Complaints Prompt Scrutiny of St. Barnabas Hospital

On June 25, Yvette Green, a pregnant detainee at Rikers Island, went to one of the jail’s medical clinics in labor and three centimeters dilated. Ms. Green, 33, is known to New Yorkers as the guardian of Sabrina Green, the 9-year-old girl who was found dead in her apartment with burned and gangrenous hands. Ms. Green, charged with both second-degree murder and manslaughter, as well as with child endangerment of her half-sister, currently resides in protective custody at Rikers, a status reserved for women accused of crimes so heinous–like abusing and killing children–that they are under threat from other inmates.

Under city law, female prisoners about to give birth are supposed to be taken to a medical facility outside the jail. But at the clinic, administered by St. Barnabas Hospital, a physician assistant–less highly trained than an M.D.–decided Ms. Green could wait for hospitalization and sent her back to her cell. Yet common obstetrical logic is that a woman who’d had 10 children, as Ms. Green had had, would be a likely candidate for rapid labor. Sure enough, she was. With the help of other inmates, she quickly gave birth, in her cell, to a baby in distress who was then rushed to Elmhurst Hospital Center.

The irony of this story is rich: A woman incarcerated by the city for having allegedly killed a child gives birth in a city prison cell, in conditions that endanger the child.

While Rikers staff members have told The Observer that what happened to Ms. Green is an indication of problems at the jail, any claim by her would probably be far down on the list of troubles for St. Barnabas. On Aug. 24, almost eight months after the hospital assumed control of health care for Rikers, the city convened an extraordinary quality-assurance meeting. Packing a conference room at the headquarters of the Health and Hospitals Corporation, the city agency that was placed in charge of prison care in 1996, were high-level city doctors and administrators, and representatives from St. Barnabas, including its president, Dr. Ronald Gade. The medical charts of a handful of inmates were examined during the meeting. Ongoing assessment of medical care at Rikers, through which 133,000 inmates pass a year, is common. But this meeting was unusual because of the seniority of the administrators in attendance and what prompted it: steady complaints from doctors that medical standards at the jail have plummeted dangerously under St. Barnabas’ watch.

In August, the Manhattan District Attorney began a preliminary investigation into whether medical supplies are being diverted from the detention center, The Observer has learned. According to a senior law-enforcement source, investigators from the racketeering division have contacted at least one person at H.H.C., seeking information about supply orders and inventories.

Physicians have claimed, and internal memos seem to support, severe shortages of basic but necessary medical staples–gauze, paper towels, latex gloves, Foley catheters, specimen bags. Yet St. Barnabas has ordered roughly the same levels of supplies as its predecessor. If the District Attorney determines that the shortages do indeed exist, the question then would be, where are the supplies going? Sources have alleged to investigators that they are being diverted from Rikers to other St. Barnabas-run facilities.

Officials at St. Barnabas declined to be interviewed for this article, but did respond in a letter to written questions. “We are aware of no investigation by the office of the Manhattan District Attorney,” the response read. “No one at the hospital has been contacted by anyone in law enforcement … and we state categorically for the record that there is no basis whatsoever for any such investigation.”

H.H.C. released a two-paragraph statement which read, in part: “[H.H.C.'s] Office of Correctional Health Services and its affiliate, St. Barnabas Hospital, are committed to providing high-quality care to inmates at Rikers Island. This includes a quality assessment/improvement program with continuous monitoring of the care that we deliver. Furthermore, ample pharmaceuticals and medical/surgical supplies are provided for the clinics we operate and the patients we serve.”

All together, eight Federal, state and city agencies and watchdog groups are looking at St. Barnabas’ medical practices and management, some at Rikers Island and others at another facility it administers, Lincoln Medical and Mental Health Center in the South Bronx. On July 21, the Federal Health Care Financing Administration issued a 12-page report on deficiencies at Lincoln hospital that it found were “of such serious nature” that they limited the hospital’s ability to provide adequate care and meet the conditions for receiving Medicaid and Medicare revenue. The agency cited, among other things, inadequate triaging of emergency-room patients and waits for critically injured patients of up to six hours for consultations with specialists like neurosurgeons.

Yet H.H.C., in its statement, said that Lincoln has always met Health Care Financing Administration standards, continues to do so, and has not been excluded from the two Federal programs, which in 1997 reimbursed the hospital $271 million. St. Barnabas responded that the hospital, along with H.H.C., had disagreed with various of the Federal agency’s findings. “In the time since that report, a secondary survey has found that every standard of care is being met–or exceeded–at Lincoln.”

However, a Health Care Financing Administration spokesman said that the hospital was still being monitored by the state because of deficiencies. “These statements appear to be dismissive and cause me to be concerned about whether the facility takes these findings seriously,” she said.

St. Barnabas’ Rocky Road

Even as St. Barnabas faces these charges and findings, Dr. Gade appears to be contemplating expanding his reach. The Observer has learned that on Aug. 6 and 7, St. Barnabas representatives attended a mandatory preproposal conference in Philadelphia for any potential bidders interested in providing health care for inmates in that city’s correctional system. On Sept. 4, bids are due for that contract, which may be worth more than $17 million per year. St. Barnabas declined to comment on those plans.

New York’s award to St. Barnabas of the Rikers contract–the most lucrative prison-care deal in the country–has been fraught with controversy from the beginning. On Sept. 5, 1997, six medical groups submitted bids to H.H.C. The lowest bidder, St. Barnabas, won the contract with a managed-care-style plan to computerize patient records, improve care and cover inmates’ hospital costs. The Bronx hospital estimated that it could do this for a base amount of roughly $301 million over three years; the highest bid, in comparison, came in at $373 million. (Last December, Saint Vincents Hospital and Medical Center–which previously had shared the prison contract with Montefiore Medical Center–filed a lawsuit against St. Barnabas and H.H.C., alleging that there were irregularities in the bidding process. The suit is still pending.)

Six months prior to the awarding of the Rikers contract, Dr. Gade had emerged from another competitive city bid with a three-year, $94 million deal to provide health care at Lincoln. Again, St. Barnabas, the lowest of five bidders, had proposed to cut costs through a vigorous triage of 40 percent of hospital staff and a streamlining of residency training programs. With the 1998 prison contract, the city used H.M.O. logic. It gave St. Barnabas a lump sum to pay for hospital visits. If there is money left at year’s end, St. Barnabas gets to keep it. The city, under its previous Rikers Island medical contract, picked up the costs of inmates’ hospitalization. A March 1998 New York Times story reported that in February, hospital visits by inmates were roughly half what they were in February 1997 when Montefiore administered the contract. St. Barnabas wrote The Observer that its “model of care has produced a record of innovation, cost-effectiveness and markedly improved public safety by reducing the number of off-site trips by prisoners.” Donna Bell, a senior obstetrician at the clinic Ms. Green visited, said, “Under Montefiore, there were a lot of unnecessary procedures” being performed on inmates. “Under St. Barnabas, I have not had any problems with patient care.” When asked about the case of Ms. Green, she replied, “No comment.”

Yet the spate of inquiries raise several questions. Does the contract, under a managed-care model approved by the city, provide a dangerous incentive to withhold care? And can the complicated lives behind bars at Rikers–often tainted by H.I.V., drug habits, sexual abuse and multiple diseases–bend to a pared-down, managed-care model?

Staffing and Supplies

A review by The Observer of 20 patient records, more than 100 internal memos, and interviews with five inmates, seven current and nine former staff members, reveals chronic supply shortages, severe understaffing and significant delays in treatment.

Shortly after St. Barnabas took over the contract on Jan. 1, 1998, Rikers staff members said, they began to experience a lack of basic supplies. “You’re examining an AIDS patient and you don’t have gloves,” said a physician who recently left the correctional facility. “If you don’t have paper towels and you’re seeing 15 to 20 patients, what do you do? Many times, I brought my own.”

In February, alarm bells over missing supplies began to ring at H.H.C.’s Correctional Health Services division, which oversees the contract. Then executive director of the division, Greg Kaladjian, investigated allegations that supplies were being diverted. Mr. Kaladjian, now a private consultant, met secretly with a senior Rikers administrator at a Holiday Inn near La Guardia Airport, where the possibility of diversion of supplies to other St. Barnabas facilities was first discussed. “There was no documented evidence,” said Mr. Kaladjian, “just rumors and innuendo. I would send out my people on unannounced visits and the [warehouses] and closets were filled to the gills. We looked at the ordering patterns, too, and we could never establish why [the shortages] were happening.”

The supply shortages are well documented in interoffice memos obtained by The Observer . On March 12, Rikers medical program director Richard Daines wrote to senior managers about supplies, “New purchases (wheelchairs, shower chairs, nebulizers, exam tables, sphygs, opthalmoscopes)–managers feel like they are not getting definitive answers and are not updated on the status of their requests.”

The day before, a group of clinic managers at the prison had typed up a more candid account. Their note begins: “This page was not sent to [H.H.C. central office], just some specifics we discussed.… Supplies: Paper towels! Basics like these are not being provided. There are no medication forms! Items such as shower chairs, wheelchair tires, batteries have been ordered but we are getting no response or feedback–consider offering us a time frame during which time we will receive items.” At the end of a list of problems, from a backlog of dental consults to a shortage of lab coats, the note says, “Concern with the quality and compromise of patient care.”

Rikers clinicians, who declined to be identified, said that severe supply shortages forced them to improvise. A source at the Anna M. Kross Center, where inmates are first evaluated, said that on one occasion, “We didn’t have specimen bags, so we were putting specimens in test tubes into trash bags. Sometimes … we have to use unsterile gauze for dressing changes.”

For a three-week period earlier this summer at North Infirmary Command, Rikers’ medical clinic, inmates were apparently forced to reuse disposable Foley catheters to drain urine from their bladders when the stock of new ones ran out, according to a nurse, several inmates and an inmate’s attorney. St. Barnabas said that it had never heard of such a claim. In one documented case, a family purchased a box of catheters for an incarcerated relative.

“There is no factual basis for any statement that ‘there have been extreme shortages’ of supplies on Rikers Island,” St. Barnabas’ letter read. “Since taking over the contract, St. Barnabas has enhanced and improved the flow of supplies to the correctional facilities.” St. Barnabas further stated that as required by the city, the hospital maintains a “perpetual inventory, and is in full compliance with the contract.”

A System Under Stress

Hillel Bodek, a veteran social worker in the city’s court and prison systems who on July 5 was profiled in The New York Times as an expediter in a sluggish bureaucracy, said, “There hasn’t been a crisis of this proportion in providing health care to the city’s prisoners in all the 20 years that I’ve been doing this. I very often get calls by judges when lawyers finally complain to them about [inmates'] health care. I’ve had more calls in the last six months than in the two years before.”

It would appear that supply shortages and understaffing may be affecting patient care. Joseph Kennedy, 21, a paraplegic inmate, was treated at Rikers for bed sores above his buttocks which turned into decubitus ulcers. His wounds became so infected that in January, at Bellevue Hospital Center, his leg was amputated and its skin used to cover his wounds.

Mr. Kennedy was returned to Rikers, where his wounds reopened. The next four months were a battle for needed supplies and treatment in the face of escalating infection, according to his medical records.

The largest ulcer was documented as four inches long, two inches wide and an inch-and-a-half deep. On March 12, a clinician wrote of the wound, “extremely foul odor noted (like a dead animal) … additional symptoms (tendons) now are exposed.”

It was also noted that the patient’s catheter was leaking urine because the only available connector for the tubing was too large. Mr. Kennedy was using tape around the connector in an effort to stem the leak.

In April, notations show that a plastic surgery consultation at Bellevue was needed, but not scheduled, despite calls up the bureaucratic chain. A dry flotation cushion to ease pressure on his wounds was ordered, but did not arrive. Mr. Kennedy’s infection progressed. A June 20 notation reads: “[Patient] very anxious to go to hospital for flap and very concerned about his condition.” Two days later, it was noted that a hospital appointment was still unscheduled.

By June 24, Mr. Kennedy began to vomit up a “yellowish material” and had a 103-degree fever. Sepsis had set in, and he was transferred to Bellevue, where he underwent emergency treatment of the wounds. Mr. Kennedy is now back at Rikers.

In some patient cases, doctors seemed to chart the inmate’s deterioration defensively, noting their recommendations for emergency care in bold lettering and with exclamation points. On Jan. 22, a clinician wrote in capital letters in the chart of one inmate, “Needs urgent evaluation at Bellevue or Elmhurst hand clinic for reevaluation of gangrene of remaining fingers.”

The patient’s chart reveals that over the course of seven weeks, he requested painkillers of increasing strength as dry gangrene crept up his right hand. Necrotic tissue was noted on Jan. 8. On Jan. 27, he refused treatment at the Elmhurst Hospital clinic.

On Feb. 27, his condition deemed urgent by Rikers doctors, the inmate was sent to Bellevue, where he underwent a bypass graft for a clotted artery in his right arm and had several fingers amputated. On March 11, his chart notes that he told a Rikers clinician, “‘You are not doing anything for me–why should I come to [the prison clinic]?’ [Patient] wheeled himself back to bed.”

Staff members said that cases like those are born of a system that is stretched to the breaking point. They claim there are too few staff members, many of them inexperienced, and that patients are leaving clinics without treatment because of excessive waiting times. According to staffing plans obtained by The Observer , under St. Barnabas, four-fifths of the medical staff are physician assistants.

St. Barnabas said of its staffing that it had essentially continued Montefiore’s patterns and was meeting its obligations under the contract. It added, “[T]o the extent that any changes in that pattern have occurred, they have resulted–in the findings of our H.H.C. monitors under these contracts–in improvements in care.”

An administrative assistant in charge of scheduling who recently resigned from Rikers described a depleted staff pool. Montefiore, she said, maintained a per diem staff pool of approximately 200 it could draw on to fill shifts; she said that St. Barnabas’ per diem pool is one-quarter that size, and that on any given shift, there was at least one unfilled position in each clinic. “The staff is just overwhelmed and stressed,” she said. “There are no buffers.”