommendations:
1. Woodbury County Jail should provide a medical history screen, which includes
current medical conditions and medications, along with a mental health history
screen for all inmates entering the jail. The Ombudsman supports the use of the
Brief Jail Mental Health Screen or other health-authority-approved mental health
form to identify potential mental health conditions among inmates. The jail should
consult with its current nursing staff and Siouxland to determine which screening
form would be appropriate for the jail.
2. The jail must respond to an inmate’s requests for mental health complaints in a
reasonable amount of time.
2. Decision to Use Restraint Devices
Woodbury County Jail policy provides several reasons for placing an inmate in a restraint
device, though under what conditions an inmate may be placed in a restraint device varies
throughout the written policy.
Under “Purpose,” the restraint board policy states:
To restrain a subject as to keep them, from harming themselves or
others.343 (emphasis added).
Under “Policy,” it states:
343

WOODBURY COUNTY JAIL POLICY, JSOG 149 4.4.2, Restrainer Board (Jan. 1, 2007).

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The restrainer board may be used when an inmate is combative,
belligerent, suicidal or destroying his/her cell.344 (emphasis added).
Under “Guideline,” it states:
Restraint devices shall not be applied as punishment and shall be used
only when a prisoner is a threat to self or others or jeopardizes jail
security.345 (emphasis added).
Later under “Guideline,” it states:
Verbal threats in themselves are not justification for the restraint
device, or actions that are annoyances to the jail, i.e. food throwing,
yelling, fist pounding or kicking. However, head banging may result in
physical injury to the subject and cause rise to consider use of the
device.346 (emphasis added).
Still later under “Guideline,” it states:
Inmates that are belligerent and are destroying cell areas and causing
extreme destruction to the cell and physical harm to themselves may
become necessary to use the restraint device.347 (emphasis added).
Each of these statements directing when the restraint board can be used appear on the
first page of the policy. The policy provides contradictory directions when restraint
device use is authorized. While the “Purpose” section does not mention destruction of
the cell, it is mentioned in the “Policy” section. While the “Guideline” states restraint
devices will be applied only when a person is a threat to self or others, or jeopardizes jail
security, it later authorizes the use of restraint devices when the inmate is destroying a
cell area and causing extreme destruction to the cell.348
While the policy seems to contradict itself, there is no provision in Iowa law allowing an
inmate to be placed in a four- or five-point restraint for destruction of his cell while no
other element of threat to self or other, or jeopardizing jail security is present. The
section of the policy stating an inmate will be placed in a restraint device only on those
344

Id.
Id.
346
Id.
347
Id.
348
Id. It must be noted the policy under “Guideline” provides four elements connected by “and.” The
policy is unclear whether any single element can justify restraint device use, or if all four must be present to
justify its use. The general principle would be that all four elements would have to be present under the
conjunctive “and,” and if any single element would justify its use, the policy would have used the
disjunctive “or.” See State v. Valin, 724 N.W.2d 440, 446 (Iowa 2006). But see In re Detention of Altman,
723 N.W.2d 181, 187 (Iowa 2006).
345

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Ombudsman Investigative Report 
 
 
 
occasions when the inmate is a threat to self or others, or is jeopardizing jail security is
consistent with Iowa law.
Restricting restraint device use to only the circumstances provided under Iowa law raises
concerns about how the restraint board and the restraint chair were used on G.A. Incident
reports from the officers involved during the September 3 placement do not indicate G.A.
was a threat to himself or others, or a threat to security. Officer Blanchard’s report reads
as follows:
Officer Hutzell was opening the food pass to the cell to give [G.A.] his
peanut butter when it was noticed that he had a piece of padding from
the wall of the cell. [G.A.] told me that all we had to do is listen to him
and he wouldn’t give us these problems. I then asked for an Officer to
bring the restraint chair to booking so that G.A. could be placed in it
again. . . .
While waiting for RISC team member to arrive [G.A.] was taunting
Officer’s (sic) as they would pass the windows or door to his cell.
[G.A.] was making threat to beat Officer’s (sic) and that we should
know better than to mess with him. I heard G.A. continue with his
threats and behavior until I left the booking area.349
Officer Lewis’ report reads:
On the above date and time, Officer Blanchard informed me that Inmate
G.A. was threatening Officers and that we were going to call the RISC
Team.350
Officer Heckert’s report reads:
When I arrived to Booking officer [sic] Blanchard advised that we were
going to go in and take the piece of the wall that Inmate [G.A.] had broken
off and were going to place him on the restraint board.351
None of the reports provided by the jail stated G.A. was a threat to himself or others, or
was jeopardizing jail security. Instead, references were made that G.A. was making
verbal threats against officers, even though the jail’s own policy states verbal threats in
themselves are not justification for the restraint device. While the reports mention
padding being torn from the wall, video of the cell entry and restraint board placement
shows only some padding on the floor torn from the window area; much less than
“extreme destruction to the cell” requirement provided in written policy.
349

Belligerent Inmate Report from Officer Blanchard (Sept. 3, 2006).
Belligerent Inmate Report from Officer Lewis (Sept. 3, 2006).
351
Belligerent Inmate Report from Officer Heckert (Sept. 3, 2006).
350

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The Ombudsman is also concerned about the use of the restraint board and chair as the
first step to prevent further destruction of the cell. Iowa law allows use of four- and fivepoint restraints only after other restraints have proven ineffective. The Ombudsman
interprets this provision to mean less restrictive alternatives to four- and five-point
restraints must be employed and have failed before restraint chairs, boards, and beds can
be used. Other than placement in a padded cell, there is no apparent attempt to use less
restrictive restraints on G.A. The Ombudsman believes the analogies from Management
and Supervision of Jail Inmates with Mental Disorders, addressing alternatives to the use
of restraints, are on point in this case:
Consistent with the notion of using the least restrictive alternative,
officials should consider whether an inmate simply can be placed in a
cell out of earshot of other inmates prior to gagging. Similarly, if an
inmate is tearing up a cell, is placing him in a strip cell, which contains
nothing he can destroy, a less restrictive response than putting him in
restraints?352
The Federal Bureau of Prisons has contemplated the use of less restrictive restraints
before resorting to restraint devices. The federal policy incorporates the practice of
progressive restraints, including the use of ambulatory restraints, which allow an inmate
to eat, drink, and take care of basic needs without staff assistance.
Conclusion: The Ombudsman finds Woodbury County Jail violated its own policy and
state law when it used the restraint board and chair on G.A. for only limited damage to
his cell and making verbal threats to jail staff. The Ombudsman does not believe the jail
complied with Iowa law when it did not attempt to employ less restrictive restraints
before using the restraint board and chair.
The Ombudsman makes the following recommendations:
3. Woodbury County Jail should draft written policy that is consistent internally
and with Iowa law. The policy should make clear that a restraint device should only
be used if an inmate is a threat to self, others, or the security of the jail. The policy
should also state that jail staff, when possible, should attempt less restrictive
restraint before employing a four- or five-point restraint device. Minor cell damage
and verbal abuse is not an appropriate basis for using a restraint device.
3. Type of Restraint Device Used
As indicated previously in this report, the Ombudsman has concerns regarding the
restraint board as an effective tool for restraining inmates. This is due to the prone
352

MARIN DRAPKIN ET AL., MANAGEMENT AND SUPERVISION OF JAIL INMATES WITH MENTAL DISORDERS
2-37 (2003).

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position that is required by the board. Several medical journals and professionals have
detailed the risks associated with placing an inmate in a restrained prone position, which
can restrict breathing and lead to adverse medical problems, including death.
The Woodbury County Jail has the option of choosing between the restraint chair and the
restraint board. Its restraint chair is designed without straps crossing the chest or
abdomen, reducing or eliminating the risk of positional asphyxiation. The jail transferred
G.A. from the board to the chair on the two occasions reviewed by the Ombudsman
because G.A. was able to loosen the board’s restraining straps, but there was no apparent
need to transfer him from the chair to any other device.
The Ombudsman also takes notice of one court’s observations of restraint board use in
another county jail in Iowa. The U.S. District Court for the Northern District of Iowa
provided a commentary on the restraint board when it reviewed a case of an inmate’s
placement on the device: “This device is more than just uncomfortable. It is a restraint
that should be used only for the amount of time necessary to restore order.”353
The differences between a restraint chair and restraint board were discussed in unsettling
detail in a post from a correctional officers forum:
Thread: Pro-Restraint Chairs?

06-28-2006, 10:56 PM

[username deleted]354
Forum Member
Join Date: May 2006
Location: sioux city iowa
Posts: 18

#6
We have one, we love it. Had it about 8 years now,
use it probably 12-15 times a year. We also have a
restrainer board. It's really just an over-sized piece
of plywood. It has velcro straps that secure the
head, scapular area, low back, tricep and wrist
area, hamstring,calf and ankles. Works really great
when the badboys are naked, those exposed bones
pressed down to the board. It makes the tough
ones beg........

The Ombudsman became aware of this post while conducting Internet research for this
case and subsequently learned it was written by an officer at the Woodbury County Jail.
The jail acknowledged the forum comments came from one of their officers, but claimed
an officer posted the comments under another officer’s username. “We have a shared
computer system, and we believe that [the officer] was visiting the police forum website
and was called away before logging off the internet. Another officer went to the
computer, saw the website that [the first officer] had visited, and posted the reply as a

353

Ogden v. Johnson, No. C00-0034, 2002 WL 32172301, at *3 (N.D. Iowa Sept. 5, 2002).
http://forums.officer.com/forum.showthread.php?t=49486. (last visited Oct. 30, 2008). Because the
Ombudsman did not conduct an extensive investigation to substantiate the jail’s claims and identify the
officer who posted the comments, the username has been redacted.
354

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joke.”355 Though the jail claimed the posting was a joke, it did not indicate it identified
or spoke to the post’s author before reaching this conclusion.
Regardless of the writer’s intent, the Ombudsman believes the comments were
inappropriate. At worst, it suggests a favorable view towards using the restraint board in
a punitive manner and at best it shows insensitivity to an issue that should be and was the
subject of a serious discussion on the forum. The post heightens one of the
Ombudsman’s initial concerns from reviewing inmate complaints referenced in this
report. Several inmates claimed the restraint devices were used for torture, that they were
physically abused while in the devices, or that use of the devices was excessive to abate
their behavior. The Ombudsman believes the use of restraint devices for punishment or
to inflict pain constitutes an abuse of the restraint device, a violation of Iowa law, and a
violation of an inmate’s Eighth Amendment rights.
Conclusion: The restraint board inherently carries a higher risk of injury or death
compared to the restraint chair. For these reasons, the Ombudsman prefers the use of the
restraint chair over the restraint board currently employed by the Woodbury County Jail.
The Ombudsman makes the following recommendations:
4. In all circumstances, when jail staff determine a four- or five-point restraint
device is the only option to control an inmate, jail staff should use the restraint chair
rather than the restraint board.
4. Medical Review of Inmate in Restraint Chair
G.A. was prescribed Seroquel on September 1, 2006, for depression and anxiety, and
during the following two days, the jail had to employ two different restraint devices in
response to his aggressive behavior. The jail was able to provide documentation that Dan
Nettleton, RN, reviewed G.A.’s condition while in the restraint chair on September 2,
2006. On this date, G.A. was restrained for a total of three hours. In contrast, there is no
documentation the jail’s medical staff reviewed G.A.’s condition while he was restrained
for seven hours on September 3. Mr. Nettleton told the Ombudsman he was on-call that
date, but did not recall reviewing G.A.’s condition or having any documentation of
reviewing him during his restraint. Further, Mr. Nettleton told the Ombudsman he would
have liked to have been notified.356
Woodbury County Jail uses a restraint chair manufactured by E.R.C. Inc. According to
the manufacturer’s instruction manual, detainees should not be left in the restraint chair
for more than two hours.357 The manufacturer told the Ombudsman that this time limit,
355

Letter from Robert Aspleaf, Assistant Chief Deputy, Woodbury County Sheriff Office, to Andy Teas,
Assistant Ombudsman, Iowa Citizens’ Aide/Ombudsman (Oct. 10, 2008) (on file with author).
356
Telephone interview by Linda Brundies, Assistant Ombudsman, Iowa Citizens’ Aide/Ombudsman, with
Dan Nettleton, Registered Nurse, Woodbury County Jail (Mar. 16, 2007).
357
E.R.C. Inc., EMERGENCY RESTRAINT CHAIR INSTRUCTIONS 12 (Feb. 10, 2001).

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Ombudsman Investigative Report 
 
 
 
in part, allows the correctional facility to seek medical or psychological help for the
detainee. The two-hour time limit may be extended only under direct medical
supervision by a doctor or nurse. The NCCHC standards and the ACA standards require
health services staff be notified immediately when a restraint device is used for the
purpose of reviewing the inmate’s medical record and monitoring the continued use of
the restraint device.
Conclusion: Given the extensive time G.A. was left in the restraint chair, the
Ombudsman finds that Woodbury County Jail should have contacted the nurse who was
on-call immediately after G.A. was placed in the restraint chair on September 3. The
minimal step the jail should have taken, in accordance with the restraint chair
manufacturer’s instructions, would be to contact medical staff when it determined the
restraint chair was required beyond the initial two hours of use. Medical staff would
thereafter monitor the continued use of the restraint chair until G.A.’s release. The jail
does not currently have a policy requiring medical reviews of inmates placed in the
restraint chair.
The Ombudsman makes the following recommendations:
5. Woodbury County Jail should incorporate language in its policy requiring
medical staff be immediately notified when an inmate is placed in a restraint device.
Written policy on restraint chair use should reflect the manufacturer’s instructions
by requiring direct medical supervision if an inmate must be restrained in the
restraint chair for longer than two hours.
5. Notification of Mental Health Professional
On September 1, 2006, physician’s assistant Dawn Nolan saw G.A. in response to his
medical request submitted two months prior. Ms. Nolan prescribed him Seroquel® that
day, a drug commonly prescribed for depression, bipolar disorder, and schizophrenia.358
G.A. spent three hours in the restraint chair on September 2 and seven hours on
September 3. However, Ms. Nolan was not involved in the supervision of his placement
on either date. Nor was any mental health professional or Siouxland, which provides
mental health intake screening services for the jail, notified of his placement.
The DOJ’s investigation of Black Hawk County Jail concluded that when restraints must
be used on an inmate with a serious mental illness, the jail must ensure mental health
personnel are involved in the decision to restrain the inmate.359 According to Health
Care Management Issues in Corrections, when an inmate with a diagnosed or suspected
mental illness is placed in restraints, staff should notify mental health personnel as soon
358

http://www.rxlist.com/script/main/srchcont_rxlist.asp?src=seroquel (last visited Oct. 30, 2008).
Letter from Bill Lann Lee, Acting Assistant Att’y Gen., Civil Rights Div., to Brian S. Quirk, Chair,
Black Hawk County Bd. of Supervisors, at “Minimum Remedial Measures, Mental Health Care,
recommendation 10” (Jan. 4, 1999), available at http://www.usdoj.gov/crt/split/documents/bhfind.htm.

359

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Woodbury County Jail:  Analysis, Conclusions, and Recommendations
 
 

 

as possible for clinical advice on the continuation of the restraint.360 The NCCHC and
the ACA require, pursuant to their policies, that medical personnel be notified if an
inmate who has a suspected mental illness is placed in restraints. As mentioned above,
the E.R.C. Inc. instruction manual states the two-hour time limit allows the correctional
facility to seek medical or psychological help for the detainee. The manufacturer’s
Customer Letter repeats this policy by stating “[t]his time limit was established to allow .
. . the correctional officer to seek medical or physchological (sic) help for the
detainee.”361
Conclusion: The Ombudsman believes the jail had adequate knowledge that G.A.’s
mental health condition could have played a part in his aggressive behavior. The
Ombudsman finds Woodbury County Jail’s failure to contact a mental health professional
unreasonable, given the jail’s existing relationship with Siouxland Mental Health, the
jail’s medical and mental health information from G.A.’s prior incarceration, and G.A.’s
evaluation immediately prior to the restraint chair use.
The Ombudsman makes the following recommendations:
6. Woodbury County Jail should incorporate language in its written policy
requiring a mental health review, conducted by a mental health professional, of any
inmate with a known or suspected mental illness who is placed in a four- or fivepoint restraint device.
6. Written and Video Documentation
The jail was not able to provide documentation for either restraint occasion showing G.A.
was periodically reviewed to determine whether he could be safely released from the
restraint chair. It also could not provide documentation on the jail’s rationale when it did
release him. Written officer reports cover only the events leading up to the need for the
restraints and end after G.A. was placed in the restraint chair. Aside from the cell entry
and initial placement on the restraint board and the chair, the jail did not video record its
use of the restraint chair. Only vague written logs recording when the straps were
checked, tightened, or loosened recount the events during the restraint chair use.
Jail policy states restraint devices must not be used as punishment and only used when a
prisoner is a threat to themselves or others, or jeopardizes jail security. The policy also
explicitly states “[r]estraint devises (sic) shall not be applied for more time than is
necessary to alleviate the condition requiring the use of the restraint device.”362 This
policy reflects Iowa law, federal case law, and the manufacturer’s policy. Cited
throughout this report are federal district court cases, including two in Iowa, that have

360

KENNETH L. FAIVER, HEALTH CARE MANAGEMENT ISSUES IN CORRECTIONS 152 (1998).
Letter from Thomas Hogan, President , E.R.C. Inc., to Customer (Jan. 17, 2001).
362
WOODBURY COUNTY JAIL POLICIES AND PROCEDURES, JSOG 149 4.4.2 (2007).
361

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Ombudsman Investigative Report 
 
 
 
found correctional facilities liable for not being able to justify continued use of restraint
devices, even while initial placement was deemed appropriate.363
The Ombudsman’s concern with Woodbury County Jail is that the jail has no record or
documentation that justifies or demonstrates the continued need for restraints. This left
questions for the Ombudsman as to the need for the lengthy restraint and could expose
the jail to liability if the inmate brought a claim. If the restraint chair is used for more
time than was necessary to alleviate the condition requiring its use, questions arise
whether the use constitutes punishment in violation of its policy, Iowa law, and Eighth
and Fourteenth Amendment protections.
The Woodbury County Jail provided the Ombudsman with video of the cell extraction,
restraint board placement, and the transfer from the restraint board to the restraint chair.
However, the recordings end after G.A. was secured in the restraint devices. Along with
a lack of written documentation, the jail cannot provide any supplementary video
documentation showing G.A.’s behavior and need for continued restraint.
The Ombudsman strongly endorses the use and retention of video documentation for the
inmate’s duration in a restraint device. A recording provides an accurate account of the
events leading up to and during restraint. It provides a resource for supervisors to review
the actions of officers and make any necessary changes to procedures. It can also be used
to identify actions that are contrary to policy that may require disciplinary action, or to
rebut false allegations from inmates about officer abuse. All recordings of restraint
device use should be kept for at least two years, the duration of Iowa’s statute of
limitations for tort actions.
Conclusion: The Ombudsman finds the jail’s ability to provide only scant documentation
addressing the restraint chair use was unreasonable. Without documentation drafted
contemporaneously with the observation of the inmate’s actions and disposition, the jail
cannot show how the inmate remains a threat to self, others, or security at the facility.
This leads to questions whether the jail is using the restraint device for legitimate
purposes allowed under law or for punishment in violation of Iowa law and the inmate’s
constitutional rights. Absent clear documentation addressing the continued need for
restraint device use, the Ombudsman must conclude that use is not justified.
The Ombudsman makes the following recommendations:
7. Woodbury County Jail needs to show continued use of the restraint chair is
necessary and should do this by having staff document their observations either in
reports or facility logs – preferably both.

363

Sadler v. Young, 325 F.Supp.2d 689 (W.D. Va. 2004); Ogden v. Johnson, No. C00-0034, 2002 WL
32172301 (N.D. Iowa Sept. 5, 2002); Rogers v. Dunn, No. C00-0188-PAZ, 2001 U.S. Dist. LEXIS 22710
(N.D. Iowa Nov. 27, 2001).

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8. The jail should incorporate the practice of video recording the placement of an
inmate in a restraint device, the duration of its use, and the release of the inmate.
This practice should also be reflected in the jail’s written policy as part of the
procedures for restraint device use. Copies of each recording should be retained for
a minimum of two years.

105

 

   

  

Appanoose County Jail – Findings, Conclusions, and Recommendations
A. Findings of Fact
T.F. wrote to the Ombudsman on February 3, 2007, claiming she was harassed by the
Centerville Police Department on December 31, 2006. She described being held in a
restraint chair for ten hours after her arrest. She claimed that when she was “hollering for
someone to let me out so I could go to the bathroom” during her restraint, a female jailer
came to the door with a male officer. The male officer told her if she didn’t shut up she
would be “tazered” (sic) while holding the Taser in his hand.364 She claimed she
defecated when officers left her in the chair.
1. Inmate Reception and Placement in Restraint Chair
An officer’s incident report states T.F. arrived at the jail at 7:00 p.m. and was aggressive
from the beginning when she refused to get out of the patrol car.365 A video reviewed by
the Ombudsman showed T.F. in handcuffs escorted into a small room by several officers.
She appeared to be hyperventilating, not responding to questions, and unintelligible,
except for repeating the words “get them off,” apparently referring to the handcuffs. An
ambulance was called 15 minutes after T.F. arrived at the jail, but medical personnel
could not find anything wrong with her. Soon after medical staff left, Officer Cairns’
report states T.F. jumped out of a chair and hid behind the booking counter. The report
states T.F. began punching herself in the face, hitting her head against the wall, and
jammed her thumbs in her eyes. She told officers if she stayed there, she would die. She
was then placed in the restraint chair for the first of two occasions that night at 7:40 p.m.
She soon calmed down and was released at 7:56 p.m.366
The video, referred to in an incident report as the “O.W.I. camera,” was used to record
T.F.’s actions and the breath test. It was not intended to record or observe her placement
in the restraint chair. When T.F. refused to participate in the breath test, the camera was
shut off, approximately an hour after it started recording. Officer Cairns’ report stated
T.F. tried to get her medications out of her purse after the breath test. When an officer
tried to stop her, a struggle ensued. At 8:16 p.m., T.F. was placed in the restraint chair a
second time and moved to a temporary cell, where she remained for the next ten hours.367
2. Restraint Chair Monitoring
Officer Cairns reported he checked on T.F. every 15 minutes and loosened the arm
restraints twice. At one point, T.F. was able to get her head under a shoulder strap, trying
to strangle herself with it.”368 Officer Cairns notified T.F. several times that if she
364

A Taser is a weapon that uses electrical impulses to cause neuromuscular incapacitation in a subject.
http://www.taser.com/research/technology/Pages/NeuromuscularIncapacitation.aspx.
365
Incident Report from C.O. Mitch Cairns (Dec. 31, 2006).
366
Id.
367
The Jail’s restraint chair was purchased from E.R.C. Inc. in 2001.
368
Incident Report from C. O. Mitch Cairns (Dec. 31, 2006).

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Appanoose County Jail:  Findings of Fact
 
 
calmed down, he would remove her from the restraint chair. For the remainder of his
shift, which ended at 11:00 p.m., T.F. continued to yell and curse at officers. When
Officer Vicky Butler arrived at that time, she reported hearing an inmate yelling and
threatening jail staff. Soon after her shift started, Officer Butler reported hearing T.F.
yell, “I will kill you if you don’t get me out of this chair.”369 An hour-and-a-half later,
T.F. yelled, “I will kick your ass when I get out of this chair.”370
T.F. remained verbally disruptive for the next five hours. Officer Butler’s report states at
5:35 a.m., T.F. began rocking the restraint chair in an attempt to tip it over. Officer
Butler called additional officers to the jail. “Deputy Carter, Wayne Moore, and Rick
Butler arrived in the jail. Deputy Carter advised T.F. to stop yelling and trying to tip the
chair over or she would be Tased.”371 According to T.F.’s letter to the Ombudsman, she
was yelling because she needed to use the restroom, and defecated herself when officers
refused to let her out. She was released from the restraint chair at 6:00 a.m.
The Ombudsman obtained a shift log indicating when T.F. was checked during Officer
Butler’s shift and the incident reports from Officer Cairns and Officer Butler. However,
Jail Administrator Deloris Beck stated no other officer wrote a report, including Officer
Carter who threatened to use the Taser on T.F. While the Ombudsman was able to
review the O.W.I. video, the jail could not provide a copy of the security tape that
documented T.F. in the restraint chair because it had automatically been recorded over.
The jail has no in-house medical or mental health staff, and the jail does not routinely
contact medical or mental health professionals during or after an inmate has been placed
in the restraint chair. Nor does written policy require contact with medical or mental
health staff. In its entirety, the Appanoose County Jail restraint chair policy and
procedure states:
POLICY
The Emergency Restraint Chair (E.R.C.) is intended to help control combative, self
destructive, or potentially violent inmates. All staff involved in the use of the
Emergency Restraint Chair shall be trained in the proper usage of the chair.
PROCEDURES
1. When appropriate all detainees’ personal property shall be removed prior to
placement in the ERC.
2. The detainee should be handcuffed and wearing leg irons when warranted.
3. Restraint straps are not to be placed around detainee’s chest, head, or neck.
4. Detainees placed in the Emergency Restraint Chair must be monitored
continuously by CCTV. Personal observation will be every 15 minutes.

369

Incident Report from C.O. Vicki Butler (Dec. 31, 2006).
Id.
371
Id.
370

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Ombudsman Investigative Report 
 
 
 
5. Detainees are to be removed from the chair when it is believed that there is no
longer a threat to self or others.
6. Detainees shall not be left in the Emergency Restraint Chair for more than two
hours at a time. This time may be extended, but only under direct medical
supervision. [Second sentence added during June 26, 2007, revision.]
7. Jail Administrator and/or Jail Supervisor shall be notified as soon as possible
that a detainee has been placed in the Emergency Restraint Chair.
Administrator Beck stated in a letter to the Ombudsman dated March 12, 2008,
that T.F. was the only inmate the jail has left in the restraint chair for more than
two hours and did so because staff felt they were in danger since she was
displaying aggressive behavior throughout the night.

B. Analysis, Conclusions, and Recommendations
The decision to place T.F. in a restraint chair arose soon after her arrival at the
Appanoose County Jail. As such, the jail could not conduct a full medical and mental
health background to determine her history and needs in these areas. Based on the
documented physical aggression of T.F. and verbal threats, the Ombudsman believes the
jail had sufficient security concerns to place her in the restraint chair. However, several
areas of concern need to be addressed after her placement, including the periodic medical
and mental health reviews of T.F., an officer’s threat and the jail’s policy of allowing the
use of a Taser device on inmates in the restraint chair, and the lack of video
documentation during the restraint chair use.
1. Medical and Mental Health Review During Restraint Chair Use
Before T.F.’s first 15-minute placement in the restraint chair, jail staff called for an
ambulance to review her medical condition due to her hyperventilating. A brief review
determined she did not require medical attention. Shortly after medical personnel left,
staff placed her in the restraint chair when she began punching herself in the face, hitting
her head against the wall, and jamming her thumbs in her eyes. She was placed in the
restraint chair a second time when she tried to get medication from her purse and
struggled with jail staff. The second placement lasted almost ten hours.
The jail uses a restraint chair manufactured by E.R.C. Inc. According to the
manufacturer’s instruction manual, an inmate is not to be left in the restraint chair for
more than two hours – a policy the manufacturer repeats on its website, instructional
video, and letter to customers. This time limit may only be extended after direct medical
supervision by a doctor or nurse. The chair’s manufacturer, Tom Hogan, explained to the
Ombudsman that the initial two hours allows jail staff to observe any unusual behavior by
the inmate and contact a medical or mental health professional as necessary. The
NCCHC standards and the ACA standards recommend jail staff notify health services
immediately when restraints are used in order to review the inmate’s medical record and
monitor the continued use of the restraint device.
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Appanoose County Jail:  Analysis, Conclusions, and Recommendations
 
 
 
According to Jail Administrator Deloris Beck, the jail does not routinely contact a
medical or mental health professional during or after an inmate’s placement in the
restraint chair.372 However, according to written policy, an inmate cannot be left in a
restraint chair for longer than two hours unless under direct medical supervision.
Administrator Beck also stated that the jail has no in-house medical or mental health
personnel, and instead relies on a local hospital for emergency medical care. The local
hospital was not consulted during or after T.F.’s placement, and no other medical
professional reviewed her condition.
T.F.’s behavior before her placement and the length of time that was needed for the
restraint chair use should have alerted staff of a potential mental illness. A suspected
mental illness may come from responses to questions during the medical screen at
admission, or it could come from the inmate’s statements or behavior after admission. In
this case, the video showed T.F. to be violent and incoherent, and officer reports stated
she was hitting herself and trying to jam her thumbs in her eyes. This behavior should
have raised concerns about the presence of a potential mental illness. A mental health
professional would have been able to evaluate T.F. to determine if the aggressive actions
were behavioral or the result of a mental illness. A mental health professional would also
have been able to evaluate the inmate to determine whether the jail had the capacity to
provide for her or whether she needed to be placed in another facility.
T.F. apparently was an exceptional case for the jail. Administrator Beck reported she
was the only inmate the jail has left in the restraint chair for more than two hours. This
provides additional evidence that medical staff and mental health professionals should
have been contacted during the restraint chair use. This was not a normal circumstance
where the device was used for a brief incident until an inmate calmed down. The
exceptional use of the restraint chair on T.F. should have alerted jail personnel that there
could have been a medical or psychological emergency causing T.F.’s aggressive action,
as is contemplated by the manufacturer’s instruction manual, instruction video, and
Customer Letter.
Conclusion: The Ombudsman concludes the Appanoose County Jail acted contrary to its
own policy when it failed to consult a medical professional. It is important a medical
professional evaluates the inmate in-person to determine whether any medical needs must
be addressed. The jail acted unreasonably when it failed to contact a mental health
professional during T.F.’s restraint, given her aggressive behavior before and during the
restraint.
The Ombudsman makes the following recommendations:
1. Appanoose County Jail should adopt written policy detailing when medical and
mental health staff should be contacted during restraint device use.
372

Id.

109

Ombudsman Investigative Report 
 
 
 
a. Medical staff should be notified immediately when an inmate is placed in
a restraint device. The written policy should reflect the manufacturer’s instructions
requiring direct medical supervision if the restraint device is required beyond the
initial two hours.
b. Written policy should require jail staff to contact a mental health
professional in the event an inmate with a known or suspected mental illness needs
to be placed in a restraint device. The jail should enter a formal relationship with a
mental health professional to provide this service. The sheriff’s office should work
with the county’s central point of coordination (CPC) to locate a mental health
contact that can provide these services.
2. In the event that cost and the lack of local services is a prohibitive factor in
obtaining mental health services, the jail should review the use of telemedicine to
obtain these services outside the region.
2. Potential Use of Taser Device While in Restraint Chair
According to T.F.’s letter to the Ombudsman, she hollered at staff to let her out so she
could go to the bathroom. A correctional officer threatened to “Taser” her if she did not
shut up. An officer’s incident report states T.F. was rocking the restraint chair and trying
to tip it over, at which time Deputy Carter told her to stop yelling and trying to tip the
chair over, or she would be “Tased.” T.F. stopped yelling and claims she defecated while
in the chair. Administrator Beck informed the Ombudsman there is no record of T.F.
requesting to use the restroom and according to jail staff, she did not urinate or defecate
while in the chair.373
Based on the Ombudsman’s review, there are no Iowa or Eighth Circuit cases involving
the deployment of a Taser device on inmates who are also in a restraint device. However,
the Ombudsman reviewed a federal district court case from Missouri that described a jail
inmate suffering from the effects of narcotics who had to be placed in a restraint chair.374
When medical staff attempted to insert an IV to counter the effects of the narcotics, the
inmate would make movements to dislodge the IV or cause it to reverse its flow. Jail
staff then deployed the Taser against the inmate’s neck. The district court found the use
of the Taser to be objectively reasonable since jail staff deployed it for the inmate’s
safety to administer the IV, for officer safety to prevent the spread of communicable
disease, to maintain control of the jail, and to gain the inmate’s compliance.375
The Ombudsman questions the rationale for the use of a Taser device on an inmate
placed in a restraint chair. The restraint chair is used as a means to control a violent
inmate who may be a threat to themselves or others. If the inmate continues to be a threat
373

Id.
McBride v. Clark, No. 04-03307-CV-S-REL, 2006 WL 581139 (W.D. Mo. Mar. 8, 2006).
375
Id. at *23.
374

110

Appanoose County Jail:  Analysis, Conclusions, and Recommendations
 
 
 
to themselves or others after being placed in a restraint device and a Taser is needed for
control, the usefulness of the restraint device to control an inmate is called into question.
The Ombudsman spoke with Tom Hogan, who invented, manufactured, and marketed the
restraint chair used by the Appanoose County Jail. When asked about the use of a Taser
device, Mr. Hogan replied, “I cannot think of a circumstance where someone would use
pepper spray, Taser, or stun gun on an inmate who is in the restraint chair.”376 According
to Mr. Hogan, it is almost impossible to tip the restraint chair if the inmate is strapped in
properly. Further, he suggested a simple solution of backing the restraint chair into a
corner to minimize any possibility of tipping the restraint chair. Given the low likelihood
the restraint chair could be tipped over, he contemplated that it may even be beneficial to
let the inmate “bounce around” in the chair to use energy and hopefully calm down
sooner.377
The Ombudsman observed a solution another county jail came up with to secure the
restraint chair. The jail, which uses the same restraint chair as Appanoose County Jail,
bolted a metal “lip” to the concrete floor that hooked on the foot plates of the chair.
While it is not known whether this method is approved by Mr. Hogan, the Ombudsman
believes it is a better alternative to deploying a Taser on an inmate to prevent the chair
from tipping.
Conclusion: Although a Taser was not deployed in this incident, jail staff indicated it
potentially could be used on the inmate in the restraint chair. The Ombudsman opposes
the use of Taser devices while an inmate is in a restraint device unless absolutely
necessary and other less restrictive options for reducing the threat to the inmate’s self are
not available.
The Ombudsman makes the following recommendations:
3. Appanoose County Jail should draft a policy detailing the limited circumstance
when a Taser device may be deployed on an inmate who is secured in a restraint
device. The jail should explore alternatives that would reduce the likelihood of the
restraint chair tipping due to an inmate’s aggressive behavior that do not include
the use of a Taser.
3. Toilet Breaks
The Ombudsman cannot substantiate the inmate’s claim that she defecated while in the
restraint chair when staff refused to let her use the toilet. Jail staff reported she did not
defecate or urinate while in the chair, and no video documentation is available to
substantiate either party’s claim. However, it is relevant to review procedures set forth
by other organizations and agencies to determine what practices should be in place for
county jails who restrain inmates for extended periods of time.
376
377

Telephone Interview with Tom Hogan, President, Emergency Restraint Chair, Inc. (June 11, 2008).
Id.

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Ombudsman Investigative Report 
 
 
 
According to the APA’s Resource Document, which addresses the use of restraint
devices for mental health interventions in jails and prisons, nursing staff should perform a
medical assessment of the inmate every two hours, which would include the need for
toileting.378 Separate from the medical assessments, toileting of the patient should be
provided at least every four hours and more often if necessary. In the event the toilet
facilities are outside the restraint area and safety concerns suggest that release would be
unnecessarily dangerous, a urinal or bed pan should be used with appropriate
considerations of both privacy and safety.379
The Federal Bureau of Prisons’ policy provides the use of the toilet at every two-hour
review, “unless the inmate is continuing to actively resist or becomes violent while being
released from the restraints for this purpose.”380 While the policy places conditional
language for the break, it contemplates providing a break even if the inmate is a present
threat to himself or staff if released:
Based on the particular nature of the situation, the Lieutenant who has
offered the inmate a bathroom break will determine how many staff are
needed to release the inmate from restraints and provide the inmate a
bathroom break. The Lieutenant will assemble the staff and visually
observe and direct staff as they complete this task. The Lieutenant will
determine what protective equipment is needed, if any, for the staff assisting
with the inmates (sic) bathroom break.381
Conclusion: The Ombudsman believes it is possible T.F. needed to use the toilet during
her restraint, given the alleged event occurred nine hours after her restraint. To not allow
for toilet breaks and force inmates to sit in feces or urine is both unsanitary and
inhumane.
The Ombudsman makes the following recommendations:
4. Appanoose County Jail should develop written policy allowing for toilet breaks
of restrained inmates, including time increments to offer such breaks and the
number of staff members required to facilitate the breaks.
4. Video Documentation
The Appanoose County Jail provided the Ombudsman with video of T.F.’s initial
admission to the jail for purposes of O.W.I. documentation. However, once the attempt
378

JEFFERY L. METZNER ET AL., COUNCIL ON PSYCHIATRY AND LAW, THE USE OF RESTRAINT AND
SECLUSION IN CORRECTIONAL MENTAL HEALTH CARE 6 (2006).
379
Id.
380
FEDERAL BUREAU OF PRISONS, PROGRAM STATEMENT P5566.06(10)(e) (2005), http://www.bop.gov/
policy/progstat/5566_006.pdf
381
Id.

112

Appanoose County Jail:  Analysis, Conclusions, and Recommendations
 
 
 
to administer the breath test was complete, the video was shut off. When the
Ombudsman inquired about any additional video, Administrator Beck stated the jail did
not have video of T.F. in the restraint chair because “[t]he time for us to copy T.F. in the
restraint chair had been recorded over before we knew we would need the video.”382 T.F.
contacted the Ombudsman approximately one month after her December 31, 2006,
placement in the restraint chair. The Ombudsman contacted the jail two weeks later, and
formally requested video documentation from the jail two months after the incident.
Conclusion: The video could have provided helpful evidence to evaluate T.F.’s claim
that she defecated in the chair, and verified whether her behavior and actions justified
continued use of the restraint chair or even the threat of the Taser deployment.
The Ombudsman makes the following recommendations:
5. Appanoose County Jail should use and retain video documentation of the
placement, duration of use, and release of an inmate in a restraint device. Such
documentation should be retained for at least two years, the statute of limitations
for tort actions in Iowa.

382

Letter from Deloris Beck, Jail Adm’r, Appanoose County Sheriff’s Office, to Andy Teas, Assistant
Ombudsman, Iowa Citizens’ Aide/Ombudsman (Mar. 12, 2008) (on file with author).

113

   

  

Wapello County Jail – Findings, Conclusions, and Recommendations
A. Findings of Fact
J.L. entered Wapello County Jail for public intoxication on May 20, 2007, at 7:25 p.m.
He called the Ombudsman on May 24, 2007, saying the jail ignored his bronchitis when
it claimed he was faking the condition. He asserted he was put in the restraint chair when
he tried to get medical attention for his bronchitis. An officer reportedly jumped on his
chest, jammed fingers under his rib cage, and pulled his hair while he was restrained.
J.L. later told the Ombudsman he had a rib fracture, caused by an officer striking him in
the middle of the chest repeatedly. J.L. also alleged the officer also tried to pull his ribs
out.
Based on the accusations, the Ombudsman obtained the incident reports and videotape of
the incident. Many of J.L.’s accusations could not be substantiated by the video. The
Ombudsman had further questions about the severity of J.L.’s bronchitis considering he
was arrested for being belligerent, yelling at a mother and daughter, and registering a
.239 on a preliminary breath test.383 However, the Ombudsman did have concerns
regarding language in an officer’s report and an incident filmed on a CCTV camera that
showed an officer struggling with J.L. and striking him while in the restraint chair.
1. Placement in Restraint Chair
Approximately ten minutes after J.L. arrived at the jail, officers began preparing the
restraint chair to restrain him. According to Officer Travis Bates’ report, J.L. began
hitting his head against the cell’s window. Officers decided to use the restraint chair for
J.L.’s safety. The restraint chair was set outside of J.L.’s cell, out of the full view of the
camera. Though partially obstructed by a wall, the video shows two officers placing J.L.
in the restraint chair. However, the tape ends at approximately 7:37 p.m. before
placement was complete
The next tape begins prior to officers removing J.L. from the restraint chair at 9:44 p.m.
The removal occurred outside of J.L’s cell, and again, the camera view was partially
blocked by a wall. J.L. told the officers he was fine and would cause no more trouble,
but soon after being released, he began striking the cell’s window again.384 Thirteen
minutes after his first removal from the restraint chair, officers initiated a second
placement in the restraint chair.
While the video shows two officers present – identified as Officer Jeremy McDowell and
Officer Nicole Cassatt in supplemental reports – only Officer McDowell was actively
involved in placing J.L. in the restraint chair. Again, the restraint chair was set outside
J.L.’s cell, out of full view of the security camera. J.L. immediately began resisting
McDowell’s efforts and in the ensuing struggle pushed the restraint chair into full camera
383

Complaint & Affidavit, Ottumwa v. [J.L.], OTSMSM024472 (Iowa Dist. Ct. Wapello County, May 20,
2007).
384
Correctional Officer’s Supplemental Report from Jeremy McDowell (May 21, 2007).

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Wapello County Jail:  Findings of Fact
 
 
 
 
 
view. Officer McDowell is seen struggling to place J.L. in the restraint chair while
another security camera angle shows Officer Cassatt holding the cell door open. After
strapping J.L.’s arms, shoulders, and waist into the chair, Officer McDowell’s report
described what happened next:
While getting this fastened he kicked me in the head with his right foot. He
tried again a couple of times to kick me again and I instructed him to put his
legs down and quit kicking me. When he didn’t comply I struck him in the
sternum and told him to put his legs down again and to quit resisting till I
got control of his legs and had them fastened.385
After placing the lap belt around J.L.’s waist, the video shows Officer McDowell reach
back in a striking pose. Due to the choppy nature of the video, it does not show the
impact of the blow. It does show Officer McDowell’s arm extended outward into J.L.’s
chest area and the restraint chair moved back several inches. Immediately afterward,
another officer approaches the restraint chair and helps secure J.L.’s legs.
2. Documentation of Restraint Chair Use
The CCTV video at the time of J.L.’s restraint was set to only capture action through still
pictures and was not streaming. In addition, there was no video observing J.L. while he
was restrained during each of his two-hour sessions in the restraint chair. The camera
closest to the cell was placed on the opposite side of the reception area and did not
capture enough detail to provide the Ombudsman with any useful information on what
took place in the cell. Any type of video observation was rendered useless the second
time J.L. was placed in the restraint chair because the lights in his cell had been turned
off.
The Ombudsman received three officer reports explaining the rationale for J.L.’s
placement in the restraint chair, as well as Administrator Weller’s summary to our office
of his review. As cited above, Officer McDowell’s report states that he struck J.L. in the
sternum when J.L. would not stop trying to kick him. Administrator Weller’s account
states that Officer McDowell struck J.L. with a “soft blow to the stomach area,” while
Officer Cassatt’s report states he struck J.L. right below the ribs.386
The video and officer reports are the only documentation the jail provided to the
Ombudsman. However, these sources did not document the events over the duration of
restraint chair use. Though specifically requested, no 15-minute log of the restraint chair
was provided by the jail. Written jail policy states a daily activity log must be maintained
on the inmate after placement in the restraint chair, documenting observations and
activity every 15 minutes. While written policy also stated the inmate should be
385

Id.
Letter from Jeremy Weller, Jail Adm’r, Wapello County Jail, to Ombudsman’s Office (June 8, 2007);
Use of Restraint Chair on Inmate J.L. from C.O. Nicole Cassatt (no date provided).
386

115

 

Ombudsman Investigative Report 
 
 
 
considered for removal at least hourly, no documentation was provided showing this was
done, nor was any reason given for why J.L. remained in the restraint chair beyond the
initial hour after placement.

B. Analysis, Conclusions, and Recommendations
The Ombudsman relied on the security videos, written documents, and conversations
with Jail Administrator Jeremy Weller for its conclusions. The Ombudsman identified
three areas of concern, including (1) the application of the restraint chair, (2)
documentation of the use of force, and (3) video documentation of the use of force. A
full understanding of policies and practices of the jail was impaired by a lack of
responsiveness from the jail during the investigation.387 However, the Ombudsman
obtained sufficient facts and information to arrive at the conclusions listed below.
1. Application of Restraints
J.L. was placed in the restraint chair on two occasions the night of May 20, 2007, with a
15-minute break in between.388 J.L. was placed in the restraint chair on the first occasion
for his own safety when he began hitting his head against the window of his cell.
Security video of the first restraint shows two officers placing him in the restraint chair.
After approximately two hours, officers released J.L. from the restraint chair. J.L. said he
was fine and would cause no more trouble; but soon after being released, he began
breathing heavily, claiming he had asthma, and pretended to pass out on the cell floor.389
When officers ignored him, he began hitting the glass with his arms and banging his head
against the cell floor. Officers then decided to place him in the restraint chair a second
time.
According to Officer McDowell’s supplemental report, he called for assistance to place
J.L. in the restraint chair the second time. The report stated he and Officer Cassatt
removed J.L. from the cell and placed him in the restraint chair, but video of the incident
showed only Officer McDowell actually trying to place J.L. in the restraint chair. Officer
Cassatt is seen holding the cell door open, even after J.L. was removed from the cell.
Officer McDowell is seen struggling with J.L. in an attempt to place him in the restraint
387

After reviewing the videos, written policy, and officer reports, the Ombudsman sent Administrator
Weller a list of written questions on February 28, 2008, relating to the May 20, 2007, use of force by jail
staff. The Ombudsman received a call from Administrator Weller on March 4 stating he understood the
Ombudsman previously concluded staff had done nothing wrong. The Ombudsman explained no such
conclusion had been reached at that point and the investigation was still open, as represented by the letter.
When the Ombudsman heard nothing further from Administrator Weller, he left three messages for
Administrator Weller and one for Chief Deputy Mark Miller between April 15 and May 13. The
Ombudsman never received a return call. Instead, the Ombudsman received a set of documents via fax on
May 14, many of which were duplicates of documents already obtained by the Ombudsman. None of the
enumerated questions were directly responded to, and the only document the Ombudsman requested, the
15-minute activity log, was not provided.
388
Wapello County Jail, Emergency Restraint Log (May 20, 2007).
389
Correctional Officer’s Supplemental Report from Jeremy McDowell (May 21, 2007).

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Wapello County Jail:  Analysis, Conclusions, and Recommendations
 
 
 
 
 
chair for over two minutes. During that time, Officer Cassatt never assisted Officer
McDowell with the placement. Officer McDowell succeeded in applying the arm,
shoulder, and waist straps, but when he attempted to apply the ankle straps, J.L. kicked
him in the head. This was followed by Officer McDowell punching J.L. in the chest.
After more than two minutes of struggling alone with J.L., Officer Cassatt and another
officer approached and assisted Officer McDowell with applying the ankle straps.
The Ombudsman has not previously reviewed any cases presented to this office where a
single officer is used to place an inmate in a restraint device. In fact, the Woodbury
County Jail used five officers for its cell extraction, placement on a restraint board, and
transfer to the restraint chair in one case reviewed by the Ombudsman. The Polk County
Jail employed five officers in a restraint chair placement reviewed by the Ombudsman,
with another two officers on hand. Five officers were used on at least one occasion by
Jefferson County Jail during their placement of an inmate, and no fewer than three
officers were actively involved in other restraint chair placements. While the restraint
chair instruction manual does not provide a recommended number of officers to use the
restraint chair, the instructor on the video informs the viewer, “Now, to do this properly,
we should have a person on either side of the chair.”390 During an interview with the
Ombudsman, E.R.C. Inc. President Tom Hogan confirmed he recommends at least two
officers should be used to place an inmate in the restraint chair.391
The Ombudsman believes the use of a single officer to actively place a resistant inmate in
the restraint chair directly resulted in the officer getting kicked in the head. In addition,
the subsequent punch by Officer McDowell occurred when J.L.’s arms, shoulders, and
waist were restrained to the chair. The Ombudsman questioned whether this was the
appropriate response from the officer when it appeared the officer had the opportunity to
step away from the inmate, without the risk of a further attack from the inmate, until
additional help could arrive. The Ombudsman did not receive any response to this
written question from Administrator Weller.
Conclusion: Officer McDowell acted unreasonably when he attempted to place J.L. in
the restraint chair by himself. The Wapello County Jail should ensure at least two
officers are used to place an inmate in a restraint device. Using at least two officers
means they would actively control and handle the inmate, not only observe the inmate’s
placement in the restraint device. The number of officers recommended by the
Ombudsman is based on the observations of the procedures employed by other county
jails and the recommendation from the restraint chair instruction video. The use of at
least two officers is necessary to prevent injury to the officers and the inmate.
Punching J.L. in the chest was not a reasonable response to being kicked in the head. The
interest in gaining compliance at that moment did not outweigh the risk of serious injury
or death that could have been caused by the punch to the chest. Officer McDowell had an
390
391

Videotape: Emergency Restraint Chair Instructions (E.R.C. Inc.)
Telephone Interview with Tom Hogan, President, Emergency Restraint Chair, Inc. (June 1, 2008).

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Ombudsman Investigative Report 
 
 
 
opportunity to step away from J.L. until another officer could arrive to help with the
restraint. J.L. was restrained by his arms, shoulders, and waist, and he posed no further
physical threat to staff if Officer McDowell had stepped away.
The Ombudsman makes the following recommendations:
1. The Wapello County Jail should include language in its written policy and
training requiring at least two officers to actively place an inmate in the restraint
device.
2. The jail should adopt language in its policy that details what type of force may be
used on inmates who are fully or partially restrained in a restraint device.
2. Observation and Documentation
Iowa law requires 15-minute checks of the inmates and the restraint device as well as
documentation of all decisions and actions.392 The jail’s written policy in effect at the
time of J.L.’s placement in the restraint chair stated:
During the time period that the inmate is restrained in the chair, an
activity log will be kept with detailed entries being made every 15
minutes.393 (emphasis added).
The Ombudsman requested, but never received, a log of the 15-minute checks on J.L.
during each of his two-hour sessions in the restraint chair. Administrator Weller faxed
documents on May 14, 2008, with the cover sheet stating “[h]ere are the documents you
requested.” The Ombudsman must conclude that no logs exist documenting the 15minute checks. In addition to Administrator Weller failing to provide an activity log with
detailed entries of the 15-minute checks, the Ombudsman only received the portions of
the security video pertaining to the placement and removal from the restraint chair.
Therefore, the Ombudsman has no written or video evidence proving the 15-minute
checks were conducted pursuant to Iowa law.
Wapello County Jail policy also requires the inmate “be considered for removal from the
chair at least hourly.”394 Administrator Weller did not provide any documentation that
J.L. was considered for removal hourly on either occasion he was restrained. While the
officer reports detail the placement of each incident, they do not indicate an hourly check
was conducted or a rationale for why J.L. was left in the chair each successive hour.
The Ombudsman has further concerns regarding the cell where J.L. was placed during the
restraint chair use. The security video shows the room used during the restraint, along
392

IOWA ADMIN. CODE r. 201—50.13(2)(f) (2008).
WAPELLO COUNTY JAIL POLICY AND PROCEDURE I-8A at 6 (2003).
394
Id.
393

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Wapello County Jail:  Analysis, Conclusions, and Recommendations
 
 
 
 
 
 
with the other cells near it, had the lights turned off. As a result, it is impossible for the
security camera to capture discernable events inside the cell where J.L. was restrained in
the restraint chair. This creates a potentially dangerous situation if the inmate begins to
have medical problems that require an immediate response and staff cannot see into the
room, whether in-person or via the CCTV monitor. This also raises questions about how
the jail would be able to comply with Iowa law requiring continuous observation if an
officer cannot see the inmate in the darkened room.
Conclusion: The Wapello County Jail failed to provide evidence that 15-minute checks
were conducted during the restraint chair use on J.L. The failure to keep an activity log
with 15-minute entries is a violation of jail policy. The failure to conduct 15-minute
checks is also contrary to the requirements of restraint device use under Iowa law. In
addition, the jail did not follow its policy to conduct hourly checks of the inmate or
document any decisions to keep the inmate in the restraint chair. The hourly checks serve
to comply with Iowa law and inmates’ constitutional rights that an inmate remain in the
restraint device only for the amount of time the inmate remains a threat to self, others, or
jail security.
The designated room for restraint chair use should be well-lit to enable staff to
immediately determine if an inmate needs emergency attention. Turning the lights off in
an observation room, when Iowa law requires continuous observation of an inmate in a
restraint device, creates a dangerous situation for the inmate and potential liability for the
jail.
The Ombudsman makes the following recommendations:
3. Wapello County Jail staff must conduct 15-minute checks of the inmate and
restraint device application and maintain logs documenting the 15-minute checks of
the inmate and the restraint device application.
4. The jail should ensure lights in a cell holding the restrained inmate are always
on, regardless of whether the jail uses in-person staff or CCTV to comply with the
continuous observation requirement under Iowa law.
3. Video Monitoring
The security video reviewed by the Ombudsman was motion-activated and recorded in a
series of still shots. This made it difficult to accurately review the events from the video,
including the exact moments when J.L. kicked Officer McDowell and Officer McDowell
punched J.L. However, due to the time sequencing of the still shots, the Ombudsman
was still able to discern these actions occurred. According to Administrator Weller, the
jail has since switched to “streaming” video, so the action recorded is fluid.
The Ombudsman also had concerns about the placement of the security cameras. While
it is difficult to determine the exact distance between the camera and the cell, it is
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Ombudsman Investigative Report 
 
 
 
apparent they were on the opposite ends of a large booking area. The Ombudsman
strongly endorses the use of video to record the placement and duration of restraint
devices use, even if it is not required under Iowa law. The use of such video loses its
relevance if the video does not capture any of the events it is intended to record. This
issue is particularly relevant since the Iowa Administrative Code now allows continuous
monitoring to be accomplished by CCTV.395 The distance between the camera and the
subject and lighting of the area, as mentioned above, are two important considerations if
video for documentation or continuous monitoring purposes is to be used.
In addition to the streaming video, Administrator Weller assured the Ombudsman the
video camera has been placed in a position that clearly and accurately records the inmate
in the restraint chair.
Conclusion: Video of the restraint chair use did not clearly and accurately capture the
events that transpired while J.L. was restrained due to the distance between the security
camera and the cell where J.L. was placed. The Ombudsman questions how jail staff
could respond to an emergency if staff rely on the video for continuous monitoring but
cannot clearly see the inmate on the video.
The Ombudsman makes the following recommendations:
5. The Wapello County Jail should ensure the video documenting the restraint
chair use provides an accurate account of the events that transpire. This would
include an unobstructed view of the placement and a clear, detailed image of the
inmate during restraint use. Copies of each restraint video should be retained for a
minimum of two years.

395

IOWA ADMIN. CODE r. 201—50.13(2)(f)(1) (2008).

120

   

  

Polk County Jail – Findings, Conclusions, and Recommendations
A. Findings of Fact
M.B. was placed in a restraint chair at Polk County Jail on December 21, 2007. An
officer’s Incident Report stated M.B. flooded his cell and covered the door window with
toilet paper.396 When officers entered the cell to remove him, M.B. refused an order to
turn around and kneel by his bunk and proceeded to come after staff in an aggressive
manner. He was Tasered, removed from the cell, and placed in the restraint chair.397
M.B. contacted the Ombudsman claiming he was strangled by an officer while in the
restraint chair and had bamboo sticks pushed under his finger nails.
The Ombudsman reviewed the incident reports and video of the placement and use of the
restraint chair. The Ombudsman found no indication M.B. was strangled or had bamboo
pushed under his fingernails. However, the Ombudsman did note potential violations of
Iowa law and jail policy, including no apparent 15-minute checks of the inmate and the
restraint as required under Iowa law, no hourly reviews to determine whether the inmate
could be removed from the restraint chair as required under jail policy, and no medical
review of the inmate after the initial two hours of restraint as recommended by the
restraint chair manufacturer.
1. Inmate Monitoring During Restraint Chair Use
Approximately three minutes after officers entered his cell for the extraction, M.B. was
placed in the restraint chair. Video of the restraint chair use recorded an officer ordering
to staff “I want him facing the wall,” before M.B. was placed in an observation cell.
M.B. was placed in the cell at approximately 6:35 a.m. and was eventually released at
11:16 a.m. During this restraint, the Ombudsman only identified four potential checks
before M.B. was released. Those checks, observed on the video, included:
6:40
6:42
8:14
10:02
11:15

Officer enters cell with medical staff to check inmate.
Officer enters cell to reposition chair after inmate rotates restraint chair.
Officer enters cell and appears to check inmate.
Officer speaks to inmate through door.
Staff begin releasing inmate from restraint chair.

According to Lt. Greg Peterman, the security tape “clearly shows staff walking past the
restraint chair room.”398 He explained that staff do not open the door to the cell to check
inmates, but look through the window to observe them. The Ombudsman reviewed the
video to look for any occasion where staff made a deliberate attempt to check the inmate,
even if an officer did not stop to observe the inmate, talk to the inmate, or enter the
inmate’s cell. Counting these occasions, the Ombudsman observed:
396

Incident Report from Officer Susan Michalski (Dec. 21, 2007).
Id.
398
Letter from Lt. Greg Peterman, Polk County Sheriff’s Office, Jail Div., to Andy Teas, Assistant
Ombudsman, Iowa Citizens’ Aide/Ombudsman (Apr. 8, 2008) (on file with author).
397

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Ombudsman Investigative Report 
 
 
6:40
6:42
6:46
6:57
7:32
7:36
8:14
10:02
11:15

Officer enters cell with medical staff to check inmate.
Officer enters cell to reposition chair after inmate rotates restraint chair.
Officer looks in cell.
Officer looks in cell.
Officer looks in cell.
Officer looks in cell.
Officer enters cell and appears to check inmate.
Officer speaks to inmate through door.
Staff begin releasing inmate from restraint chair.399

During the four additional occasions where officers appeared to make an attempt to check
on M.B., he and the restraint chair were facing the wall opposite the cell door’s window.
The restraint chair has a high back in which photos taken of the inmate show the chair’s
back extending to the top of his head. Thus, the most an officer would be able to observe
from behind is the back of the chair, the very top of the inmate’s head, and the back of
the inmate’s arms.
The Ombudsman requested and received the special inmate supervision logs that
documented the 15-minute checks. The logs appear to be entered by the same person for
each 15-minute check, though the Ombudsman did not identify on the video a specific
officer conducting the checks. The logs also show the checks were done exactly at 15
minutes on the hour, though the video showed irregular checks being conducted that did
not match the logs. The jail did not respond to written questions inquiring about who
specifically conducted the checks and if that person was the same who entered the checks
in the logs.
In addition to the 15-minute checks, Polk County Jail policy requires the inmate be
considered for removal from the chair at least hourly. This consideration is based on the
inmate’s immediate past behavior while restrained and the staff and supervisor’s
observations of the inmate. The Ombudsman inquired about these periodic hourly
reviews of the inmate that were not apparent on the video, and no log or report indicated
it was done. Lt. Peterman replied “[a]t one point in the video there was an officer who
entered the room and physically checked [M.B.].”400 A review of the security video
shows an officer entered the observation room at approximately 8:15 a.m., 90 minutes
after the last physical check of the inmate. No other physical checks of the inmate were
conducted during the next three hours of M.B.’s restraint, when he was release at 11:15
a.m.
Lt. Peterman did not explain why there was only one such review of the inmate when the
jail’s policy requires reviews to be conducted at least hourly. Further, for the one
399

Excluded from this list were occasions when officers were conducting other tasks, but looked in the cell,
such as officers escorting prisoners through facility, transporting laundry carts past the cell, and washing
their hands at a sink across the hall from the cell.
400
Id.

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Polk County Jail:  Findings of Fact

periodic review that was allegedly done, there is no documentation detailing what was
observed or the rationale for keeping M.B. in the restraint chair after the review.
Polk County Jail policy requires the jail’s health authority to be notified when an inmate
is placed in the restraint chair:
[T]he health authority or designee on duty must be notified to assess the
inmate’s medical and mental health condition and to advise whether on the
basis of serious danger to self or others, the inmate should be placed in a
medical/mental health unit for emergency involuntary treatment with
sedation and/or medical management as appropriate.401
Approximately five minutes after M.B. had been placed in the restraint chair, the security
video showed a staff member in a medical uniform enter the observation room with a
correctional officer. The medical staff member stayed approximately one minute before
exiting the cell. No documentation from this medical staff member was provided to the
Ombudsman that detailed his observations or assessment of the inmate. So, it is not
known what the medical staff member’s conclusions were of M.B.’s medical and mental
health condition, or what he conveyed to other correctional staff.
2. Documentation
According to Polk County Jail policy, when an inmate is restrained in the restraint chair,
“an activity log will be kept with detailed entries being made every 15 minutes.”402 The
activity log provided to the Ombudsman included a form with the date, time, inmate’s
activity, remarks, and the initials of the officer who entered the data. The inmate’s
activities documented on the form include a checklist of eight actions, including:
9
9
9
9
9
9
9
9

Pacing
Sleeping
Sitting
At Door
Resting
Reading
Writing
Watching TV

The activity log entries are hand-written precisely at 15-minute intervals for the times
covering M.B.’s placement in the restraint chair and marked as “Sitting” each time for his
activity. While 18 activities were documented on the activity log, only two entries were
listed under “Remarks.” At 6:35 a.m., the activity logs states “Placed into restraint
chair,” and at 11:20 a.m., it states “Removed From Chair.”403 Therefore, based on
401

POLK COUNTY SHERIFF’S OFFICE, JAIL DIVISION, SECURITY AND CONTROL, RESTRAINT CHAIR No.
6600.59(II)(A)(1) (2001).
402
Id. at 6600.59(II)(A)(6).
403
Special Inmate Supervision Log for M.B. (Dec. 21, 2007).

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Ombudsman Investigative Report 
 
 
information provided by the activity log, a reviewer is informed M.B. was placed in the
restraint chair, was sitting during its use, and was then released.
Missing from the activity log sheets is any documentation between 7:00 a.m. and 8:00
a.m. According to Lt. Peterman, this time period was during a shift change “and the log
was probably over looked.” However, he states the video shows the inmate had eye-on
contact during this time. The Ombudsman’s review of the video did not show the 15minute checks being done.

B. Analysis, Conclusions, and Recommendations
The Ombudsman identified several areas raising concern about M.B.’s placement in the
restraint chair, including 15-minute checks, periodic reviews, medical reviews, and
documentation. The Ombudsman believes staff violated Iowa law and the jail’s written
policy by failing to adequately observe M.B. throughout his placement and document
each action and decision.
1. Fifteen-Minute Checks
The Activity Log maintained during M.B.’s restraint indicates checks were done at
exactly 15-minuted intervals. This is not consistent with what the video documentation
shows during the restraint session. The Ombudsman only noted five occasions during the
almost five-hour restraint when it appeared staff made a deliberate effort to check on
M.B. “Deliberate efforts” included only those occasions when staff entered the cell to
check the inmate or had verbal contact with the inmate from outside the cell.
To determine what is required under Iowa law during the 15-minutes checks, the
Ombudsman relied in part on statements made by a representative of the Iowa State
Sheriffs and Deputies Association during a Legislative Administrative Rules Review
Committee that addressed the jail rules. According to Linn County Sheriff Don Zeller,
when asked by Representative Dave Heaton what was required during the 15-minute
checks, the checks require staff “going in to look at the individual and checking the
restraints that are placed on there . . . .”404 The Ombudsman shares the views Sheriff
Zeller expressed to the Iowa legislators during the ARRC meeting. Jail staff must enter a
cell and check the inmate and the restraints. This requires more than looking at the back
of an inmate and restraint chair through a cell door window.
The Ombudsman must also consider a scenario posed by a commenter during the public
comment period of the Centers for Medicare and Medicaid Services regulations on
restraint and seclusion, which applies to most hospitals:

404

Proposed Amendments to Ch. 50 Update Jail Inspection Standards: Hearing on ARC 6641B Before the
Admin. Rules Review Comm., 2008 Leg., 82nd Gen. Assem., 2nd Sess. (Iowa 2008) (Statement of Don
Zeller, Linn County Sheriff).

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Polk County Jail:  Analysis, Conclusions, and Recommendations
 
 
 

 
 
Another commenter argued that there is no substitute for face-to-face
monitoring with periodic checks of patient’s vital signs. The commenter
recounted two separate instances where patients died while in restraints and
seclusion. In both instances, the paramedics were unable to ventilate the
patients because they were unable to place a tube down the throat of the
patient. The onset of rigor mortis demonstrated that these patients had been
dead for several hours before hospital staff discovered them and called the
paramedics. The nursing logs for both patients indicated that the patients
had been checked every 15 minutes. In these instances, “checked” meant
looked at through the window into the seclusion room.405 (emphasis
added).

Giving wide latitude on what constitutes a “check,” at one point during M.B.’s restraint
almost two hours pass between checks by jail staff. According to the video, an officer
entered the observation cell and appeared to check M.B. at 8:14 a.m. At 10:02 a.m.,
another officer stopped outside the cell and can be heard talking to M.B. The officer did
not appear to be a jail correctional officer and does not actually enter the cell or check the
restraints. If the Ombudsman were to not count this as a “check,” a total of three hours
would have passed between checks, the next being when M.B. was removed from the
restraint chair at 11:15 a.m.
Conclusion: The Ombudsman concludes the Polk County Jail failed to conduct 15minute checks in violation of Iowa law. The checks must be conducted every 15 minutes
and include up-close, face-to-face checks on the welfare of the inmate and the application
of the restraints to ensure restraint straps or other devices are not affecting the inmate’s
circulation.
The Ombudsman makes the following recommendations:
1. Polk County Jail must conduct 15-minute checks of the inmate and the restraint
device application throughout the duration of the inmate’s placement in a restraint
device. The jail should immediately review this practice with staff and ensure it is
addressed during regular training on restraint device use in the jail.
2.

Periodic Review

The jail was not able to provide evidence justifying M.B.’s continued restraint for almost
five hours. The 15-minute Activity Log provides no detail of M.B.’s behavior other than
to describe him as “sitting.” The security video does not indicate M.B. posed a continued
threat, and the jail did not present any documentation or reports from jail staff detailing
why M.B.’s continued restraint was required. The video offers some insight into why

405

Medicare and Medicaid Programs; Hospital Conditions of Participation: Patient’s Rights, 71 Fed. Reg.
71,378, 71,414 (Dec. 8, 2006) (to be codified at 42 C.F.R. pt. 482).

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Ombudsman Investigative Report 
 
 
 
documentation of periodic reviews was not provided to the Ombudsman; there were no
reviews conducted after 8:14 a.m. until his release three hours later.
The details of M.B.’s release raises further concerns about his disposition. No reviews of
M.B.’s disposition were conducted in the immediate time period prior to his release.
Instead, an officer is heard off-camera say “I’m going to take [M.B.] out of the chair,”
and staff immediately proceed to remove him from the chair without incident. Jail staff
apparently determined M.B. no longer posed a threat to himself or others, or jeopardized
jail security without entering his cell, talking to him, or otherwise observing his behavior.
The Ombudsman believes the jail’s failure to provide evidence justifying the continued
use of the restraint chair may violate M.B.’s constitutional rights to be free from
punishment and Iowa law requiring the use of restraints for only the amount of time
necessary to alleviate the condition causing the restraint. It also risks exposing the jail to
civil liability. The U.S. District Court for the Northern District of Iowa found the fivehour restraint of a Linn County Jail inmate was unreasonable and constituted punishment
where the need for restraints ended after an hour and 15 minutes.406 In a separate case,
the court found the same jail was liable when it could not provide evidence – such as
documentation of reviews and evaluations – justifying the eight-hour restraint of an
inmate.407
The Polk County Jail also violated its own written policy on the use of the restraint chair,
which states “[t]he inmate will be considered for removal from the chair at least
hourly.”408 Asked about this policy and its application to M.B., Lt. Peterman only replied
that an officer at one point entered the room and physically checked M.B. Assuming the
purpose of the officer’s check was to determine whether M.B. could be removed from the
restraint chair, it still does not explain why the required three additional checks are
unaccounted for.
Conclusion: The Polk County Jail cannot provide evidence showing the continued use of
the restraint chair was justified, even while the original placement may have been
reasonable. The Ombudsman questions whether the extended use of the restraint chair
was used for punishment as opposed to controlling an existing threat to the inmate’s self,
others, or jail security. The jail also failed to follow its own written policy requiring an
inmate be considered for removal from the chair at least hourly.
The Ombudsman makes the following recommendations:
2. Polk County Jail should refrain from placing an inmate in a restraint device for a
pre-determined time limit. Such placement could be considered punitive and
406

Ogden v. Johnson, No. C00-0034, 2002 WL 32172301 (N.D. Iowa Sept. 5, 2002).
Rogers v. Dunn, No. C00-0188-PAZ, 2001 U.S. Dist. LEXIS 22710 (N.D. Iowa Nov. 27, 2001).
408
POLK COUNTY SHERIFF’S OFFICE, JAIL DIVISION, SECURITY AND CONTROL, RESTRAINT CHAIR No.
6600.59(II)(A)(4)(a) (2001).
407

126

Polk County Jail:  Analysis, Conclusions, and Recommendations
 
 
 
 
 
contrary to the inmate’s constitutional rights and Iowa law, especially if that predetermined time limit extends to periods when the inmate is no longer a threat to
self, others, or jail security.
3. The jail should conduct periodic checks of the inmate’s disposition and actions to
determine whether the inmate may be released. The jail should train all staff who
may be involved in restraint chair use on the jail’s existing policy requiring “at least
hourly” reviews of a restrained inmate to determine if the inmate may be released.
If the inmate must remain in the restraint device, the jail must document the
inmate’s actions justifying continued restraint.
3. Medical Review
The security video shows a medical staff member checked M.B. five minutes after his
placement in the restraint chair, though no written documentation states what was
observed. During the next 4 hours and 35 minutes, medical staff did not review his
condition. According to the jail’s restraint chair manufacturer, E.R.C. Inc., an inmate
may only be held in the restraint chair for two hours, which may only be extended under
direct medical supervision. This policy is stressed in the instruction manual, the
manufacturer’s Customer Letter, and its instruction video.
Tom Hogan, President of E.R.C. Inc., informed the Ombudsman the initial two hours of
restraint should be used to determine if the inmate’s behavior has underlying medical or
mental health causation, and make those services available to the inmate. The need to
use restraints beyond the initial two hours may itself be an indication the aggressive
behavior is medical or mental health-based.
Conclusion: The Polk County Jail incorporates a good practice of having medical staff
review the inmate after initial placement in the restraint chair. However, the restraint
chair instructions state the restraint chair is only to be used beyond the initial two-hour
time limit under direct medical supervision by a doctor or nurse.
The Ombudsman makes the following recommendations:
4. Polk County Jail should follow the manufacturer’s guidelines recommending
direct medical supervision in the event the restraint chair must be used longer than
the initial two hours, and incorporate this procedure in the written policy.
4. Written Documentation
The Ombudsman has concerns about Polk County Jail’s documentation of the 15-minute
checks, the periodic reviews to determine if an inmate can be removed from restraints,
and the medical checks of inmates. Written documentation on each of these areas is scant
or nonexistent.

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The jail’s Activity Log states checks were done precisely at 15-minute intervals, though
these checks were not reflected on the video showing the inmate and the area around his
cell. The activity log also appears to be entered by the same person, though the
Ombudsman could find no pattern of a single officer checking the inmate. The
Ombudsman sent written interrogatories inquiring about who conducted the 15-minute
checks and who marked the Activity Log, but they were never answered by the jail.409
While checks were marked every 15 minutes, a span of 1 hour is missing from the logs
between 7:00 a.m. and 8:00 a.m. Lt. Peterman explained this was only an oversight by
staff to mark the log during a shift change, but the checks were done on the inmate. The
Ombudsman was not able to substantiate 15-minute checks were conducted during this
time frame based on his review of the video.
Jail policy requires staff to consider restraint removal at least hourly, based on the
inmate’s behavior while restrained and the staff and supervisor’s observations of the
inmate. While Lt. Peterman cites to a single occasion when an officer entered the
observation cell and checked on M.B., which the Ombudsman concludes occurred at 8:14
a.m., there is no written documentation detailing what the officer observed or why the
officer determined M.B. should remain in the chair. Relying on the security video, a
viewer is not informed what the purpose of the check was for, what discussion took place
between the officer and M.B., or what the officer’s conclusions were upon leaving the
cell. Nor is there even documentation identifying who the officer was that performed the
alleged review.
The Ombudsman cannot conclude an effective hourly check took place in accordance
with the jail’s policy requiring hourly reviews of the inmate. There is no video or written
documentation detailing the check or the officer’s observations that shows the officer
reviewed M.B.’s behavior and disposition, nor is there any documentation showing how
he posed a threat to himself, staff, or jail security. The Ombudsman believes the jail
cannot justify the need for the continued restraint after the 8:14 a.m. review of the inmate,
though M.B. was left in restraints until 11:15 a.m. Further, when an inmate is held in
four- or five-point restraints, Iowa law requires correctional staff to document all
decisions and actions.410 The Ombudsman must conclude the jail did not follow this
requirement during the check.
The Ombudsman was not able to determine the conclusions of the medical staff’s checks
as no written documentation was provided by the jail for this event. The security video
showed a medical staff member entering M.B.’s cell with an officer and leaving soon
after. However, the video cannot offer the verbal discussion that might have taken place
or any concerns medical staff may have raised. The Ombudsman believes it is important

409

Letter from Andy Teas, Assistant Ombudsman, Iowa Citizens’ Aide/Ombudsman, to Lt. Peterman, Polk
County Sheriff’s Office (May 5, 2008) (on file with author).
410
IOWA ADMIN. CODE r. 201—50.13(2)(f)(4) (2008).

128

Polk County Jail:  Analysis, Conclusions, and Recommendations
 
 
 
 
 
for any medical observations and conclusions reached about the inmate during restraint
be documented in writing.
Conclusion: The Polk County Jail did not document actions and decisions in accordance
with Iowa law for 15-minute checks, periodic reviews, or medical checks.
The Ombudsman makes the following recommendations:
5. Polk County Jail must document each action and decision addressing an inmate’s
four- or five-point restraint. It must ensure the checks are done and ensure the
documentation is not “overlooked.” Documenting all actions and decisions, under
Iowa law, also includes the decision whether to release the inmate or continue
restraint use after each hourly review that is required under jail policy. This
applies to any medical reviews during and after the use of restraints on the inmate.
6. The jail should incorporate in its written policy the procedures for written
documentation of all actions relating to restraint chair use.
5. Video Monitoring and Documentation
The Polk County Jail currently video records restraint chair use, and this standard
procedure proved very useful during the Ombudsman’s investigation to identify problems
with procedures and policy, as well as rebut allegations of assault and abuse raised by the
inmate. The Ombudsman did note some problems with the recording that should be
addressed, including placement of the camera and retention of videos.
While the camera was able to capture many of the events involving the application of
restraints and the events outside the observation cell, it was not as effective for
determining what occurred inside the cell. This was due to the location of the camera and
the position of the inmate within the cell. During most of the restraint, a door frame
blocked a portion of the inmate’s body. In addition, the inmate was facing away from the
door, hindering the camera from capturing the inmate’s torso, legs, and face. Soon after
the initial placement, staff entered the cell twice to reposition the chair to face away from
the door after M.B. was able to shift the chair to the side. Ironically, M.B.’s defiant
action of shifting the chair a third time without correction by staff offered the least
obstructed view of the inmate.
The Ombudsman believes an unobstructed camera view of the inmate is necessary to
accurately review the events of the restraint application and use. The Iowa Department
of Corrections recently added a provision to the Iowa Administrative Rules allowing the
use of CCTV for continuous monitoring.411 This additional tool now available to the jails
supports the importance of a clear, unobstructed view. In the event an inmate begins to
have problems that require emergency medical attention, a view that is obstructed by a
411

IOWA ADMIN. CODE r. 201—50.13(2)(f)(1) (2008).

129

 
 

Ombudsman Investigative Report 
 
 
 
door frame, or one that cannot see the inmate’s face, torso, or limbs could result in
missed signals of that emergency, leading to serious injury or death. As explained by
CMS, in reply to a comment for additional information on the “close proximity”
requirement for audio and video use, “the intent is to ensure that staff is immediately
available to intervene and render appropriate interventions to meet the patient’s needs.”412
In Polk County Jail, an obstructed view can be remedied by turning the inmate to face the
cell door and the camera. If the inmate needs to face away from the door for security
reasons, a camera inside the observation cell could accomplish the same goal. The
Ombudsman has reviewed cases in Iowa county jails where the camera was located
inside the observation cell with the restrained inmate, which recorded an accurate account
of the events during restraint.
The Ombudsman was also informed that Polk County Jail only retains video of restraint
incidents for 45 days. As mentioned above, video recording is an invaluable tool for
identifying potential violations of jail policy and unreasonable actions by staff, enabling
supervisors to update training or revise jail policy. It is also instrumental for refuting an
inmate’s false allegations of inappropriate or abusive behavior against staff. The
Ombudsman believes the jail should retain copies of each restraint device incident for a
minimum of two years, reflecting the statute of limitations for tort claims in Iowa.
Conclusion: The position of the CCTV and the holding cell created an obstructed view
of the restrained inmate, thereby preventing a reviewer from accurately observing the
events inside the cell. An obstructed view may prevent staff from responding
immediately in the event an emergency arises inside the cell, which in turn creates an
unreasonable risk of serious injury or death for the inmate.
The Ombudsman makes the following recommendations:
7. The Polk County Jail should ensure the video documenting the restraint device
use provides an accurate account of the events that transpire. This would include
an unobstructed view of the placement and use of the restraints. This is important
for vivid documentation and necessary if used for continuous monitoring purposes.
The jail should retain copies of videos for each restraint device use for at least two
years.

412

Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients’ Rights, 71 Fed. Reg.
71,378, 71,415 (Dec. 8, 2006) (to be codified at 42 C.F.R. pt. 482).

130

   

  

Systemic Mental Health and Professional Resource Challenges
Two common themes the Ombudsman heard repeatedly during the course of this
investigation were (1) the lack of a systemic mental health program to address the
growing problems of mentally ill citizens receiving care before they enter the criminal
justice system, and (2) the financial and resource constraints placed on jails who
eventually must care for those inmates who did not receive care before incarceration.
The situations may involve inmates whose criminal records consist of only minor crimes,
but due to an untreated mental illness the crimes have escalated. They also often involve
inmates released from prison who have received insufficient treatment during
incarceration or after release. The lack of correctional, judicial, and community mental
health services each contribute to the numbers of mentally illness inmates seen by a
county jail, and many of whom eventually go to prison. As of December 2007, over 41
percent of Iowa prison inmates had a diagnosed mental illness.413 Inmates with serious,
persistent mental illness accounted for 30.4 percent of the total population.414
These issues are systemic problems that go far beyond the walls of the county jail and
cannot be properly addressed in this report. However, the Ombudsman believes a few
programs merit consideration.

A. Iowa Department of Corrections Reentry Plans
Part of the cycle facing county jails involves inmates with mental illness who are released
from prison without the proper post-incarceration services available to respond to their
mental health needs. These former inmates often commit crimes, are arrested, and begin
the legal and correctional process over again at a much higher rate than former inmates
with no mental illness. In April 2007 the Durrant Group, Inc. issued the first phase
(Phase I) of a systemic study of the Iowa correctional system on behalf of the State of
Iowa and issued the second phase (Phase II) in April 2008. In addressing the issue of
improving community corrections outcomes, the study looked at ways to reduce
recidivism.415 It found each of the eight judicial districts expressed the need for
additional mental heath and dual diagnosis services and funding for medications.416
According to Phase II, 26 percent of male parolees and 55 percent of female parolees in
2005 were mentally ill.417 Looking at the inmates released in 2003, the study found the
number of inmates with mental illness comprised 27 percent of prison releases, but
represented 39 percent of those returning to prison within three years.418
413

DURRANT GROUP INC. ET AL, STATE OF IOWA SYSTEMIC STUDY FOR THE STATE CORRECTIONAL SYSTEM,
PHASE II 70 (2008).
414
Id. at 69.
415
Id. at 213-14.
416
“Dual diagnosis” refers to a situation where a person suffers from a diagnosed mental illness and a
substance dependency or addiction.
417
Id. at 214.
418
DURRANT GROUP INC. ET AL, STATE OF IOWA SYSTEMIC STUDY FOR THE STATE CORRECTIONAL SYSTEM,
PHASE I 50-52 (2007).

131

Ombudsman Investigative Report 
 
 
 
Phase II compared the recidivism rate of chronically mentally ill male inmates and those
with no mental illness for 2004 releasees. It found those with mental illness had a
recidivism rate of 51.6 percent compared to 28.1 percent for those without a mental
illness.419 Among former female inmates, those with chronic mental illness had a
recidivism rate of 44.7 percent compared to 18.9 percent for those with no chronic mental
illness.420
Return Rates to Prison: FY2004 Releasees
60.0%

51.6%

l:
0

500% - t - - - - - 4 4 7 % - - - - - - f

rr.

40.0%

'tI

30.0%

.!!!

,£
Gl

l:

18.9%

3

a; 20.0%
c::
'#. 10.0%
0.0%

Females
• Not Chronical~

Mental~

Males
III

[]

Chronical~ Mental~

III

Source: DOC: Prell, ICON Data

421

Phase II further found the recidivism rates increase for each additional mental health
diagnosis.
Return Rates to Prison, FY2004 Prison Exits

By Number of Chronic Mental Illness Diagnoses
Chronic MI
Diagnoses

Total
Released

Total
Returned

Recidivism
Rate

2,388
583
285
160
117

654
184
170
120
99

27.4%
31.6%
59.6%
75.0%
84.6%

None
1
2
3
4 or More

422

With the recidivism rate of mentally ill inmates being significantly higher than those
without mental illness, the need for mental health services during parole or after an

419

DURRANT GROUP, PHASE II at 71.
Id.
421
Id. at 72, fig. IV-B-6.
422
Id. at 74, fig. IV-B-10.
420

132

Systemic Mental Health and Professional Resource Challenges 
 
 
 
 
 
 
 
423
inmate discharges the sentence is apparent. Based on the figures provided by the
Durrant Report, 40.7 percent of offenders in Community-Based Corrections (CBC)
residential facilities and CBC field supervision who have mental illness and co-occurring
disorders (substance abuse and at least one mental illness diagnosis) are not receiving
treatment.424
The study recognized the need to respond to the mental health needs of offenders when
released from prison through parole and work release. Offenders may be released with
few well-grounded plans for community treatment and follow-up, and there can be a poor
response from the community to providing treatment to offenders who may still be a part
of the Department of Corrections system.425 The study also recognized that “[t]oo often
these offenders serve the full term of their sentences in prison and are released directly
into the communities without necessary supports in place.”426 It found a lack of special
services throughout Iowa, including mental health courts, jail diversion, mobile crisis
teams, and assertive community outreach teams.427
The study recommended a curriculum to meet the basic mental health training needs of
all CBC probation and parole officers, as well as case managers.428 Advanced training
programs should be developed for CBC staff that work primarily with offenders who
have mental illnesses and co-occurring disorders. This training would include building
community relationships, case management planning, and “using incentives and
Recovery Model interventions to encourage treatment and correctional supervision
compliance.”429 CBC “Reentry Coordinators” have recently been added to the eight
judicial districts in Iowa, who screen potential resources in the communities and find the
appropriate resource for offenders returning to the CBCs.430 The study recommended the
Department of Corrections continue to work on building communication strategies
needed for collaboration between the institution, the judicial districts, and the community
providers to identify and meet the needs of offenders with mental health and co-occurring
disorders.431

B. Mental Health Courts
The Ombudsman believes a proposed pilot project for mental health courts like the one
previously introduced by the Iowa Legislature could benefit Iowa counties.432 Under the
423

According to Phase II, 66.6% of male and 17.3% of female special needs inmates expired their
sentences in 2004. DURRANT GROUP, PHASE II at 71.
424
Id. at 86-88.
425
DURRANT GROUP, PHASE I at 66.
426
DURRANT GROUP, PHASE II at 57.
427
Id. at 92.
428
Id. at 108.
429
Id. at 109
430
Id. at 37.
431
Id. at 110.
432
H.F. 613, 82d Gen Assem., 1 Sess. (Iowa 2007).

133

Ombudsman Investigative Report 
 
 
 
proposed bill, three mental health courts would have been established and located in
separate counties based on the county’s size, and the project would be administered by
the Iowa Judiciary. The courts would be available for nonviolent criminal offenders who
suffer from mental illness.433
Several sheriffs, jail administrators, and corrections professionals have expressed
frustration to the Ombudsman about what they describe as a revolving-door treatment
system. A person with a mental illness may be civilly committed, but that person will
have a short stay at a hospital or MHI only to be stabilized on medications and then be
released with no follow-through. In many cases, the person will begin to digress because
of little oversight or scarce community-based supervision. If the person quits taking their
medication and no one is aware of it, mental health declines, legal trouble often ensues,
and the person is taken to jail to face criminal charges. In cases where the charges are for
non-violent crimes, the inmate may get little or no incarceration time and is released back
into society with no structured mental health supervision. This can often lead to
additional petty crimes or lead to more serious violent felonies.
In the case of T.H., the jail administrator and sheriff were very familiar with him based
on continued run-ins in the community. Two months before T.H.’s incarceration in
February 2007, he was civilly committed at University of Iowa Hospital and Clinics
(UIHC), his ninth hospitalization since 2001. He was referred to UIHC by the county
hospital due to his aggressive mental state after he was arrested for making threats against
a convenience store. Upon his entry to UIHC, a psychiatrist noted T.H.’s high agitation
level and uncooperativeness. After adjusting medication levels, T.H. was released from
UIHC three weeks later. Medical notes report T.H.’s mania was resolved. He was
cooperative, and there was no evidence of psychosis or thought disorder.
T.H. followed the typical pattern of behavior from petty offenses to much more serious
charges. Four days after he was released from the hospital, T.H. was charged with drug
possession. Eight days later, he was charged with trespass. One month later, he was
arrested for robbing a bank. While it is impossible to know whether T.H. would have
been a successful candidate for a mental health court, such a program may have proved
beneficial in his case.

433

The Ombudsman corresponded with Rebecca Colton in her capacity as a lobbyist of the Judiciary-Iowa
Supreme Court, when he noticed Ms. Colton was declared “Against” the proposed pilot project legislation.
According to Ms. Colton, there are not enough treatment programs or other services available to
accompany the mental health court. In addition, the mental health court would be far more labor-intensive
than conventional court systems. The Ombudsman believes these are the issues a pilot project was meant
to identify so further action can be taken by the Legislature to address those problems if needed. It is not
known how the treatment programs and services were lacking, since the communities in which the pilot
projects would be located had not been determined.

134

Systemic Mental Health and Professional Resource Challenges 
 
 
 

 
 
1. Woodbury County

The Ombudsman researched information about the only fully integrated mental health
court in Iowa. Woodbury County first set up its mental health court in July 2001 with the
cooperation of Siouxland Mental Health Center (Siouxland), the county jail
administrator, the county sheriff, the county attorney, the county CPC, a public defender,
and a judge willing to work the mental health court docket.434 Prior to the mental health
court, Siouxland worked with Woodbury County Jail to identify inmates who needed
services for mental illness, substance abuse, and co-occurring disorders, and would
provide those services once the inmate was released from jail. That involvement
provided the groundwork for the mental health court.
The concept of the mental health court came as a result of a survey that found 15 percent
of inmates at Woodbury County Jail suffered from mental illness. According to Kim
Fischer-Culver, Director of Community Services for Siouxland, the agency was involved
in learning about the administration of a mental health court by visiting Broward County,
Florida, one of the first mental health courts in the country.435 With the cooperation of
law enforcement, the court system, and county administrative players, the services
Siouxland were providing expanded into the mental health court currently operating in
Woodbury County.
Through screening by Siouxland caseworkers, as well as referrals from other sources,
inmates at Woodbury County Jail are identified as potential clients for the mental health
court docket. The court only accepts defendants who are charged with misdemeanor
crimes and must be approved by a caseworker after a 30-day trial period. If approved by
Siouxland, the public defender, the county attorney, and the judge, the court will have
authority to review the goals and service activities of the defendant and follow the client
for the following year. The Siouxland case manager provides the judge with status
reviews about the progress being made by the defendant. The judge, along with the case
managers and attorneys, determines if the client will continue in the mental health court.
According to Ms. Fischer-Culver, funding for the court is entirely based on the county’s
mental health funds. The county CPC was instrumental in starting the mental health
court because funding approval was needed from the county board of supervisors. No
financial assistance comes from the state or federal programs. The board of supervisors
approves funding for the court on a yearly basis.
Ms. Fischer-Culver described a positive working relationship with the other agencies
involved with the court, and support is received from the county attorney, the jail, and the
sheriff’s office. A single judge, Judge Patrick McCormick, currently works the docket,
and has since the mental health court’s inception.
434

Telephone Interview by Andy Teas, Assistant Ombudsman, Iowa Citizens’ Aide/Ombudsman, with Kim
Fischer-Culver, Dir. of Cmty. Servs, Siouxland Mental Health Ctr. (May 14, 2008).
435
Id.

135

 
 

Ombudsman Investigative Report 
 
 
 
The most significant fact of the mental health court is its report rate of recidivism.
According to the Third Judicial District’s 2007 Annual Report, the program reported a
91.6 percent reduction in recidivism among those who participated in the court between
July 2001 and June 2006.436 Siouxland also reported a 97 percent reduction in jail days
among clients who participated in the mental health court, from 2,796 days to just 83
days.437 Ms. Fischer-Culver also noted the benefits among the community resources that
reach beyond the mental health court, stating “[t]he outcomes of the program are positive
in that there has been an increase in linkages to mental health services and resources in
the community allowing for stability in the client’s living environment.”438
2. Rock Island County, Illinois
The mental health court system in Rock Island, Illinois, was the subject of two news
articles published by the Quad City Times in January 2008. According to the articles, the
mental health court in Rock Island was established by a county associate judge after he
read about the suicide of a bipolar inmate at the Rock Island County Jail in 2006. The
inmate had been deemed incompetent to stand trial and was awaiting transfer to a mentalhealth hospital. During his time in jail, the inmate spent five months with no medication,
no treatment, and no mental health evaluation.439
Rock Island County Associate Judge Ray Conklin received support from the county
attorney, local outpatient offices, fellow judges who volunteered to split cases, the county
sheriff, and the jail administrator who “have complained for years that some inmates are
too sick to be in jail. . . and that their problems are sometimes too much for correctional
officers to deal with.”440 According to the county attorney, “[k]eeping people locked up
is probably the worst thing you can do with mental-health issues. Get them out, get them
treatment and monitor them.”441
The court in Rock Island accepts referrals from family members, case workers, defense
attorneys, prosecutors, and judges. The court is not available for all criminals and only
allows few exceptions for those charged with felonies. It is voluntary and operates under
recognizance bonds, with the condition that the defendant complies with the judge’s
orders. Orders can include taking medication, undergoing regular drug screenings,
submitting to an evaluation, showing up on court dates, and meeting with case managers
436

THIRD JUDICIAL DISTRICT COURT OF IOWA, 2007 ANNUAL REPORT (2008), available at
http://www.judicial.state.ia.us/wfdata/frame6037-1511/File1.pdf.
437
Id.
438
Letter from Kim Fischer-Culver, Director of Community Services, Project Compass, to Tom Mullins,
Woodbury County Attorney (2006) (On file with author).
439
Barb Ickes, Jail Suicide Inspires RI Judge to Start Mental Health Court, Q.C. TIMES (Davenport, Iowa),
Jan. 13, 2008, http://www.qctimes.com/articles/2008/01/13/news/local/doc4789952685577227156651.txt.
440
Barb Ickes, Courting Justice: Mental Health Court Places Emphasis on Rehabilitation, Q.C. TIMES
(Davenport, Iowa), Jan. 14, 2008.
http://www.qctimes.com/articles/2008/01/14/news/local/doc478af10a9908b739718165.txt.
441
Id.

136

Systemic Mental Health and Professional Resource Challenges 
 
 
 
 
 
and probation officers. Receiving medication and treatment is the alternative for being
locked up in the county jail. The expected benefit for everyone is preventing
misdemeanants from becoming felons.
Before and after T.H.’s commitment in December 2006, he was on probation through the
Fairfield office. However, T.H. was not under a court ordered outpatient program for
mental health. Any mental health services he sought would be voluntary. While his
probation officer told the Ombudsman she encouraged T.H. to seek ongoing treatment,
T.H. often refused to go, citing he did not like the psychiatrist who served the area. The
Ombudsman is not in a position to say a mental health court would have prevented T.H.
from robbing the bank and going to jail. However, the purpose of the mental health court
is to address such circumstances as T.H.’s and intervene during petty offenses before a
violent crime occurs.
Due to the concept of a mental health court still being in its infancy, experts on its form
and function are few. After a year of operation, the Rock Island court is being visited by
officials from other jurisdictions who want to see how the court functions.442 Illinois has
nine mental health courts in the state, out of 102 counties, and hosted its first seminar in
summer 2008 addressing the issues of a mental health court.443 Ms. Fischer-Culver from
Siouxland stated her office has provided limited training to other counties and is willing
to share with other jurisdictions what it has learned about the mental health court process
since it inception.
3. Essential Elements of a Mental Health Court
A report prepared by the Council of State Governments Justice Center (CSGJC) in 2007
for the U.S. Department of Justice, Bureau of Justice Assistance, reviewed ten elements
necessary for a mental health court.444 Those elements include:
1) Planning and Administration. This element encourages the incorporation of a
multidisciplinary planning committee, which would include, among others, law
enforcement, judges, prosecutors, court administrators, and mental health
providers and advocates.

442

Barb Ickes, Mental Health Court: Local Legal System Takes on Mental Health Issues, Q.C. TIMES
(Davenport, Iowa), Apr. 7, 2008, http://www.qctimes.com/articles/2008/04/07/news/local/
doc47f9a8c4834fe213543001.prt.
443
Id.
444
The Council of State Governments Justice Center describes itself as a nonpartisan resource whose board
of directors includes state legislative leaders, judges, corrections administrators, juvenile justice agency
directors, and law enforcement professionals. The CSGJC provides technical assistance to the U.S.
Department of Justice for mental health issues involving law enforcement, mental health courts, and
corrections. Justice Center, Council of State Governments Homepage,
http://justicecenter.csg.org/about_us/background (last visited June 30, 2008).

137

 
 

Ombudsman Investigative Report 
 
 
 
2) Target Population. The type of defendants who will be served by the court will be
dependent on the resources in the community.
3) Timely Participant Identification and Linkage to Services. Participants are linked
to community-based service providers as quickly as possible after being
identified, referred, and accepted into mental health courts.
4) Terms of Participation. The terms of participation must be clear, promote public
safety, provide positive legal outcome, and carry consequences for the defendant
if not followed.
5) Informed Choice. Defendants are provided legal counsel and fully understand the
program requirements.
6) Treatment Supports and Services. Mental health courts connect participants to
comprehensive community treatment supports and services, dependent on their
individual needs.
7) Confidentiality. Providers and representatives of the court must adhere to federal
and state law protecting confidentiality.
8) Court Team. A team of criminal justice and mental health staff, and service and
treatment providers, receive ongoing training to help achieve treatment and
criminal justice goals by reviewing and revising the court process.
9) Monitoring Adherence to Court Requirements. The court must have up-to-date
information through regular hearings on whether participants are taking
medications, attending treatment sessions, abstaining from drugs and alcohol, and
adhering to other supervision conditions.
10) Sustainability. Data describing the court’s impact on individuals and systems
should be collected and analyzed to demonstrate the impact of the mental health
court.445
The elements listed above are meant to provide an overview and do not constitute an
exhaustive review of the report. The Ombudsman encourages readers interested in
mental health court projects to access the report themselves, available for no charge at the
CSGJC website. CSGJC, through its Mental Health Consensus Project, provides many
other resources on mental health courts and administrative issues addressed by local,
state, and federal policy makers.

445

MICHAEL THOMPSON ET AL, IMPROVING RESPONSES TO PEOPLE WITH MENTAL ILLNESS: THE ESSENTIAL
ELEMENTS OF A MENTAL HEALTH COURT 1-10 (2007), available at http://justicecenter.csg.org/resources/
mental_health.

138

Systemic Mental Health and Professional Resource Challenges 
 
 
 
 
 
 
 
An extensive study issued in 2007 analyzed the recidivism rate of persons with mental
illness who went through a mental health court, compared to persons in the same
community with mental illness who did not participate in the program.446 The study,
conducted by two psychiatry professors from the University of California, San Francisco,
looked at any criminal charges after completing the program or being released from jail
and charges involving violent crime.447 The authors hypothesized that those who
participated in the mental health court, regardless of finishing the program, would not
incur additional charges for a longer period of time for all crimes compared to
nonparticipants, and those who “graduated” from the program would not incur additional
charges for a longer time than those whose cases were adjudicated in regular court.448
After following 170 mental health court participants and 8,067 “treatment as usual”
defendants, the authors’ hypothesis was provided documented support when the study
found the mental health court graduates and participants went longer periods of time
without incurring new charges, including violent crime charges.449
The more time that passed, the greater the difference between the two groups. At 18
months, mental health court participants were 26 percent less likely to be charged with a
new crime than the treatment-as-usual group. The likelihood of a new violent crime
charge during this time frame was 55 percent lower among the participants compared to
nonparticipants.450
The study concluded its findings “provide evidence of the potential for mental health
courts to achieve their goal of reducing recidivism among people with mental disorders
who are in the criminal justice system.”451 While most mental health courts in the
country are not available to individuals charged with felonies, the results of the study
found “it appears possible to expand the mental health court model beyond its original
clientele of persons charged with nonviolent misdemeanors in a way that public safety is
enhanced rather than compromised.”452

446

DALE E. MCNIEL & RENEE L. BINDER, Effectiveness of a Mental Health Court in Reducing Criminal
Recidivism and Violence, 164 AM. J. PSYCHIATRY 1395 (2007).
447
Id. at 1395. At the time of the report, Dale McNiel was a professor of clinical psychology in the
Department of Psychiatry at the University of California. Renee Binder was a professor in residence in the
Psychiatry and the Law Program at the University of California, San Francisco. Aaron Levin, Mental
Health Courts: A Strategy That Works, PSYCHIATRIC NEWS, Sept. 21, 2007, at 6.
448
McNiel, supra, at 1396.
449
Id. at 1396, 1401.
450
Id. at 1401.
451
Id.
452
Id. at 1401-02. For a review of the mental health court costs, the Council of State Governments
sponsored an extensive study on the fiscal impact of mental health courts, conducted by the RAND
Corporation, which analyzed the Allegheny County Mental Health Court in Pennsylvania. M. SUSAN
RIDGELY ET AL, JUSTICE, TREATMENT, AND COST: AN EVALUATION OF THE FISCAL IMPACT OF ALLEGHENY
COUNTY MENTAL HEALTH COURT (2007).

139

Ombudsman Investigative Report 
 
 
 

C. Multi-County Jails
The Ombudsman understands the financial and administrative pressures the
recommendations contained in this report place on some smaller jails. Providing mental
health services can be costly and difficult if there are no providers in the locale. The
Ombudsman spoke with several county jail officials who expressed interest in combining
resources with neighboring counties to broaden the tax base and pool resources for jail
updates and services. The issue is not that the jails do not want to provide services for
inmates who require them. A violent, mentally ill inmate creates more work and
oversight for jail staff, and also creates a much more injury-prone environment for jail
staff. Rather, the jail cannot provide the services to the inmate due to financial and
administrative costs.
As part of its 2008 legislative priorities, the Iowa State Association of Counties (ISAC)
provided its position on the development of multi-county jails. According to Dave
Vestal, , ISAC’s legal counsel, ISAC receives input from county law enforcement
officials when developing its legislative priorities. In addition, the Public Safety Division
of ISAC that lays out its recommendation for multi-county jails is chaired by a county
sheriff. ISAC endorses the concept of multi-county jails due to the costs of replacing old
jails. Many counties are ready to band together to build new jails but cannot due to the
lack of a statewide program to “encourage the planning, development and operation of
multi-county jails.”453 ISAC recommends the development of a state board, a process for
counties to use in creating a commission to operate the jail, a state grant and loan process
for jails, and other legislative and funding support. It also states that any multi-county
jail, if constructed, should be under the control of the sheriffs of the counties serviced by
the jail. The Ombudsman supports exploring proposals to create multi-county jails.

453

IOWA STATE ASS’N OF COUNTIES, 2008 LEGISLATIVE PRIORITIES: 82ND GENERAL ASSEMBLY, 2ND
SESSION 29 (2008).

140

   

  

Glossary
ACA

American Correctional Association. The ACA is a correctional
association that provides certification, accreditation, and testing as well as
issues standards and research publications in the field of corrections.
http://www.aca.org/

APA

American Psychiatric Association. Provides education and career
development initiatives as well as publications in the field of psychiatry.
http://www.psych.org/

BJMHS

Brief Jail Mental Health Screen. A screening tool for use by jails to
help identify the presence of potential mental illness in new inmates
during intake. The screen was funded by the National Institute of Justice,
a research arm of the U.S. Department of Justice.
http://gainscenter.samhsa.gov/pdfs/disorders/bjmhsform.pdf

CCTV

Closed-Circuit Television. The Iowa Department of Corrections adopted
language in the Iowa Administrative Code in 2008 to allow continuous
monitoring by CCTV of inmates placed in four- and five-point restraints.

CMS

Centers for Medicare and Medicaid Services. A federal agency that
regulates the administration of Medicare and Medicaid programs. CMS
has authority to promulgate rules and regulations of facilities under its
jurisdiction, including many health care facilities. This report cites rules
and regulations covering the use of restraints by covered entities.
http://www.cms.hhs.gov/

CRIPA

Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997. This
act authorizes the U.S. Attorney General to conduct investigations and
litigation relating to conditions of confinement in state or locally operated
institutions. http://www.usdoj.gov/crt/split/cripa.php

DOJ

U.S. Department of Justice. This report frequently refers to the DOJ’s
investigations of correctional facilities through its Civil Rights Division,
with authority granted by CRIPA. http://www.usdoj.gov/crt/

IBOM

Iowa Board of Medicine. A state agency that regulates the practice of
medicine and medical doctors under Iowa administrative rules.
http://medicalboard.iowa.gov/

ILEA

Iowa Law Enforcement Academy. A state agency that provides broad
training to law enforcement officers. http://www.state.ia.us/ilea/

MHI

Mental Health Institute.

141

 
 
National GAINS Center
A federal agency that serves as a locus for the collection
and dissemination of information about effective mental health and
substance abuse services for people with co-occurring disorders in contact
with the justice system. http://gainscenter.samhsa.gov/html/
NCCHC

National Commission on Correctional Health Care. The NCCHC
provide standards for health services in correctional facilities, including
prison, jails, and juvenile detention facilities. The NCCHC also provides
accreditation to correctional facilities and issues publications.
http://www.ncchc.org/

UIHC

University of Iowa Hospitals and Clinics.

142

 

 

Appendix A: Emergency Restraint Chair

EMERGENCY
RESTRAINT CHAIR
IT~Q\;\ !lllTh;® ill

jpl:l1cdlcdl®<dl ~Illl
QQ

iIDIIl wlliJ®®lliI

QQ

THE LATEST BREAK THROUGH IN SAFETY!
http://www.restraintchair.com

143

Appendix A:  Emergency Restraint Chair 
 
 
EMERGENCY RESTRAINT CHAIR

• Iloto r»t ...m.:t nonrlIoI braohinol

_ _indi,_ ..ithoofifjllry

You "'""" .~w

'" be ..ithooI th<

EME~G~:NCY ~~[NTCII"I~
~·... """,,~caII,
1~1t.C.

,.,.

r.u. Il<>. u,
Il<.i>o•. ,,, Sl~~l
1'I>on<: (7\!126J·~291

f",,:(7\lj 26J-46JJ

http://www.restraintchair.com

144

 

 

Appendix B: Organization Research Chart
Intake Screening
NCCHC

ACA

Federal BOP

DOJ CRIPA Investigations

Receiving screening is
performed on all inmates
immediately upon arrival
at the intake facility.
Person who are mentally
unstable or otherwise
urgently in need of
medical attention are
referred immediately for
care. Reception
personnel, using a healthauthority-approved form,
inquire about past and
current mental illness,
including
hospitalizations.
(J-E-02).

The admission processes
for a newly admitted
inmate include medical,
dental, and mental health
screenings. (4-ADLF2A-21).
All inmates receive an
initial mental health
screening at the time of
admission to the facility
by a mental-health
trained or qualified
mental-health care
personnel. The
screening includes, in
part, inquiries into the
inmate’s present
medications, current
mental health
complaints, current
treatment, and history of
psychiatric treatment and
substance abuse. The
screening also includes
observations of general
appearance and behavior,
and current symptoms of
psychosis, depression,
anxiety and/or
aggression.

(Not relied on as
a source for jail
intake
screening).

Black Hawk County Jail,
Iowa:
The jail should not rely on
inmate self reporting in group
setting. The jail should
establish a system of
collecting mental healthrelated information that
ensures confidentiality.

All inmates must receive
a mental health screen,
separate from the
receiving screen,
conducted by a qualified
mental health
professional or mental
health staff. The mental
health screen should
include, in part, inquiries
into the history of
psychiatric
hospitalization and
outpatient treatment,
violent behavior and
current status of
psychotropic
medications.
(J-E-05).

145

Dallas County Jail, Texas:
The jail shall implement and
comply with policies to
provide adequate medical and
mental health intake
screening to all inmates.
Newly admitted inmates who
present current risk of acute
mental health needs will be
immediately referred for
mental health evaluation by a
mental health professional.
Terrell County Jail, Georgia:
Jail shall appropriately screen
all inmates upon arrival to
identify serious medical and
mental health conditions,
including mental illness,
suicide risk, and drug and/or
alcohol withdrawal. Inmates
who screen positively for any
of these items shall be
referred for immediate or
prioritized screening by
qualified health care staff.
Initial screening should
record inmate’s mental health
history, including health
treatment, medication, and
hospitalization.

Appendix B:  Organization Research Chart 
 
 

Mental Health Assessment After Admission
NCCHC

ACA

Federal BOP

DOJ CRIPA Investigations

Inmates with a positive
mental health screen
must receive a mental
health evaluation.
Patients who require
acute mental health
services beyond those
available at the facility
are transferred to an
appropriate facility.
(J-E-05).

Inmates who are
referred for assessment
as a result of the mental
health screen or by
staff referral will
receive a mental health
appraisal by a qualified
mental health person
within 14 days of
admission to the
facility.
(4-ADLF-4C-30).

(Not relied on as
a source for jail
inmate
assessments).

Black Hawk County Jail, Iowa:
Provide an adequate and timely
mental health evaluation, by a
qualified and appropriately
trained mental health
professional, of inmates who
screen positive for possible
mental illness at intake and of
inmates who exhibit symptoms
of mental illness at any time
during their incarceration.
Terrell County Jail, Georgia:
The defendants shall develop
and implement adequate
policies, procedures, and
practices consistent with
generally accepted professional
standards to ensure timely and
appropriate mental health
assessments by a qualified
mental health professional for
any inmate who becomes
suicidal and those inmates
whose mental health histories,
whose responses to initial
screening questions, or whose
behavior indicate a need for
such assessment.
Dallas County Jail, Texas:
Defendants shall ensure timely
access to a qualified mental
health professional when
presenting symptoms of mental
illness require such care.
Defendants shall provide
adequate on-site psychiatrist
coverage for inmates’ serious
mental health care needs and
ensure that psychiatrists see
inmates in a timely manner.

146

Appendix B: Organization Research Chart 
 
 

 

 

Medical Staff Notification of and Reviews During Restraint Use
NCCHC

ACA

Federal BOP

DOJ CRIPA
Investigations

When restraints are used
by custody staff for
security reasons, health
services staff are notified
immediately in order to:
(1) review the health
record for any
contraindications or
accommodations required
which, if present, are
immediately
communicated to
appropriate custody staff,
and (2) initiate health
monitoring, which
continues at designate
intervals as long as the
inmate is restrained.
(J-I-01).

When four/five-point
restraints are used, the
health authority or
designee must be
notified to assess the
inmate’s medical
condition, and to advise
whether, on the basis of
serious danger to self or
others, the inmate
should be in a medical
unit for emergency
involuntary treatment
with sedation and/or
other medical
management, as
appropriate.
(4-ADLF-2B-03).

When the inmate is
placed in four-point
restraints, qualified
health personnel shall
initially assess the
inmate to ensure
appropriate breathing
and response (physical
and verbal). Staff
shall also ensure that
the restraints have not
restricted or impaired
the inmate’s
circulation. When
inmates are so
restrained, qualified
health personnel
ordinarily are to visit
the inmate at least
twice during each
eight-hour shift. Use
of four-point restraint
beyond eight hours
requires the
supervision of
qualified health
personnel.
(P5566.06 (10)(f)).

Black Hawk County Jail,
Iowa:
Absent exigent
circumstances, a
supervisor should be
present when inmates
are first placed in the
restraint chair. Inmates
in restraint must be
checked by personnel
with appropriate training
every 15 minutes and by
medical at appropriate
intervals. Proper
measures should be
taken to ensure that
inmates in restraints
have their limbs
exercised to avoid
circulation problems,
and adequate attention
must be given to food,
hydration, and bodily
fluids.

147

 

Appendix B:  Organization Research Chart 
 
 

Mental Health Professional Review During Restraint
NCCHC

ACA

Federal BOP

DOJ CRIPA
Investigations

If the restrained
inmate has a mental
health condition, the
physician is notified
immediately so that
appropriate orders
can be given.
(J-I-01).

When four/five-point
restraints are used, the
health authority or
designee must be
notified to assess the
inmate’s medical and
mental health
condition, and to advise
whether, on the basis of
serious danger to self or
others, the inmate
should be in a mental
health unit for
emergency involuntary
treatment with sedation
and or medical
management, as
appropriate.
(4-ADLF-2B-03).

Psychological services
staff must examine an
inmate once during every
24-hour period that the
inmate is restrained.
Examinations will
include:
(1) a review of the
inmate’s psychological
history,
(2) a description of the
interview conducted with
the inmate,
(3) a review of the 15minute, two-hour, and
health services review
logs,
(4) a description of the
inmate’s current mental
health status,
(5) recommendations, and
(6) whether the inmate is
being referred for mental
health institution
placement and an
explanation.
(P5566.06 (10)(f)).

Black Hawk County Jail,
Iowa:
Develop a comprehensive
policy on the use of
restraint and isolation on
inmates with serious
mental illnesses. Ensure
that mental health
personnel are involved in
decisions to restrain or
isolate mentally ill
inmates, and in the
monitoring of such
inmates while restrained or
isolated. Develop policies
and procedures to ensure
that inmates with acute
psychiatric conditions,
who cannot function long
term in the general jail
population, are transferred
or committed to
appropriate treatment
facilities as expeditiously
as possible.

148

Shelby County Jail,
Tennessee:
Policies should ensure that
mental health professionals
are consulted before any
planned use of force or
non-routine use of
restraints on any inmate
with a diagnosis of mental
illness.

Appendix B: Organization Research Chart 
 
 

 

 

Periodic Reviews to Determine Release From Restraints
NCCHC
(No regulation
available)

ACA
(No regulation
available)

Federal BOP

DOJ CRIPA
Investigations

A review of the inmate’s
placement in four-point
restraints shall be made by
a lieutenant every two
hours to determine if the
use of restraints has had
the required calming effect
and so that the inmate may
be released from these
restraints (completely or to
lesser restraints) as soon as
possible.
The goal of the two-hour
reviews is to determine, as
soon as possible, that the
inmate has regained selfcontrol and may be placed
in lesser restraints. Staff
should look for a pattern
of non-disruptive behavior
over a period of time
indicating the inmate has
regained self-control and
is no longer a disruptive
threat.
(P5566.06(10)(e)).

(No regulation available)

149

 

 
 

Appendix C: Brief Jail Mental Health Screen
BRIEF JAIL MENTAL HEALTH SCREEN
Sed ion 1
Name:

DelaineI' #:
fin'

Time:

Dale:

AM

PM

""

Section 2

Questions
1.

No

General Comments

y"

Do you currently believe tnat someone can
COfitrol your mind by putting thoughts into
your hCild or laking thoughts out of your head?

2.

3.

Do you currently f.... lthal other people know
your thoughts and (;30 read your mind?
H;we you currently l05t or gained as much as

Iwo pounds a week for sever;!1 weeks without
even trying?

4.

Have you or your family or friends noticed Ihat
you are currenlly much more active than you

uSUilllyare?
5.

6.

Do you currently feel like you have to talk or
move more slowly than you usually do?
H.wO' there currently been a few weeks when

you felt like you were useless or sinful?
7.

,

currently l<lking any medication
prescribed for yOll by a physician for any
emotional or ment,ll health problems?
Are you

Have you ever been in a hospital for emotional
mental health problems?

Of

Section] (Optional)
Officer's Comments/Impressions (check <II/that apply):

o
o

language barrier

o

Under the influence of drugs!'llcohol

Oi(ficul1y unde~tanding questions

o

Other, sfX><:ify:

o

Non-conp.'rahve

Referrallnslructions: This delainee should be referred for further menial heallh evaluation if he/she answered:
•
•
•
•

YES to ilem 7; OR
YES to item 8; OR
YES 10 al least 2 of items 1 Ihrough 6; OR
If you feel it is necessary for any other reason

o Not Referred

o Referred on _ _ 1_ _

to

_

Person completing screen

_

INSTRlJ(1l0NS ON REVERSE
@2005 Policv Reseach ,\ssociales. Inc.

http://gainscenter.samhsa.gov/pdfs/disorders/bjmhsform.pdf
150

Appendix C:  Brief Jail Mental Health Screen 
 
INSTRUCTIONS FOR COMPLETING THE BRIEF JAIL MENTAL HEALTII SCREEN
GENERAL INFORMATION:
This Brief Jail Mentall-lealth Screen (BJMl-IS) was de\'e1oped by Policy Research Associates, In..:.. with a grant from the National Institute
of Justi..:e. The BJr>.111S is an ellieient mental health screen that will aid in the early id..:ntifieation of se\'ere mental illnesses and other acute
psychiatric problems during the intake process.
This screen should be administered by Correctional OllicctS during thc jairs intakclbooking process.
INSTRUCTIONS FOR SECTION 1:

NAME:
DETAINEE#:
DAfE:
H\IE:

Entcr detainees name - tirst. middle initial. and last
Enter dliainec number.
Enter toda)"s month. day. and year.
Enter the current time and drde AM or 1'/1.1.

INSTRUCTIONS FOR SECnON 2:
ITEMS [-6:
['lace a ehL'Ck mark in the appropriate column (lor··NO· or ··YES·· response).
If the detainee REFUSES to answer the question or says that hclshe DOES NOT KNOW the answer to the question. do not check ··NO··
or ··YES.·· Instead, in the GencrJI Comments section. indicate REFUSED nr DON'T KNOW and include information explaining why
the dliainee did not answer the question.
ITEMS 7-8:
ITEM 7: This reters to any prescribed medication tor any emotional or mental health prohlems.
ITEM 8: Include any stay of one night or longer. Do NOT indudeL'Ontact with an Emergency Room ifit did not!cild to an admission
to the hospital
If the detainL'C REFUSES to answer the question or says that hc!she DOES NOT KNOW the answer to the question, do not ehttk "NO"
or ··YES." Instead. in the General Comments section, indicate REFUSED or DON'T KNOW and include information explaining why
the detainL'C did not answer the question.
GCllCGll

C{lmmell!s Column:

As indi..:atL'd above, if the detainee REI'USES to anSI\er the qUL'Stion or says that hc!she DOES NOT KNOW the answer tu th"
question. do not ..:hcck ··NO·· or ··YES:· Instead. in the Cieneral Comments section, indi..:atC' REFUSED or DON'T KNOW and includ..:
information e.xplaining why 'he detainee did not answer thc question.
AII··YES·· rC'sponses fl.'qoire a note in the General Comments s'-'I;tion to do<.:ument:
(I) Inlonnation about the dC'tainee thatthC' ollicer lecls rek"ant and important
(2) Inlimnation spcdfieally requesK'd in question
If at any point during administration of the I\JMHS the detainc<; experiences distress. he/she should follow the jails procedure I'lr
referral sen ices.
INSTRUCTIONS FOR SECTION J:
OFFICER'S COMII-'IENTS: Chl'l;k an)' one or more of the four prohlems listed if applicable to this scr"ening. If an} other problemts)
oc..:urn-d. please ehe..:k OTHER. and note" hat it was.
REFERRAL 1,"iSTRUCTIOl"S:
An}' detainee answering YES to rt..:m 7 or YES to Item 8 or YES to at Icastlwo of Items [-6 should I)c referred for furth..:r ml'IHal
health evaluation. [rthere is any olher informati{ln {lr reason why the ollker feds it is n"C'essary for thC' dClain..:e to han' a mental health
e\ aluation. the detainee shoold be referred. l'lease indicate whether or not the detaint'l; was referred.

http://gainscenter.samhsa.gov/pdfs/disorders/bjmhsform.pdf

151

 

 
 

Jefferson County Jail’s Reply

Office: (641) 472·4146
Fax: (641) 469-3353
E·mall: jeffCOSQt;kasl.net

Sheriff
Jerry R. Droz
!Jeufenanl

1200 W. Grimes· FairfIeld.1A52556

Randy Lewis

January 13, 2009
Mr. William AngricL:,
We have attached Jefferson Counties' response from our Health Professionals.
Please note that we are following our Health Professional's guidance at this time.

We would ask thai you include both sides of this incident when publishing your
findings to the general public. We ....'lUIt the public 10 know what was occurring to cause
the excessh'e use of the Emergency Restraint Chair (ERC) and that we were NOT
blaramly disregarding policies and procedures. and that ....-e were indeed trying to keep
Mr. Halley from hanning himselfor others at the time of the incidenlS. We feel it is very
important and very fair that )'ou publish both sides. Also, explain the fact that there were
NO injuries to Mr. Halley from the use of the ERC.

We would further ask that when you publish these finding, that you get the names
correct. It is Sheriff Jerry R. Droz and not Terry. This was relayed to Mr. Andy Teas in
person to which he only replied '·whatever".

C2
Jail Administmor. MichKl S. Simons

Cc: nm Dille.lcffftson Counly Allomey
Or, N<lnnan JoIwIsoo. AHC

Deputy: Tim Simmons

""""" """ """"""'"

Deputy: Gregg Morton
0eJMy. David Wyatt

152

Deputy: Jerry Marcellus
secretary: Judi Robinson

 

 

 

~ED

CORRECTIONAl+HfAlJHCARE
December 16, 2t':XlJ

5heriffjeny Oroz
Jefferson County Correctional Facility

1200 West Grimes
Fairfield, IA 52556
Dear Sheriff Droz,

I am writing in regard to the investigation of restraint device use in Iowa's County jails from the
state of Iowa Citizen's Aide/Ombudsman William P. Angrick. IL dated November 5, 2008.
After reviewing the executive suounary, in paragraph 5 on page 1, there was a list of eight
recommendations. I will take each of these in order to discu.s5 our thoughts and recommendations.
1) Mental health screening of new inmates; Vice President of Quality Assurance &: Risk

Management sent you a copy of the recommendations on mental health screening from our
mental health team. A copy is enclosed with this letter. You will note the reconunended
questionnaire is actually more comprehensive than the GAINS questionnaire recommended
by the Ombudsman. I believe it is reasonable to incorporate these questions into yOUT book~
in screening sheet.
2) Follow up mental health assessment for inmates who screen positive for mental illness;
Your physician has been trained to handle mental health issues according to NCrnc
(National Commission of Correctional Healthcare) standards. He has further support and
training from our mental health team and has received special training from our team. It is
my opinion that he is fully qualified to evaluate thOL'le people with mental health problems
in your facility.
3) When to use restraint devices; I believe that your policy, 1-10, i!l well written and
compreheNive. As long as your officers are trained in that policy, J see no need to change
anything at this time.
4) What types of restraints are appropriate; it is my opinion, after reading your policies, 1-10
and 1·10A, which cover these types of restraints, given the situatiOl\!l that you face these
policies appear to address the problem. I do not believe it is necessary to purchase further
restraint devices, such as restraint bed. I don't believe any further protocols or policies are
necessary.
5) Monitoring restrained inmates; Enclosed you will find a copy of the Jackson County,
Missouri restraint monitoring policy. This is a very large facility and they do occasionally

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find the need for chair restraints. This program has worked very well and has resulted in
no injuries to the inmates. I believe it is reasonable to incorporate this monitoring system at

your facility.
6) Medical and mental health reviews of inmates; I believe by extending the screening to
include the mental health questions we have recommended and having your physician
review the medical and mental health of the inmates, as you presently are doing, you will
meet the recommendations of the Ombudsman. For an inmate who is placed in chair
restraint, the officer should pull the medical record and alert the physician to any medical or
mental health issues that may exist.

7) Documentation of restraint use; The documentation of the restraint use is two fold - first to
document the reasons for the restraint, and second to document what is going on with the
detainee while in the restraints. The second part of this is already handled in question
number 5. The first part, documentation of the reasons, should be handled through your
routine coITectional officer's notes and documentation. J believe no further changes are
necessary.

8) Time limits for restraint use; as discussed during the visit, we would recommend after a
period of 2 hours the detainee should be released and allowed to stand up, If behaviors
begin again he can be placed in restraints again for an additional 2 hour period. This will
get past the issue of having a detainee in prolonged, 6 - 12 hour restraints. It will also get us
past the need for medical review since the inmate is able to get out and move all extremities
without di£ficulty.
If you have the ability to place the chair on video, I believe that would be an excellent way
to document length of time and the procedures that the officers are using, as well as the
combative behavior of the detainee.

At the present time, Advanced Correctional Healthcare is in the process of developing a
video psychology and a video psychiatry program. It may be that the video psychology
program on an as needed basis might work well in your facility. We are in the process of
putting the elements togetheI. As soon as this is completed we would let you know how it
would work in your facility and what costs would be necessary to get it initiated.
Again,. thank you for aUowing us to assist you in this very important work. After reviewing
these recommendations, let me know if we can assist you in any other way.

. Respectfully,

~
Norm

CEO

Ce

~crA./71J--D

Johnson, MD

dvanced Conectional Healthcare

(309)~56

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Woodbury County Jail’s Reply

KLASS 1 - - - - - - - - - - - - -

- - - - - - - - - - - - - 1 LAW
Andrea H. Buckley *+
Timothy A. Clausen *+
Rene Charles Lapierre *+
William H. Larson *+
Sharese Manker *+

FIRM LLP

Barbara F. Orzechowski *+
Douglas L Phillips *
James R. ViHone *
Brian L Yung
Marvin J. Klass (1913

~

4280 Sergeant Road
Mayfair Center, Suite 290
Sioux City. IA 51 106

2000)

* Also admitted in Nebraska

Telephone' 7 I2-252-1866
Writer's Extension· 230
Fax' 7]2-252-5822

+ Also admitted in South Dakota

December 31, 2008
Via E-Mail
William P. Angrick II
Citizens' Aide/Ombudsman
Ola Babcock Miller Building
1112 East Grand Avenue
Des Moines. lA 50319
Re:

Woodbury County Jail Investigation

Dear Mr. Angrick:
1 represent the Woodbury County Sheriff. In your letter of November 5,2008, addressed to the
Sherift~ you asked that he advise whether he will accept the rccommendations contained in your
investigative report issued on November 5, 2008. The purpose of this letter is to respond to that
request.
I. Recommendation regarding intake screening and response to medical requests (p. 92). The
Woodbury County Jail does provide a medical history screen, both at the timc of booking, and in
a more thorough assessment for detainees committed to general population. Both the screening
and the assessment address current medical conditions, medications and mental health history.
The forms used, questions asked and information gathered eomply with the requirements of the
current state jail standards. To the extent the Ombudsman is recommending that this procedure,
or the forms currently in use be changed, that recommcndation is rejected.

2. Recommendation regarding responses to inmate requests/i)r mental health care (p. 92). The
Jail does respond to inmate requests for mental health care, and rejects the suggestion that it did
not respond in the case of G.A.

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William P. Angrick II
Citizcns' AidelOmbudsman
December 3 I, 2008
Page 2
Woodbury County Jail Investigation
Re:

3. Recommendation regarding revisions to Jail Policy governing use ol'restraint devices (p. 95).
The Jail maintains that the applicable policies and guidelines comply with the requirements of
state and federal law. The cases to which the Ombudsman refers are based upon facts that have
no similarity to the allegations made by G.A. Jail statf are properly trained and understand that
when forcc of any kind is used, they are always required to use the least amount of force
necessary to accomplish their legitimate goals. The applicable policies and guidelines make it
clear that in the case of cell damage, destruction must be "extreme." In the case of G.A., the
officers that were present when the incident happened were convinced that restraints were
appropriate. This recommendation is rejccted.
4. Recommendation regarding use 01' a restraint chair instead ol'a restraint board (p. 97). No
two incidents are alike. The circumstances of the individual incident and the availability ofthe
particular device govern the choices that are made. From the standpoint of otTtcer safety, a
restraint chair is ordinarily easier to use than a board, and for that reason, the chair is often
preferred. To the extent that the Ombudsman is recommending that the Jail never use a restraint
board, however, that recommendation is rejected.
5. Recommendation requiring notification ol'medical sh!fland direct medical supervision (p.
98). While the factual basis for this recommendation is disputed, the Jail accepts the
recommendation that medical staff be notified when a restraint device is used. The Jail rejects
the recommendation that direct medical supervision be required in cases where use of a restraint
chair exceeds two hours.
6. Recommendation regarding mental health review (p. 99). Mental health services are provided
in accordance with the medical needs and legal rights of detainees. The Jail rejects this
recommendation.
7 and 8. Recommendations regarding documentation and video taping "I'use (p. 100). The
current policy and practice meet the requirements of the applicable state jail standards. This
recommendation is rejected.

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William P. Angrick II
Citizens' Aide/Ombudsman
December 3 I, 2008
Page 3
Re:
Woodbury County Jail Investigation
Sincerely,

Douglas L. Phillips
cc:

Glenn Parrett
Greg Logan
Robert AspJeaf
Lynette Redden

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Appanoose And Wapello County Jails’ Reply
SOUTH IOWA AREA CRIME COMMISSION
P.O. Bo~ 943
FAIRFIELD. IOWA 52556

January 9, 2009
Mr. William P. Angrick, "
Citizens' Aide/Ombudsman
Ola Babcock Miller Building
1112 East Grand Avenue
Des Moines, Iowa 50319
RE: Use of Restraint Chairs
Dear Mr. Angrick:
This letter acknowledges the receipt of your letters to ShcriffGary D.
Anderson and Donald Kirkendall dated November 5, 2008. Both
Appanoose and Wapello Countics are members of the South Iowa Area
Crime Commission. Sheriffs Anderson and Kirkendall have requested that
we prepare a response on behalf of both counties as well as on behalf of all
fifteen Crime Commission member counties.
The Crime Commission assists member counties in risk management issues,
lawsuit prevention, preparation and implementation ofjail policy and
procedure manuals and training. Most of the Crime Commission members
have small rural jails with budgetary limitations and shortages in medical
and mental health services. Most of OUf jails have less than a 25 bed
capacity. Because of the diverse nature of each facility across the stale, the
age and condition of each facility, the financial and administrative pressures
in each county and the lack of services available in many of our rural areas,
it is not possible to deal universally with the issues you have identified.
In defense of the specific allegations against Wapello and Appanoosc
Counties, we will address those separately. However. both counties initially
responded to investigations started by your office. Both Jail Administrators
provided the infomlation requested with one exception that will be
addressed. Both Jail Administrators were lold by the initial investigators
that the investigations were completed. TIley were shocked when months
later they were told by a different investigator that the investigations were
llot completed and these counties had not been cleared.
-1-

A MUln·cOUNTY CRIMINAL JUSTICE PLANNING AGENCY

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Regarding the incident with inmate J.L. who was arrested for public
intoxication on May 20, 2007 and booked into the Wapello County Jail,
please note that he registered a .239 on the preliminary breath test nearly
three times the legal limit. Jail staff appropriately detennined that the use of
the restraint chair was necessary because lL. was hitting his head against
the cell window. The policies in place had been prepared by the former Jail
Planner when the new jail was built. Alrhe time, Iowa Jail Standards did
nor require constant CCTV surveillance on the restraint chair. Thejail's
policy required 15 minute in-person checks and consideration for removal
on an hourly basis. However, this exceeded the Iowa Jail Standard, which
did not require those checks. Documentation was required. Although jail
staff claims that documentation was done, the Jail Administrator has been
unable to find that documentation.
Additional training has occurred at the Wapello County Jail to address some
of the concerns raised. Streaming video equipment has been purchased.
The restraint chair has been moved to ensure 24/7 observation and proper
lighting. Two correctional officers are now required to secure an inmate in a
restraint chair. Documentation of the IS-minutes checks will be preserved
in an appropriate fonnat for any future need or reference.
The real issue here is the fact that the officer, when kicked in the head by the
inmate. reacted instinctively and defensively, by striking the inmate. While
this was a reactive movement, it did not occur without provocation by the
inmate. This was not punitive; it was reactive and defensive in nature. The
policies in place were in compliance with the Iowa Jail Standards.
Concerning the Appanoose County Jail incident, jail personnel acted
appropriately throughout the night when dealing with the inmate in question.
She was abusive. assaliltiv~. and self-injurious. She was examined by
medical providers upon admission to the jail. These providers found no
medical problcm in need oftreatmcnt. She was provided many
opportunities to cooperate with staffbllt chose to act in a violent manner.
Furthermore, there was no place to take this inmate. Appanoose County has
an extremely difficult time gctting any type of mental health commitment.
Even if a commitment is approved, there are no medical facilities which will
take these inmates. The safest place for this inmate. whether she was
mcntally ill or not, was in the jail.
-2-

159

 

 

 

The policy in effect did provide for direct medical supervision. The Crime
Commission is recommending that this policy be changed since the Iowa Jail
Standards do not require direct supervision by a medical provider or limit
the hours needed for restraint. Clearly, this inmate needed to be in the
restraint chair for the time indicated for her safety as well as the safety of
staff. As soon as she senled down, she was released from the chair.
This inmate was not tased. Staff are trained that it is permissible, but not
recommended, to tase a restrained arrestee if the circumstances warrant it.
However, it is recommended that extreme caution be used under these
circumstances. This inmate did stop rocking the restraint chair after she was
advised of the possibility of being tased. It was not long after this that she
started to behave and was removed from the chair. She was drunk, not
mentally ill. Her behavior after that point suggested no mental illness.
There is absolutely no evidence that the inmate urinated or defecated in the
chair. StafTmust be given discretion to determine if it is safe enough to
release the inmate. The Appanoose County Jail is an extremely small
facility with few officers. They do not have the same manpower as the
Federal Prisons. Therefore. the Fcdera! Bureau of Prisons' policy is a luxul)'
a small town jail cannot 3n~lrd.
And finally, Appanoose County was not contacted about this incident until
after the tape had been taped over. This is a common practice in jails across
the country, because of the cost in replacing tapes frequently. Furthermore,
Jail Administrator Beck was told by the investigating ombudsman that the
incident had been reviewed and the county was not found at fault.
The list of recommendations provided in your report is laudable, but far
from attainable due to budget shortages not only in Iowa Jails but in the
mental health arena. Even ifit is clear lhat the inmate is mentally ill l either
staff cannot get the inmate committed because of a lack of cooperation by
some judicial officials or medical providers refuse to verify the need.
Medical providers and judges have said the safest place for these inmates
and the public is in a county jail. And, even if a commitment is successful,
there are no hospital beds for inmates with aggravated misdemeanor or
felony charges. It takes months for a bed to open up at Oakdale for inmates
with these charges. Where are these inmates supposed to go?

160

 

 

 

Most of our jails are small, in rural areas with little 10 no mental health
services provided. The Jail Standards require that all inmates are screened
for mental health. However assessment by a mental health professional is
not an easy task not only because of budgetary constraints but also because
of the absence of mental health professionals in these areas. Telemedicine
may be a useful tool in the future, but currently it is out of reach for small,
economically stressed rural counties. The cost may only be $750 for the
equipment, but the cost for the service cannot be billed to the inmate (even if
the inmate were capable of paying) as it is to the patient as suggested by the
hospital example given in the report.
In the review of when to use restraint chairs, it is clear that the policies are in
place to use these devices when needed. However, do we wait until the
inmate seriollsly injures himself, stafT or other inmates before we intervene
by using the device? This is reactive behavior and not proactive behavior
which results in litigation. Correctional officers must be given discretion in
the need for the device during an emergency situation. It is difficult to
review these incidents in hindsight and judge whether the officer's decision
was necessary. During an emergency situation, an officer must look at the
totality of circumstances in determining the need for the restraint device.
For instance, a threat upon the officer may be adequate cause for restraint
rather than waiting for the assault to occur. Many of these inmates are wellknown by the jail stafT and their propensity for violence is well-known. A
threat by an inmate with a known history of serious assault may be adequate
for the use of the restraint device.
Often it is difficult tojudge whether the use of the restraint device was
punitive or not. What may be viewed as punitive to one person lllay be seen
as in the best interest of another persoll. The lines between safety and
security can orten be blurred and viewed as punitive by the inmate. Verbal
abuse and threats made by the inmate against staff or other inmates can be
sufiicient to justi fy lise of the restraint device. If an officer waits until the
inmate carries out the abuse, it is too late to protect the safety and security of
the inmate(s) and stafT.
Medical review of restraint chair use simply is not practical or realistic in
our jails. Besides the issue of money. even if mental health professionals are
available, it is difficult to hire a medical provider to come to the jail usually
at odd hours of the day or night to deal with the criminal element.
-4-

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We acknowledge that there may be times that a mentally ill inmate may be
placed in a restraint chair. However, that is often the only mechanism
immediately available to jail staff to ensure the safety of the inmate, other
inmates and staff.
Camera usage is required pursuant to the Iowa Jail Standards. However,
video feed is recorded over after a period of time. If the Jail does not receive
notice of a reason to preserve the tape, it is simply recorded over. That does
not mean the Jail does not comply with the Standards. Ifvideo feed is
required to be preserved after every incident that occurs in the jail, there
could be a potential storage problem as well as added operating expense to
already stressed jails. The problem is further compounded by the lack of
medical providers, the lack of medical beds and local funds to provide the
mental health services you have suggested.
Our counties try to hire the best staff available. However, employment as a
correctional officer in a small town jail is not the most glamorous or sought
aHer position. Often, these officers work long hours, with low pay, being
subjected to physical and verbal abuse by inmates on a daily basis. These
employees are also subjected to bloodbome and airborne pathogens that can
be potentially deadly. It is difficult to pay these officers what they are really
worth. Policies arc developed and training is provided. The majority of our
officers are conscientious, dedicated employees who try to provide the best
care for inmates as possible in spite of the abuse they receive in return.
However, even a good employee can react instinctively and defensively to
an assault by an inmate. Employees are taught defensive tactics routinely at
jail schools to allow them to defend themselves during an assault.
The report details the need for mental health courts, and an overhaul in the
mental health system in the State of Iowa. Other suggestions include
regional jails. In many of our counties, bond issues for new jails have failed
repeatedly because taxpayers do not want to fund new state of the art
facilities. The funds are simply not available to pay the cost for these jails.

Regarding the recommendations made on pages 6 and 7 of the report, we
would provide the following responses:

-5-

162

 

 

 

I.
Mental heahh Screening fonns may be a useful tool incorporated into
our current Medical Screening Fonns. However, it does not solve the
budgetary and mental health issues due to lack of money, few mental health
resources, refusal to commit by judicial officials and/or doctors. and refusal
by mental health facilities to accept commitments of difficuh inmates, who
may be charged with a felony or aggravated misdemeanor.
2.
The same arguments can be made regarding your recommendation for
further assessment. Again, where do we transfer these inmates?
3.
Our policies restrict when restraint dcvices may be used. Howcver,
we request that you do not second guess the LIse ofa restraint device during
emergency situations. Officers do not know when a verbal threat can
escalate to actual assault. Ifan assault occurs after we know of the verbal
abuse or lhreat, our litigation liability and risk increases.
4.
Our policies require that the least restrictive means of force is used to
control the inmatc. Our officers are continually trained on this. Any use of
force in excess of the minimum force necessary is excessive. Our officers
are trained to use their best judgment under extenuating circumstances.
5.
Video equipment is used. Depending on the Jail facilities and the
equipment that can be afforded, video tape may b~ of good quality or it may
be marginal as experienced in Wapcllo County. Our jails are constantly
striving to update and improve equipment based upon budgetary restrictions.
6.
Personal, visual observation is required by the Iowa Jail Standards.
Our policies also require this.
7.
Officers are actually trained to determine whether an inlllnte can be
removed every 15 minutes, but at lcast hourly. Some officers arc bellcr at
documcnting specifics than others.
8.
Medical rcvicw is simply not in the budget. The State of Iowa has
increased the amount oftimc an inmate can serve in our coulllY jails. This
was to take the stress ofT the state system. County Jails were initially
intended for short teml incarcerations. Now. inmates can serve up to a year
in jail. 1-10\\ ever, this increase in the use of our jails did not come with an
increase in funding by the State.
-6-

163

 

 

 

9.
Again, direct in-person medical reviews may be desirable, but they are
not practical with restricted money and few mental health resources.
10. The Crime Commission respectfully disagrees that the employment of
a licensed medical professional by the Jail is a potential conflict of interest.
If the County has the luxury to hire staff medical personnel, those
individuals should be allowed to review the use of a restraint device. This is
a possible if the Jail can afford to do so. However, most of our jails do not
have the money to hire on-staff medical providers.
II.
We would respond essential1y as above regarding the need LO contact
medical providers every time a restraint device is used or if it is needed
beyond two hours. We will be updating our restraint chair policies for our
counties in the future, removing reference to the requirement that a medical
provider has 10 be contacted, and removing reference to an automatic
limitation on the time used for these chairs.
12. Again, documentation is required on the use of all restraint devices.
Officers are trained on this and strongly encouraged to be specific in their
documentation. While ILEA mayor may not specifically train on the use of
restraint devices, the Crime Commission has conducted familiarization
lraining on the restraint chair and has annually conducted a review oflegal
cases around the country involving these devices, documentation and
excessive force cases.
13.
We have addressed repeatedly the issue of video use. However,
retaining and preserving a tape to be kept for two years is simply not
practical in light of the high number of incidents that occur in county jails.
[t would be up to each individual jail to determine whether these tapes could
be maintained.
While the report does documcnt ongoing mental health problems in the
state's correctional system, the recommendations provided assume that
minor changes can be made with minimal financial impact. Thesc
recommendations do not fully consider all the underlying causes and assume
that the Jails have total control of these issues. That is clearly not the case.
Mandating these recommendations without the funds or resources to do so is
not in the best interest of the State. The financial impact could bankrupt
many of our counties.
-7-

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The Crime Commission will be reviewing its restraint chair policies for our
member counties and will recommend some changes suggested by your
repon. We are always looking for ways we can improve the operation of our
jails. However, based upon our review of the use of restraint chairs in our
area, we believe that they are a valuable tool to assist our jails in controlling
inmates and preventing injury to the inmate(s) and staff. Implemcnting all
of the recommcndations in your repon would be vinually impossible due to
budget restrictions and lack of mental health resources.
We would also likc to request that the namcs of the jail personncl involved
remain confidcntial,just as the inmate names remain confidential.
Thank you for your consideration.
Respectfully submitted,

Sieve McCoy. Director
The South Iowa Area Crime Commission

-8-

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Polk County Jail’s Reply
POLK COUNTY SHERIFF'S OFFICE
Polk County Jail
1985 ....'E 51st Place
Des

~oines.1A 503J3-2.51~

..

SHERIFF DENl\7S JY. ANDERSON

www.co.polk.ia.usfdepanmentslsheriff
Office
(515) 286-3800
F:u

(SIS) 323-5473

William P. Angrick n
CitizeIl!' Aide/Ombudsman
Ola Babcock Miller Building
liZ East Grand Avenue
Des Moines., Iowa 50319

Dear Mr. Angrick:
Thank you for the opportunity to reply to your report. The Polk County Sheriffs Office
appreciates the analysis, conclusions and recommendations from your agency. We take
this report ..."try seriously and will take the corrective measures you have put forth in
order to comply with all constitutional rights, Iowa laws and the restraint chair
manufacture's recommendations.
The Polk County Sheriff's Office agrees to the general recommendations for jails made
on page #65 of the report. The Polk County Sheriffs Office General Orders now reflect
compliance to the recommendations and a copy of our revised General Order on the use
of the restraint chair accompanies this response. Staffwill be advised of the updated
policy through roll calls, online training on the new General Order and through annual inservice training. All new hires are shown the restraint chair manufacture's (EKe. Inc.)
usage video during basic jail schooL A copy of the video used for restraint chair training
also accompanies this response.
We have also addressed the issues presented in your report specificaJly addressed to Polk
County which are pages 116 to 125.
I. Page #120 - Polk County must conduct 15~minute checks of the inmate and the
restraint device application throughout the duration of the inmate's placement in a
restraint device. The jail should immediately review this practice with staff and
ensure it is addressed during regular training on restraint device use in the jail.
Response: The Polk County Sheriff's Office General Order # 6600.59 has been
updated to reflect the mandate of 15 minute checks. Please refer to Page #2 of the
attached GeneraJ Order Procedure Section F 4(a-f). The updated General Order will
immediately be reviewed with staffin the manner I have described above.

166

 

 

 

2. Page# 121 - Polk County Jail should refrain from placing an inmate in a restraint
device for a pre-determined time limit. Such placement could be considered
punitive and contrary to the inmate's constitutional rights and Iowa law,
especially if that pre-determined time limit extends to periods when the inmate is
no longer a threat to self, others, or jail security.
Response: The Polk COUDty Sheriff's Office General Order # 6600.59 has been
written to clearly state; restraint devices such as the restraint chair, shall not be
applied as punishment. Please refer to the attached General Order Policy description
as well as the General Order Procedure Sections G through J. The updated General
Order will immediately be reviewed with staff in the manner I have described above.
3. Page #121/122 ~ The jail should conduct periodic checks of the inmate's
disposition and actions to determine whether the inmate may be released. The jail
should train all staff who may be involved in restraint chair use on the jail's
existing poticy requiring "at least hourly" reviews of a restrained inmate to
determine if the inmate may be released. lfthe inmate must remain in the
restraint device, the jail must document the inmate's actions justifying continued
restraint.
Response: The Polk County Sheriff's Office General Order # 6600.59 has been
written ensure that staff conducts regular 15 minute checks and consideration is given
to the inmate for removal from the restraint chair at least hourly. Also; the General
Orders have been updated to reflect the requirement to document the reasons for
continued restraint at least hourly. Please refer to the attached General Order
Procedure Section G. The updated General Order will immediately be reviewed with
staff in the manner I have described above.
4. Page#122 - Polk: County Jail should follow the manufacturer's guidelines
recommending direct medical supervision in the event the restraint chair must be
used longer than the initial two hours, and incorporate this procedure in the
written policy.
Response: The Polk County Sheriff's Office General Order #6600.59 has been
updated to include the restraint chair manufactures recommendation of maximum
confinement. The General Order update also requires Health Services to inspect and
review the inmate's condition, as soon as possible after the inmate is placed into the
restraint chair, at least hourly while in the restraint chair. Mental Health staffwill
also be notified if the inmate is known or believed to have a mental illness. Please
refer to the attached General Order Procedure Sections D, H, T, K and L. The
updated General Order will immediately be reviewed with jail and medical staff in
the manner I have described above. The Emergency Restraint Chair Demonstration
Video will be shown during our annual in-service training.

167

 
 
5. Page#123 - Polk County Jail must document each action and decision addressing
an inmate's four or five point restraint. It must ensure the checks are done and
ensure the documentation is not "overlooked." Documenting all actions and
decisions, under Iowa law, also includes the decision whether to release the
inmate or continue restraint use after each hourly review that is required under jail
policy. This applies to any medical reviews during and after the use of the
restraints on the inmate.
Response: The Polk County Sheriff's Office General Order # 6600.59 has been
updated to reflect the mandate requiring staff to physically check the restraints on
inmates in the restraint chair every 15 minutes and to document their observations
accurately. The Health Services Administrator Tania Porter has been advised
documentation of medical observations for inmates in the restraint chair must be
made for their records. Please refer to the attached General Order Procedure Section
F 4(a-f) and G. The updated General Order will immediately be reviewed with staff
in the manner I have described above.
6. Page#124 - The jail should incorporate in its written policy the procedures for
written documentation of all actions relating to restraint chair use.
Response: The Polk County Sheriff's Office General Order # 6600.59 Procedures
Section F (1-5), has been updated to reflect all necessary documentation relating to
the restraint chair use.
7. Page#125 - The Polk County Jail should ensure the video documenting the
restraint device use provides an accurate account of the events that transpire. This
would include an unobstructed view of the placement and use of the restraints.
This is important for vivid documentation and necessary if used for continuous
monitoring purposes. The jai1should retain copies for at least two years.
Response: The Polk County Sheriffs Office General Order # 6600.59 has been
updated to include inmate placement for digital recording documentation and
addresses digital recording retention requirements. Please refer to the attached
General Order Procedure Section B, C and N. The updated General Order will
immediately be reviewed with staff in the manner I have described above.
Thank you again for allowing the Polk County Sheriffs Office an opportunity to
respond to your report. We look forward to working with you as we continue to
advance into our new jail facility.

Respectfully;

ChiefL. Shoemaker

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Ombudsman Comment
The Ombudsman is required by law to consult with the agencies involved in an
investigative report and attach their written replies to the report.
The Ombudsman received a variety of responses, ranging from Polk County’s acceptance
of all the recommendations – including a redrafting of their restraint chair policy – to
Woodbury County’s outright rejection of all recommendations. The South Iowa Area
Crime Commission (SIACC) provided arguments to many of the recommendations on
behalf of Appanoose County, as well as the other counties it represents, which were not
the subject of the Ombudsman’s report. The Ombudsman’s Comment will address the
counties’ responses.
Polk County Jail
The Ombudsman commends the Polk County Jail for its responsiveness to the report and
recommendations. The jail assured the Ombudsman that it took the report very seriously,
accepted each recommendation, and re-drafted its policy to comply with all constitutional
rights, Iowa laws, and its restraint chair manufacturer’s recommendations. The
Ombudsman has reviewed the new policy and is very satisfied with the language.
Jefferson County Jail
Jefferson County Jail’s original response did not address the recommendations set out in
the report. The letter from Advanced Correctional Healthcare, on behalf of Jefferson
County Jail, only responded to the general issues presented in the Executive Summary
section of the report. However, a subsequent correspondence with Jail Administrator
Michael Simons yielded the response that the jail accepted each of the Ombudsman’s
recommendations.
It is also important to point out that the jail began incorporating significant changes even
before the report was issued, including consulting with an outside agency to review
medical and mental health treatment for inmates.
The only fact dispute raised in Jefferson County’s reply is the mistaken reference to
Sheriff Jerry R. Droz’s first name, identified as “Terry” in the draft report. The county’s
reply stated, “This was relayed to Mr. Andy Teas in person to which he only replied
‘whatever’.”
There was no in-person conversation between Sheriff Droz and Mr. Teas about the
mistake. Mr. Teas became aware of the error on November 14, 2008, when Sheriff Droz
informed the receptionist about the mistaken reference to his first name. The error has
been corrected for the final version of the report.

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Woodbury County Jail
The Woodbury County Jail rejected all of the Ombudsman’s recommendations, the
product of extensive research based on professional recommendations and industry
standards. The Ombudsman is disappointed that the jail has failed to take the opportunity
to improve its policies and practices on restraint device use. Of particular concern is the
jail’s decision to ignore the restraint chair manufacturer’s own recommendation that
owners of its chair employ direct medical supervision in cases where an inmate restraint
exceeds two hours.
Each argument rejecting the recommendations merits a response from the Ombudsman:
1. The Woodbury County Jail rejected the Ombudsman’s recommendation to incorporate
an intake screen that addresses an inmate’s medical and mental health history and needs.
The jail argues it already has a screen in place. However, no records of any such screen
were provided to the Ombudsman for G.A.’s admission to the jail on June 25, 2006. If
the jail already has a screen it uses for newly admitted inmates, it needs to ensure it is
used and retained for each inmate entering the jail.
2. The jail rejected the suggestion that it did not respond to G.A.’s request for mental
health care. The Ombudsman did not make any such suggestion. The concern in G.A.’s
case was that the jail did not respond in a reasonable amount of time. Based on
documents provided by the jail, it took more than two months for G.A. to be seen by
medical staff after he had submitted a medical request for depression and anxiety. The
day after he was finally seen, he was placed both on a restraint board and in a restraint
chair.
The Ombudsman believes an unreasonable delay to medical care may violate an inmate’s
Eighth Amendment rights and places the jail at risk of legal liability.
3. The jail rejected the Ombudsman’s recommendation to revise the jail’s policies on the
use of restraint devices. The jail implies that the destruction G.A. caused to the cell was
extreme. The Ombudsman stands by the facts presented in the report.
The jail’s response does not address the Ombudsman’s concerns regarding the apparent
inconsistencies within the policy, which provides varying reasons for which a restraint
device may be used. A clear policy is necessary to notify officers and jail staff when
certain force is authorized and what kind of force is prohibited. In 2002, four former
Woodbury County jailers sued the county for slander when the sheriff publicly stated that
the jailers violated policy by their use of force on an inmate. The jailers later were able
to show that there was no language in policy that prohibited their use of force against the
inmate, which included kneeing the inmate, slamming his head against a counter,
punching him in the ribs, and elbowing him in the back.

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4. The jail rejected the recommendation that staff should use the restraint chair rather
than the restraint board. The Ombudsman believes the use of the restraint chair is
preferable to the restraint board whenever possible for the reasons detailed in the report.
5. The jail rejected the recommendation calling for direct medical supervision of inmates
where the use of the restraint chair exceeds two hours. The recommendation is derived
from the chair manufacturer’s recommended use. By rejecting the Ombudsman’s
recommendation to provide direct medical supervision, the jail is putting the inmate at
greater risk of serious injury or death, and potentially subjecting the county to legal
liability.
6. The jail rejected the recommendation to incorporate language in its written policy
requiring a mental health review of any inmate with a known or suspected mental illness
who is placed in a restraint device. The jail argues it already meets the medical needs and
legal rights of inmates.
The facts presented in the report speak for themselves. A medical or mental health
professional was never contacted when G.A. was placed in the restraint devices on
September 3, 2006. This is a practice recommended by the NCCHC, the ACA, the
restraint chair manufacturer, and the U.S. DOJ’s investigation of Black Hawk County
Jail. Placing these procedures in written policies helps prevent inconsistent practices by
jail personnel.
7. and 8. The jail rejected the recommendation to have staff document the need for
continued restraint device use in its reports and logs. It also rejected the recommendation
to video record the duration of the restraint device use. The jail argues its policy and
practice meets the legal requirements under Iowa law.
The Ombudsman does not believe the jail’s response to these recommendations reflect
the best practice for restraint device use and further exposes the jail to liability, as
detailed in the report.
This report cited examples from other jails where use of video provided instrumental
evidence to substantiate or reject inmate claims of abuse. Woodbury County Jail’s
officials, in particular, relied heavily on the use of video when it disciplined four officers
accused of beating an inmate in 2002. Without those tapes, it is difficult to say where the
case would have gone if the only evidence came from the inmate’s allegations.
The Ombudsman agrees with Woodbury County Jail that the jail’s current policies and
practices meet the basic requirements of the applicable jail standards. However,
complying with existing law or rules is not sufficient. Clarification of jail policies,
following industry standards, and conforming to manufacturer guidelines is as important
for inmate and staff safety as following the minimum requirements of the law. The
Ombudsman is convinced that continued monitoring for violations of Iowa law, jail
policy, and industry standards at the jail is required for the health and safety of Iowans.

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Appanoose County Jail
The South Iowa Area Crime Commission (SIACC) replied to our report on behalf of the
Appanoose and Wapello county jails, as well as on behalf of 13 other counties it
represents. In its representation of the Appanoose County Jail, the SIACC raised its
concerns about how the county could access and afford medical reviews and mental
health care services, the use of Tasers on restrained inmates, and the circumstances under
which a restraint chair may be used.
SIACC requested that the name of jail personnel remain confidential, just as the inmates’
names remained confidential. The Ombudsman redacted the inmates’ names due to the
sensitive medical and mental health issues detailed in the report. The same concerns do
exist for jail personnel. In the spirit of transparency and accountability, the names of jail
personnel will remain in the report.
Medical and Mental Health
Our report recommended consultation with a mental health professional in the event an
inmate screens positive for a potential mental illness. The SIACC acknowledged that
Iowa law requires all inmates be screened for mental health, but stressed the difficulty
many counties have with the cost of mental health professionals’ assessments. SIACC
argued that even telemedicine does not solve the problem of paying for the services of a
mental health professional to review inmates.
While the Ombudsman sympathizes with the fiscal constraints faced by small counties,
failure to provide mental health care offers a more dire consequence than the financial
strain it places on a county. If an inmate does screen positive for a potential mental
illness in a county that cannot afford a mental health professional, what will happen to the
inmate? Will the jail ignore the inmate’s medical needs?
Refusing to contact a mental health professional for an inmate’s serious mental health
needs is an unacceptable response. It invokes a “snake pit” mentality towards mental
health treatment. The costs of seeking treatment for an inmate’s mental illness will pale
in comparison to the litigation costs of ignoring an illness if the inmate is injured or dies.
The Ombudsman hopes it is not also at the cost of human life or dignity.
The SIACC’s reply also argues about smaller jails’ ability to access mental health care,
citing resistant judges, a lack of mental health beds, and a refusal by hospitals to accept
inmates. The Ombudsman is well aware of these arguments by county officials.
The same arguments were raised by Jefferson County Jail when it restrained an inmate
with a serious mental illness on several occasions. Despite arguments that the magistrate
was known to decline civil commitment requests, the Ombudsman encouraged the county
officials to pursue an order. If the order failed, it would not be the fault of the jail or
county attorney. After the jail and county attorney agreed to the Ombudsman’s request,
the order was approved four days later.

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The Ombudsman then worked with Jefferson County’s Central Point of Coordination
administrator (CPC) when a concern about placement was raised. Much like the
argument raised by the SIACC, the county believed it would not find a bed for the
inmate, who was facing charges of robbing a bank and had a history of violent behavior.
The CPC eventually contacted 14 mental health institutes and private hospitals,
requesting to be placed on their waiting lists. Instead of taking “months for a bed to open
up,” as argued by the SIACC, within one day a bed became available at University of
Iowa Hospitals and Clinics.
The Ombudsman questions the SIACC’s generalized statements that mental health care is
unaffordable or inaccessible for its 15 member counties. The Ombudsman recently
conducted a state-wide survey of county CPC’s in Iowa, of which over half of the SIACC
represented counties responded. Questions included the willingness of magistrates to
commit inmates and the CPC’s experience with successful placement of those inmates.
The responses we received were not consistent with SIACC’s blanket statement that its
member counties cannot afford or access mental health care for inmates. The variety of
responses we received could be summarized by a CPC who represents five counties:
It varies - one county seems to commit everyone – one county won't
commit even if it seems obvious it's needed – the other 3 are good in
their evaluations and judgement of who needs commitment.
Counties should not assume or over-generalize a lack of availability in the civil
commitment process. Even those counties that have experienced problems committing
inmates should not give up. Not dealing with the problem does not make it go away.
Rather, counties should continue to work with parties involved to find solutions on
individual cases and system wide.
The SIACC seems to raise a factual dispute when it stated T.F. “was drunk, not mentally
ill. Her behavior after that point suggested no mental illness.” The Ombudsman
questions how the SIACC arrived at this conclusion. According to officer reports, T.F.
was punching herself in the face, banging her head against the wall, and jamming her
thumbs in her eyes. The Ombudsman believes it is risky for the SIACC and the jail to
make conclusions about the absence of any mental health diagnosis without first
consulting a mental health professional.

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Use of Taser Devices on Restrained Inmates
Long ago men tried to shock the insane back into sanity by throwing
them into a snake pit -- a drastic treatment which by its sudden terror
was sometimes successful. Modern methods, though superficially
more civilized, often rely on the same brutal shock to achieve their
results.
Mary Jane Ward, THE SNAKE PIT, dust jacket (Random House
1946).
The SIACC points out that a Taser device was never used on T.F., just threatened to be
used. The SIACC justifies the threat by pointing out that the desired effect was reached;
the inmate stopped rocking the restraint chair. The Ombudsman has concerns with this
argument, both for its premise and its acceptance of “shocking” the inmate with a
potential mental illness into compliance.
The Ombudsman believes it is relevant that T.F. was in the restraint chair for over nine
hours when the correctional officer threatened to use a Taser device on her. Until this
point, she was highly agitated. If the Ombudsman were to entertain the idea that the
threat of using a Taser device on inmates was an acceptable response - even where the
actual use of a Taser device would not be justified - the Ombudsman questions why the
jail waited over nine hours to employ this technique.
The Ombudsman stands by his recommendation that the jail consider non-aggressive
alternatives before escalating to force against inmates. The primary concern of the jail
should have been the inmate’s potential harm to herself by trying to tip over the chair.
The readily available, less aggressive alternative offered by the chair’s manufacturer
would have been to back the chair into the corner of the room to mitigate any tipping
hazard.
When to Use
The SIACC takes the bold stance that a restraint chair can and should be used when
inmates make verbal threats against jail staff. While the report did not criticize
Appanoose County Jail for the basis of its restraint chair use, the jail’s reply provides an
opportunity for the Ombudsman to reiterate its caution against such use.
The restraint chair must only be used when an inmate is a threat to self or others or
jeopardizes jail security. The Ombudsman believes that verbal abuse by itself, even
when the inmate has a history of violence, is insufficient reason to place an inmate in a
restraint chair. However, if an inmate displays signs of imminent violence and the
circumstance provides the inmate an opportunity to exact violence on others, the
Ombudsman could see a justification for restraint device use.

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The SIACC should consider non-aggressive alternatives like placing an inmate in a cell
by himself to cool off, or avoiding contact between staff and an inmate during periods of
inmate aggression. Both of those responses would avoid harm to staff and use of a
restraint device. In the event a restraint device is necessary, staff should be able to
articulate and document why the restraint device was required, and why less restrictive
alternatives were not available.
The SIACC argues that proactively placing an inmate in restraints before an inmate acts
out is an appropriate response, and the reactive response of waiting for an inmate to act
out leads to litigation. The Ombudsman disagrees. Litigation can arise, and has arisen,
when a jail places inmates in restraint devices based only on verbal threats.
Videotaping
The SIACC asserts that the jail’s use of video comports with Iowa’s jail standards. It
argues against the recommendation that jails retain restraint chair use videos for two
years, stating there could be a potential storage problem and added operating expense.
The SIACC also states that retention would be impractical due to the “high number of
incidents” that occur in county jails.
The SIACC did not identify what jail would be faced with a storage problem when
rejecting the Ombudsman’s recommendation. Unless specific storage problems are
identified after an attempt to retain the recordings, the Ombudsman stands by its
recommendation.
It is the Ombudsman’s impression that restraint devices are rarely used by smaller
counties like those the SIACC represents. It is not known how often Appanoose County
Jail uses the restraint chair each year, but it told the Ombudsman that T.F. was the only
inmate it used the restraint chair on for more than two hours. Jefferson County estimated
that it uses its restraint chair less than five times a year. Muscatine County told the
Ombudsman it used their restraint chair two to three times a year.
The highest number of restraint chair incidents the Ombudsman knows of came from
Polk County with 193 incidents in 2007. The Polk County Jail incorporated language in
its written policy to retain recordings for a minimum of two years in response to our
report. The Ombudsman stands by his recommendation that jails retain video copies of
all restraint device incidents for a minimum of two years.
Conclusion
The Ombudsman believes the SIACC has taken this opportunity to defend controversial
positions on the treatment of jail inmates and the use of restraint devices based on budget
restrictions and lack of mental health resources. It has offered no ideas on alternative
responses to inmate mental illness or inmate aggression that are less restrictive.

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It has even taken steps to weaken its own policy and place inmates at further risk of
serious injury. Prior to the Ombudsman’s investigation, the Appanoose County Jail went
beyond the requirements of Iowa law in its jail policy by requiring direct medical
supervision of inmates restrained for longer than two hours. This was consistent with the
manufacturer’s recommendations on restraint chair use. As a result of the Ombudsman’s
investigation, the SIACC reply stated:
The policy in effect did provide for direct medical supervision. The
Crime Commission is recommending that this policy be changed since
the Iowa Jail Standards do not require direct medical supervision by a
medical provider or limit the hours needed for restraint.
The Ombudsman urges the Appanoose County Jail resist SIACC’s advice to ignore the
manufacturer’s recommendation aimed at averting risk of harm to inmates.
Wapello County Jail
The SIACC also replied on behalf of Wapello County Jail. The Ombudsman appreciates
the following steps Wapello County Jail has taken to address some of the concerns raised
in this report, including:
•
•
•
•

Utilizing two officers to secure an inmate in a restraint chair.
Use of streaming video (change made after initiation of investigation and before
issuance of report).
Placement of chair to ensure 24/7 observation and proper lighting.
Preservation of 15-minute check documentation.

The SIACC identified the officer’s striking of an inmate as the real issue. The jail claims
that the officer who struck the restrained inmate “reacted instinctively and defensively.”
The Ombudsman believes the real issue lies with the procedures taken to place the inmate
in the restraint chair. Nevertheless, it appears the additional training includes the use of
two correctional officers to secure an inmate in a restraint chair, which should help
minimize the chances of an inmate causing harm to a correctional officer during
placement.

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