Despite Findings of 'Negligent' Care, ICE to Expand Troubled California Detention Center

When a government expert in mental health visited one of the largest immigration detention centers in the U.S. in 2017, she knew the conditions that detainees there sometimes face. A past inspection had found that staff often failed to obtain adequate mental health histories, leading to faulty diagnoses and, in some cases, treatment plans that were incorrect.

Upon arrival at the U.S. Immigration and Customs Enforcement processing center in Adelanto, California, a similar pattern emerged. One detainee she observed had a diagnosis of schizophrenia. When she asked an officer about him, she was told that the man "floods his cell, bangs his head."

She searched the man's medical chart for records from his recent stay at an inpatient psychiatric unit, but they appeared to be missing. He had been placed in what the government refers to as "segregation," a term known more commonly as solitary confinement.

Inside, the expert found, he was suffering from "active auditory hallucinations." Moreover, they appeared to worsening.

The Office for Civil Rights and Civil Liberties had previously visited the facility in 2015 under the Obama administration and detailed "negligent" medical care at that time. But rather than seeing improvements in 2017, the experts found that medical care had gotten worse.

"No correction was made," the report states, noting that the number of complaints around detainee medical care had actually increased.

The medical expert cites multiple examples of poor medical care, including long delays in appointments for broken bones and a failure to provide needed antibiotics and other medications.

In at least one case, a detainee's death was "likely related" to failures by the facility's medical staff.

As a result, the expert recommended a drastic measure:

"At-risk detainees must be immediately removed from the facility (transferred to another facility with a well-functioning medical program)."

Given the problems at the facility, the expert defined "at-risk" as any detainee with a chronic medical problem like diabetes, as well as any detainee over 55 years old.

Attorneys for detainees told NPR that there's no indication that ICE or GEO actually followed this recommendation.

ICE declined to say whether it made changes to its medical staff in the wake of the report or transferred detainees.

Allegations of 'Verbal Harassment' and 'Retaliation'

The allegations against the Adelanto facility went beyond medical care.

"Detainees suffer retaliation, verbal harassment and [are] treated with disrespect," the report found. Leadership "must hold facility staff accountable for substantiated abusive and disrespectful treatment of the detainees," the report went on, noting that this problem had not been addressed after previous inspections.

In another instance, detainees alleged even harsher measures.

In June 2017, a group of asylum-seekers from Central America went on hunger strike to protest conditions at the facility. When the group locked arms and refused to move, staff used pepper spray and physically removed them.

The corrections expert found that the use of pepper spray was "appropriate given the circumstances." But the expert saw a significant problem with the staff's subsequent actions.

Cold water is recommended to safely decontaminate pepper spray. But, the corrections expert found, "The facility does not have any access to cold water. The facility only provides a mix of cold and hot water through a shower head." The expert warned that "warm water will exacerbate the burning effect of the OC pepper spray."

When the group of hunger strikers was placed in showers, they described "writhing" in pain as the water reactivated the spray. One detainee, Marvin Josue Grande Rodriguez, said that he fainted in the shower, because "the gas and the heat of the water ... It was far too much for me."

The report says the use of a hot shower was a "significant issue" and concluded that the facility "must provide access to a cold-water shower" in the future.

In response to a lawsuit filed by the group of hunger strikers, lawyers for GEO said that water "does reactivate the tingling sensation" from pepper spray but that it was "necessary to remove the spray" and was not intended to cause pain.

Because ICE and GEO declined to answer specific questions, it's unclear if they followed the recommendation on cold-water showers.

Attorneys for detainees told NPR that they were unsure whether any changes had been made.

But it is clear that the facility staff continue to use pepper spray. ICE statistics show that pepper spray has been used more than 25 times since the 2017 inspection.

An 'Inhumane' Use of Solitary Confinement

Additionally, the government's experts found that the Adelanto facility was failing to meet federal standards for solitary confinement — known in ICE's bureaucratic language as "segregation."

Overall, the report found that GEO Group staff had "no current strategy" when it came to long-term use of solitary confinement and that people were suffering as a result.

In one case, inspectors found, a detainee was held in a "Special Management Unit," or SMU, for 426 days.

"No detainee should be held in the SMU for this amount of time," the report states. "Isolation alone can create physical safety concerns and can result in mental decompensation."

The expert inspectors were especially critical of the use of solitary confinement for immigrants with serious mental disorders. They found that about a third of the detainees held in solitary had a "serious mental illness."

Over the course of multiple stays, one detainee logged 904 days — or nearly 2 1/2 years — in solitary confinement, which the report calls "shockingly high."

The experts found that some detainees with serious mental illness were put in solitary confinement simply because it was the only available space where they could be closely watched. The report called that practice "inhumane."

"If strategies are not developed," the report warned, "the mental health and other long-term detainee cases will continue to decompensate, and the population of the SMU will continue to grow."

In response to NPR, an ICE spokesperson wrote that the agency "is compliant" with agency standards on the use of solitary confinement, citing a directive from 2013.

But again, critics of ICE say that is not true.

"You have these experts ... essentially screaming from the rooftops, 'You need to fix this problem!' " says Schwellenbach of POGO, which has also investigated the use of solitary confinement in ICE detention. "There's solutions that they're actually putting forward, but they're being ignored."

Ongoing Oversight of Immigration Detention

The state of California has repeatedly clashed with the Trump administration over immigration policy.

The office of California Sen. Kamala Harris, a former Democratic presidential candidate and former state attorney general, reviewed the documents obtained by NPR.

"It is unconscionable to subject detained persons to inhumane conditions," Harris's office said in a statement, "including issues arising from insufficient medical care as well as prolonged isolation and detention at immigrant detention facilities."

Criticism of conditions at the Adelanto ICE Processing Center by Harris and others was one factor that led to the recent California law, largely banning the use of private contractors in prison and immigration detention.

"State laws aimed at obstructing federal law enforcement are inappropriate and harmful," ICE's Haley wrote to NPR. "Policy makers who strive to make it more difficult to remove dangerous criminal aliens and aim to stop the cooperation of local officials and business partners, harm the very communities whose welfare they have sworn to protect."

In their lawsuit against the state, GEO argues that the law is a "transparent attempt by the State to shut down the Federal Government's detention efforts within California's borders" and "a direct assault on the supremacy of federal law."

East Bay Democratic Assemblyman Rob Bonta, who championed the law, tweeted that the lawsuit was, "Exactly what you'd expect fr[om] a collapsing industry in its final death throes."