Incarcerated people suffering from dementia who are booked into Baltimore jails are ending up in isolation, at a detriment to their conditions, or improperly housed in general population, where they are sometimes assaulted or otherwise injured, according to a newly released report by the independent doctor monitoring medical care in the facilities.

One patient with dementia and other medical problems was sent to jail from a nursing home, then released, only to be re-incarcerated the next day, the report found. After he was rebooked at the Baltimore Central Booking and Intake Center, he was assigned to general population, with his only medical accommodation being that he was ordered to sleep on a lower bunk, according to the report.

But that assignment wasn’t noted on the “bottom bunk report.” A day after he was assessed by nurses and admitted to the jail, the man with dementia fell off the top bunk and had to be sent to an emergency room at a nearby hospital. A doctor who saw him there recommended a psychiatric evaluation, but that never took place after he returned to the jail, the report said.

Dr. Michael Puisis, the independent monitor who wrote the report, said that patient was improperly sent to general population by custody staff when he should have been placed in the infirmary by medical personnel because of his condition: vascular dementia.

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It represented yet another failure in the long list of deficiencies that Puisis has been noting with health care in Baltimore jails as the Maryland Department of Public Safety and Correctional Services, which runs the jails, continues to lag far behind on its mandated timeline to fix them.

“Whether this is an isolated case or not, DPSCS [the state corrections department] should review it to determine why the order for low bunk did not result in a low bunk ... and how someone with dementia was sent to general population housing,” Puisis wrote in his report.

The report details another case of a 76-year-old person with dementia, who was “incarcerated directly from a hospital,” and still had a host of medical problems when he got to the facility, including difficulty breathing and “very high blood pressure.”

About a month after he was incarcerated, a health care provider at the jail wrote that the man was “nonsensical” but self-reported as feeling fine and not in pain, the report stated. Medical staff at the jail did not investigate what cognitive issues the 76-year-old might have, despite his recent hospital stay resulting in a referral to neurosurgery, the report said.

He was referred to a psychiatrist “instead of having a dementia work up,” the report found. It added that the psychiatrist “thought the patient might have a cognitive issue but started psychotropic medication.” The 76-year-old was held in general population, though a health care provider did perform a “mini-mental status evaluation” that resulted in an abnormal score, the report said.

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“Yet protective housing was not provided,” Puisis wrote in the report. “Shortly after this, the patient was assaulted and evaluated at 4:14 a.m.”

That examination, the report said, documented “moderately impaired short and remote memory” and that the 76-year-old was “not oriented to the situation but oriented to person, time and place.” After the exam, the report said, the man was assigned to be in a single cell alone, but he should have been placed in an infirmary under medical supervision.

“Isolation is known to worsen symptoms of dementia,” Puisis noted in his report.

A spokesperson for the Maryland Department of Public Safety and Correctional Services told The Baltimore Banner that the agency “was not given adequate time to review and respond” to the report.

“We cannot validate the accuracy of what’s in the report,” said Morgan Wright, the department’s communications director.

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The latest report by Puisis, dated Oct. 10 but publicly filed in court earlier this week, comes as the physician finds himself increasingly at the center of an escalating legal battle, with the Maryland attorney general’s office and corrections department on one side, and the national American Civil Liberties Union’s prisoners’ rights attorneys, joined by local advocacy groups, on the other.

The two sides have traded barbs through court filings in a decades-old lawsuit over the constitutionality of health care and mental health services in Baltimore jails. The litigation predates when the state corrections took over city jails in the early 1990s.

Over the last few months, the attorney general’s office has amped up its legal defense of city jails after enlisting the help of Butler Snow LLP, a private law firm that has gained notoriety in the Deep South for defending prison systems against class action civil rights lawsuits and federal civil rights investigations in exchange for massive multimillion-dollar contracts.

The manner by which the state attorney general contracted with the firm, however, has been shrouded in secrecy in Maryland. In the face of repeated questions, Attorney General Anthony Brown’s administration has refused to disclose how much the state is paying the private attorneys, with a senior attorney in his office claiming it is the “confidential” information of the law firm.

About two months ago, shortly after the Butler Snow legal team made their first appearances in the Baltimore jail health care case, an assistant attorney general told Puisis he could no longer communicate directly with doctors in Baltimore jails. Instead, the attorney working for the state told Puisis he should direct his questions to the medical director of the corrections department, who oversees all prisons and doesn’t work at the jail.

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The ACLU attorneys pushed back, accusing the state attorney general’s office in a court filing of “gratuitously attacking” the medical monitor.

In his most recent report, Puisis mounted his own defense, writing that the corrections department told him officials would arrange calls with jail doctors going forward, but could not assure him that those calls would be private.

“Lack of private conversations diminishes my ability to monitor,” Puisis wrote in the report.

Puisis added that routing all of his calls through the corrections department’s medical director or its attorneys “requires increased and more complicated scheduling barriers.”

“Furthermore, the manner in which this is being conducted chills staff from speaking openly about conditions and their experience at the jail,” Puisis wrote, “Especially since they have to speak in the presence of their supervisors and attorneys.”

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In addition to the issues around incarcerated people with dementia, the latest monitor’s report notes several other ongoing problems with health care in Baltimore jails, specifically flagging the fact that there is no medical director over the jail, and seemingly no one with intimate knowledge of how the jail runs has the ability to craft policies.

To that end, the corrections department continues to respond to the 2016 settlement about the jail with outdated policies that predate the agreement and are often designed for the prison system rather than the jail, he added. Puisis described the process as “dysfunctional and noncompliant.”