SACRAMENTO, Calif. — A major California prison medical center still is providing inadequate care to inmates despite a decade of oversight intended to improve care, the state inspector general said Monday, citing poor nursing care and a recent change in policy that means there are no doctors at the facility after normal hours.

The California Medical Facility in Vacaville failed on half of 14 key benchmarks.

The 61-year-old facility southwest of Sacramento provides medical and psychiatric care to more than 2,500 sick inmates. That includes hospice care for those who terminally ill, a program that received high marks despite the overall poor showing.

Caring for the seriously ill patients housed at the prison “demanded frequent provider encounters and exceptional provider performance,” inspectors said. While doctors there “overcame many systemic problems, they were not able to overcome poor nursing performance and an inadequate after-hours on-call coverage system.”

Those on-call providers “occasionally made poor and inaccurate assessments over the telephone, which markedly increased the risk of medical harm and likely contributed to one preventable death,” according to the report.

In that case, a doctor failed to discover that a patient with chronic lung disease had developed pneumonia. The doctor did not do a face-to-face evaluation, did not prescribe antibiotics or get a chest x-ray or arrange for another physician to see the patient. Three days later, the inmate had respiratory failure and later died.

Medical care in California prisons has been controlled by a receiver since a federal judge ruled a decade ago that an average of one inmate each week was dying of medical neglect or malpractice. The inspections are part of the state’s efforts to regain control, yet inspectors say eight of the 22 prisons reviewed since last year are still providing inadequate care.

Among those providing acceptable care is Calipatria State Prison, the inspector general said in a separate report also released Monday. That prison houses more than 3,800 inmates near the Mexican border.

Doctors at the Vacaville prison told the inspectors they were extremely dissatisfied with a policy change in the spring of 2015 that took away the facility’s onsite afterhours physician.

Most said the change endangered the prison’s high-risk patients, and the facility’s chief medical executive told inspectors that the change was made over his objections by the office of the federal court-appointed receiver who controls prison medical care. The executive said the change also dramatically harmed doctors’ morale and made it more difficult to keep high-quality physicians.

The inspector general recommended that the prison switch back to an onsite doctor around the clock.

Joyce Hayhoe, a spokeswoman for the receiver’s office, said the facility gave up its license as an acute-care hospital and round-the-clock physician staffing is no-longer necessary. Some of the most seriously ill inmates have been transferred to a new medical institution in Stockton, she said.

“Whenever an inmate needs medical assistance (after hours), our doctors receive calls, and depending on the circumstances either will come in to see the inmate or refer the inmate to a hospital,” Hayhoe said.

Inspectors also found that nurses did a poor job in many areas, including regularly neglecting to see inmates who reported they were sick. When they did see the patients, they often failed to recognize when the inmates needed care urgently or were slow to provide emergency care.

The medical facility was recently in the news because of a dispute over whether a mentally ill prisoner essentially starved to death.

Two pathologists initially found that 49-year-old Michael Stanley Galliher died at the prison last year from an exhausted condition resulting from lack of nourishment. Galliher was afraid to eat because of delusions that his food was poisoned, according to records obtained by The Associated Press under a public records act request.

A Solano County pathologist later said that his fatally low blood sugar could have been caused by one of the drugs he was taking. The case did not appear to be addressed in the inspector general’s report.

Despite the inspector general’s poor review, the medical facility received national accreditation last year from the Commission on Accreditation for Corrections.


Associated Press writer Jonathan J. Cooper contributed.