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One doctor at the prison said the substantial backlog for lab tests “has compromised� his ability to treat patients and prevented him from monitoring the effects of medication on his patients’ kidney and liver functions, particularly for prisoners with chronic conditions such as diabetes or hepatitis C.

The backlog has “caused medical conditions to go undiagnosed and left providers unable to appropriately treat patients,� said U.S. Inspector General Michael Horowitz in a statement.

“Delayed medical treatment can lead to more serious medical conditions for an inmate, as well as substantially increased costs for the institution,� the report said.

In one case, investigators found that a prisoner “feigned a suicide attempt� to get medical care for an untreated ingrown hair that had become infected, the report said. When finally treated, the prisoner was hospitalized for five days to treat the infection.

The inspection also found substantial shortages in health care workers and correctional officers to escort prisoners to outside medical appointments, leading to the cancellation of 101 appointments between January and November 2023.

Another 350 prisoners were on a waitlist for routine dental care in October, and about 40% of them had been on the list for two years or more, largely due to a critical shortage of dental equipment and supplies, the report said. Dental care at the prison was limited to intake and clinical exams as a result.

The inspection ran from Nov. 27 to Dec. 1. The Federal Correctional Institution-Sheridan in Yamhill County is made up of a medium-security prison, a minimum-security prison camp and a detention center. At the time, the medium-security prison housed 988 prisoners and was full, the detention center held 271 prisoners and was at 97% capacity and the camp housed 366 prisoners at 95% full.

The investigators also discovered a variety of “potentially dangerous medication distribution practices,� the report said.

For example, patients weren’t consistently identified by examining two forms of identification before they got medication. Staff also removed medication from packaging hours before the next so-called pill line was set to begin, a violation of policy that increases the risk of errors, according to the report.

A review of quarterly reports in the health department revealed multiple medication errors between January and September 2023, including two prisoners who received an extra and unnecessary injection of a prescribed medication and one person who was injected with the incorrect medication to address an opioid abuse disorder, according to the report.

At a time when many defendants in federal court are struggling with significant fentanyl addictions, the investigation found that the prison has been unable to offer its residential drug abuse program because of shortages in staff to run the program. Only five of 16 of the employee positions were filled at the time of the inspection.

More than 70 prisoners were unable to participate in the drug treatment program, although many of them had transferred to Sheridan for the express purpose of addressing their substance abuse disorder in the program, the inspection found.

The report also noted long waitlists for other programs: About 600 prisoners waiting to participate in a cognitive behavioral therapy program designed to address trauma-related mental health needs, another 500 waiting to get into an anger management program and 300 waiting to enter a work skills class.

“We found that FCI Sheridan has offered inmates limited opportunities to prepare for successful reentry into our communities,� the report said. “Three days after our inspection concluded, BOP (Bureau of Prisons) Director Colette Peters suspended the RDAP at the FCI Sheridan’s minimum-security prison camp.�

Of 145 authorized correctional officer positions at Sheridan, 117 were filled last winter, leaving 28 vacancies, the report found. To fill openings, the prison has been using mandated and voluntary overtime and temporarily assigning non-correctional officers to fill some positions.

Some officers reported feeling exhausted due to “excessive mandated overtime,� according to the report.

Investigators also found that staff shortages meant leaving camp prisoners unsupervised at times and led to incomplete prisoner-monitoring rounds in the prison.

In Sheridan’s health services department, 18 out of 27 staff positions were filled, with most vacancies among nurses. Only three of seven nurse positions were filled, the report found.

The visit marked the third unannounced inspection of a federal prison under a new on-site inspection program by the inspector general’s office.

In May and November of last year, separate reports detailed inspections of a prison in Tallahassee, Florida, and a women’s prison in southern Minnesota called Federal Corrections Institution-Waseca. The office chose Sheridan to understand conditions for male prisoners at a larger prison, according to the inspector general’s office.

Inspectors said they couldn’t determine the number of allegations of prisoner-on-prisoner sexual misconduct at Sheridan because the prison didn’t accurately track the complaints, which is required under the federal Prison Rape Elimination Act of 2003.

Many of the issues identified during the inspection mirror problems found at other federal prisons, according to the report.

Without sufficient staff, prisoners are routinely confined to cells during daytime hours, another barrier for participation in recreational activities or special programs, according to the inspectors.

The inspection called contraband a “persistent and significant challenge,� particularly in the prison camp where people can move around more freely during the day. Prisoners abuse illicit drugs, including synthetic cannabinoids such as K2 or spice, and some drugs enter through the mail.

Just before the inspection, a bag containing 62 grams of methamphetamine was seized from a prisoner’s mail, according to the report.

The inspection didn’t identify as many problems with security cameras or food service, but noted water pipe failures have caused occasional flooding in prisoner areas. Inspectors also found exposed electrical wires throughout the institution and broken toilets and sinks at the prison camp.

Investigators made their findings through observations, interviews with staff and prisoners and by reviewing security camera footage and records related to prisoner programming and education, institution staffing levels, conditions of confinement, prisoner medical and mental health care and employee and prisoner misconduct, including sexual misconduct.

Bureau of Prisons Director Colette Peters, who became director in 2022 after running Oregon’s Department of Corrections, wrote in a response to the inspection report that Sheridan “took immediate action� to reduce backlogs in health care tests but continues to face challenges in hiring new employees.

The Bureau of Prisons is working to better market the jobs and increase recruitment and retention incentives, according to Peters.

She maintained that the prison is “currently tracking all sexual misconduct allegations,�and is working to increase its programs to help prisoners reenter the community toward the end of their terms.

After the inspector general’s office provided Sheridan officials with a draft of its report, the prison took action to decrease its lab testing backlog, according to the report. As of this month, the backlog of lab orders stood at 44 and pending X-ray orders stood at 84, according to the report.

While the inspector general’s office said it is encouraged by the changes Sheridan has made in response to the report, it noted that the progress occurred only after the inspection identified significant concerns. The inspector general’s office said it will continue to monitor Sheridan’s responses.

Fidel Cassino-DuCloux, Oregon’s federal public defender, said the report is not surprising as his office has complained about the poor housing conditions and medical treatment at Sheridan for years. Clients also have protested with a prior hunger strike, he said.

“We firmly believe that everyone should have access to medical and psychological services and that clients should feel safe from sexual abuse and not be confined to lock down because of BOP staffing shortages,� he said by email.

“The Bureau of Prisons is simply not meeting their constitutional obligation to meet basic rights. Sheridan is in BOP Director Colette Peters’ backyard, so I hope these problems will be addressed swiftly.�