The Atlanta Journal-Constitution
PAPERWORK OFTEN FALSIFIED
Corrections staff already deal with more stress and health concerns than other professions and those risks are dramatically magnified as staffing levels decrease.”
Some of Georgia’s most violent state prisons are dealing with staggering numbers of unfilled positions.
As of August, troubled Smith State Prison had just 44 correctional officers on staff to cover all the shifts at a facility housing 1,400 men with high-security needs in 17 housing units. The South Georgia prison is supposed to have 162 officers, according to its staffing records. At Hancock State Prison, another high-security prison housing more than 1,100 men in 16 housing units, just 49 of the prison’s 191 correctional officer slots were filled.
Jose Morales, a retired Georgia prison warden, ended his GDC career leading the Special Management Unit in Jackson, where the state houses its most challenging prisoners. When staffing dropped during the pandemic, Morales said, it was routine to have just five or six officers working a shift that was supposed to have 27.
“We were required to conduct 30-minute checks at a minimum, and if we had anyone on suicide watch, they would have to be checked every 15 minutes,” he said. “When you have a short staff of six people out of a 27-man post, you can’t do it.”
One byproduct of the staffing shortage is a culture in which falsifying documents, particularly count sheets, has become almost routine. In case after case, the AJC found, officers signed off on documents indicating they’d made their required rounds when they had not.
“Pencil whipping” — falsely certifying that checks were done — has become common practice within the GDC. That’s because the agency demands paperwork to show that prisoners have been continually scrutinized, though there simply aren’t enough people to do it, Morales said.
“The paperwork’s gotta be done, and there’s no one to do it,” he said, describing the situation that officers often face. “So it’s all on me. I’m gonna do it the quickest and fastest (way) and I don’t care. You want the paperwork? I’ll give it to you. I’ll sign, sign, sign.”
Impact on health care
The intersection of understaffing and violence has apparently already caused one large shoe to drop: The company contracted to provide health care for Georgia’s more than 40,000 state prisoners — Wellpath, based in Nashville, Tennessee — has decided it can no longer feasibly provide it.
Wellpath, which also has contracts with departments of corrections in multiple states, took over the Georgia contract from Augusta University and its subsidiary, Georgia Correctional HealthCare, in 2021. The contract was due to be annually renewed by mutual agreement through nine years. But in June, Wellpath sent the GDC a notice of nonrenewal, saying the company would pull out of the deal in 2024, seven years early.
Although Wellpath’s letter didn’t state the reasons for the decision, it comes as the company deals with the mounting cost of inmate hospitalizations, as well as growing fears among health care workers that their own safety is in jeopardy.
One of those employees was Mary Rankin, who resigned in October 2022 as the health services administrator at Phillips State Prison, which has about 920 prisoners housed in 10 buildings. Gang violence has been particularly prevalent at the Buford facility, which had more homicides — five — than any other GDC prison in 2022.
“Recently, there has been little to no security staff covering the medical department, and inmate violence against medical staff has increased,” Rankin wrote in a letter of resignation. “I do not feel safe working here.”
Neither Sam Britton, the senior vice president who signed the nonrenewal letter, nor Wellpath’s corporate spokesperson, Teresa Koeberlein, responded to messages seeking comment for this story.
Heath, the GDC spokesperson, said in her email the department has no knowledge that violence played a role in Wellpath’s decision. Instead, she wrote, the company was concerned about “the rising costs of healthcare in general.” She said the department is continuing to negotiate with Wellpath on a new contract.
The staffing shortage also became an issue when Lee Arrendale State Prison, Georgia’s largest facility for women, was subject to accreditation by the Medical Association of Georgia in 2022. Although the organization gave the facility in Habersham County its blessing, it warned that staffing levels had become so problematic that “any significant increase in prison population, decrease in health staff or decrease in correctional officer staffing” could affect future accreditation.
‘No guards anywhere’
The brutality inside Georgia’s prisons exposes how little control correctional officers may have, especially when entire units are staffed by a single guard — if that.
The fight and stabbing that killed Marquis Jefferson at Washington State Prison in May 2022 involved multiple inmates. Two of the attackers were convicted of murder after a trial in Sandersville. Others may eventually be charged.
Riheem Jefferson said he was at home playing Call of Duty one evening when he got a call from the warden, telling him his brother was deceased and he needed to arrange for someone to retrieve the body.
“I said, ‘What happened?’” Riheem said. “He told me, ‘All I can tell you is that it was quick.’”
After arranging for his brother’s funeral, Riheem started asking questions. He requested documents and found that Washington State Prison was so understaffed that no one was watching Marquis’ dorm when he was attacked. No one noticed until other inmates carried his body to the door.
Remembering video footage shown at the murder trial, Riheem said, “You see a flood of people going in and beating him. There were no guards anywhere to be seen.”
At Calhoun State Prison, 60-yearold Angel Manuel Ortiz was days away from being paroled in 2019 when he was placed in a holding cell with Frank Hardy, 29, and was mortally wounded. According to a civil suit filed by Ortiz’s family, Hardy had already been moved for being disruptive, and he had threatened to kill anyone placed in a cell with him.
On the day of the attack, prisoners in nearby cells noticed something was wrong, said Robert Leanza Williams Jr., an attorney representing the family.
“They said they heard animal sounds, like an animal screaming, trying to get away,” Williams said. “They couldn’t tell exactly what it was. Then they heard Hardy screaming -- like a wild animal out of his mind.”
Williams, who has obtained sworn testimony through the lawsuit, said those prisoners started banging on cells to get help and screaming for guards, but they got no response. Two female guards who eventually showed up watched the attack from the cell door window instead of immediately intervening, the lawsuit alleges.
Ortiz, who was severely beaten, died after being rushed to a hospital in Macon. Hardy was charged with murder, but a psychiatric evaluation determined he was incompetent to stand trial. He will remain in custody until he’s determined to be competent to stand trial, according to the prosecutor in the case.
Barksdale, the district attorney for the Ocmulgee Judicial Circuit, said his caseload is filled with murders, assaults and contraband cases flowing out of several prisons within his eight-county district. But one case sticks with him: the murder of Bobby Ricks at Hancock State Prison.
Barksdale prosecuted Ricks’ murderers in 2019, and, as the trial opened, he told the jury what happened.
“Bobby was brutally murdered by those that he thought were his friends. His own gang. He was stalked, he was ambushed, he was chased down like an animal and he was stabbed 11 times,” Barksdale said at the trial. “Bobby found himself slipping in his own blood as he attempted to escape his attackers.”
One female guard was covering the dorm of 96 men at the high-security prison. As Ricks tried to flee his attackers — naked, covered in blood, leaving his bloody handprint on a table — the guard did little more than radio for help and watch it play out, according to evidence presented at the trial.
When Barksdale asked the guard during the trial what was going through her mind as she saw Ricks under attack, she responded: “I’ve got to get myself out of here.”
Barksdale told the AJC that prisoners in Georgia are forced to look out for themselves because the staff can’t do much to help them.
If Georgia wants to be tough on crime, it needs to make a dramatic
new investment so that the prison system can hire more staff who are better qualified and implement new technology to help, he said. The state also needs to invest in prosecutors in circuits like his, Barksdale said, where they struggle to keep up with all the cases coming out of prisons.
“You’re talking about drugs; you’re talking about gangs. You’re talking about extreme violence. Let’s not forget the sexual assaults that are taking place,” he said. “It is the wild, wild West ... Nobody wants to come in, especially from the top, and say this is out of control. But look at it.”
No checks, no balances
Officers working the isolation and segregation units in Georgia’s prisons are required to check on prisoners every 15 or 30 minutes, depending on the circumstances. They are supposed to note each time they check by signing “seg sheets” attached to clipboards on the cell doors. It’s written right on the forms.
Many of the prisoners in those lockdown units are there because they’ve shown suicidal tendencies or signs of other mental health issues, making the checks necessary. But, as staffing has diminished, officers have frequently been forced to cut corners, sometimes with tragic results.
Lackey, 39, had spent 10 years in prison for an armed robbery in Conyers, a robbery in Winder and an attempted robbery in Monroe when he was found hanging in his cell in the mental health unit at Augusta State Medical Prison. It was early in the morning on April 8, 2020, and the sheet on the door indicated that Powell had looked in every 15 minutes throughout the night. That wasn’t true. Working alone much of that time, he had been pulled away to handle a crisis in another area.
Fired by the GDC for falsifying records, Powell agreed to a lengthy, in-person interview with an investigator from Georgia’s peace officer certification agency. He didn’t mince words.
“I had asked to be moved from (the unit) several times because I knew it was an accident waiting to happen,” he told the investigator. “And I would tell other officers, ‘Working down here is a trap.’ It’s a trap because of the way they staff.”
On top of that, he said, supervisors at the prison hospital left the impression that the door sheets had to be signed every 15 minutes even if officers hadn’t actually been present. The pressure to falsify the forms was subtle but unmistakable, he told the investigator.
“Lieutenants would come by once a night and do rounds, and you might have a unit manager come by and do rounds,” he said. “And if there was nothing on that sheet … then you would be told, ‘Hey, something’s got to be there.’”
Powell told the investigator he felt deep remorse for what happened and that he had tried to do his job the best he could despite its limitations. “I liked my job, and I thought I was doing something good,” he said.
Lackey’s sister, Cassandra Willis, said neither she nor other members of her family knew the details of Lackey’s suicide until contacted recently by an AJC reporter. Those details, she said, were extremely upsetting. “We are mortified, because this could have been prevented,” she said.
The circumstances surrounding Lackey’s death were much the same as those of an incident at Rutledge State Prison around the same time. In that case, Andrew Campbell, a 28-yearold former Marine who served in Afghanistan and suffered from PTSD, hanged himself just hours after he was placed in segregation because of concerns about his mental health. When Campbell’s body was discovered at 8:40 p.m., the sheet on his cell door had already been initialed to show that he had been seen by an officer at 8:45, 9, 9:15 and 9:30 — an obvious sign that the document had been falsified.
The GDC investigation that followed determined that the only officer present in the unit that night, Antonia Jamerson, had spent much of the evening in the bathroom dealing with a stomach virus and had allowed a cadet to make rounds. The cadet, Warren Baltes, had been on the job only two weeks and had yet to go through the GDC’s basic training course.
The investigator’s notes indicate that video showed Baltes making several trips through the unit but only looking in on Campbell, whose cell was at the end of a hall, once, at 6:31 p.m. Jamerson’s one and only check was at 7:39 p.m., roughly an hour before the ex-Marine’s body was discovered, the notes state.
Jamerson was fired for falsifying documents and other infractions. In a written statement for the peace officer certification agency, he said two officers should have been on duty that night, but “staffing issues” prevented it. He said he allowed Baltes to make rounds so the cadet could “get a feel for the job” and asserted that he was unaware of what was written on the door sheets.
Jamerson expressed remorse, writing that Campbell’s death “haunts me still till this day.”
Contacted recently by the AJC, Jamerson declined to be interviewed, citing the fact that he’s a defendant in a lawsuit stemming from Campbell’s suicide. Baltes, also named as a defendant in that lawsuit, did not respond to messages from the AJC.
‘Left to decompose’
Already reeling from a contraband scandal that has ensnared its former warden, Smith State Prison is also in crisis from understaffing. Seven prisoners have been victims of homicides there this year, the most of any GDC facility, and one — Zino — presents perhaps the most gruesome picture of the inadequate staffing.
The cause of Zino’s death has been listed as asphyxia due to neck compression. His cellmate, Tommy Pickren, has been charged with felony murder in what the GDC has described as a “mercy killing.” But the department has yet to explain how the 71-year-old inmate, serving life without parole for killing his wife and teenage daughter in their Cobb County home in 1999, lay dead inside a mattress for five days before anyone noticed.
“The saddest thing is he was left to decompose and become less of a physical human being,” Zino’s sister, Barbara Chadwick, said, speaking publicly for the first time. “He made a terrible, terrible mistake. But that doesn’t mean there weren’t people who loved him. The fact that he was left to rot like a piece of meat is disgraceful.”
Zino is buried in the Georgia state prison cemetery in Reidsville, another cross with a number and no name in a field of them stretching to the horizon.
Zino’s death remains the subject of an administrative investigation focusing on policy and procedural breakdowns, Heath said. She did not provide details except to assert that “understaffing did not play a role in this incident.” In response to an open records request from the AJC, the department declined to provide documents stemming from the inquiry, saying they were protected from disclosure as “confidential state secrets.”
Zino wasn’t known to have any major health problems. But apparently, life at Smith State Prison weighed heavily on his mind. Just days before his killing, he wrote a short letter to a friend stating that “certain things have happened here at Smith, and I have things I have to sort thru and deal with.” He did not elaborate.
When the AJC interviewed the GDC commissioner in July, Oliver insisted Smith State Prison had “turned a corner” under the leadership of Jacob Beasley, who became warden in February, after Brian Adams was charged with violating the state Racketeer Influenced and Corrupt Organizations Act for his role in an inmate-run contraband smuggling scheme. Heath made a similar claim in her email, noting that Beasley has been cracking down on contraband, implementing discipline within the facility and taking other steps that have brought “significant improvements in inmate behavior.”
Facts say otherwise. Since February, records show Tattnall County EMS has been called to the prison in Glennville to transport 66 prisoners for assaults, mostly stabbings. All told, the county’s EMS personnel have been called to transport 173 prisoners for assaults since the beginning of 2020.
In mid-June, an officer at Smith, Douglas Bare, walked off the job after nine years. When contacted by the AJC, he said he had grown weary of working in such a dangerous environment as well as being repeatedly pulled from his post to make hospital runs.
Asked to describe the underlying problem, he was succinct: “Chronic understaffing. There just weren’t enough people to go around.”
Less than four months later, Robert Clark, the correctional officer working at Smith, died from injuries he suffered when he was stabbed from behind by a prisoner he was escorting from the dining hall. The 42-year-old officer had been employed by the GDC for only five months, having previously worked at Walmart.
Clark’s mother, Elizabeth Connolly, said her son struggled to keep up with the demands of the job because it wasn’t unusual for one person to guard three buildings on a shift, especially if someone had called out or an officer had to take somebody to the hospital.
She said a lot of questions remain about what went wrong the night her son was killed, but one thing is clear: Smith State Prison was severely understaffed.
“It’s no secret,” she said. “Everybody knew.”