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result, many SHU staff and supervisors were unaware that Epstein did not have a cellmate as the Psychology Department had determined was necessary, and Epstein was alone and unobserved in his cell for an extended period of time. 1. The 4 p.m. SHU Count on August 9 The OIG's investigation determined that the 4 p.m. SHU inmate count on August 9, 2019, was inaccurate because SHU staff did not physically count the inmates as required by BOP policy and instead relied upon a predetermined number of inmates believed to be in the SHU at that time. However, Epstein, who was in the SHU attorney visitation room, was correctly accounted for during the 4 p.m. and subsequent SHU counts. The OIG determined that the error in the 4 p.m. SHU count was carried over into the next inmate count at 10 p.m. that counted an inmate who had been transferred out of the SHU. The SHU inmate count was not corrected until 12 a.m. when the Morning Watch Operations Lieutenant reviewed the master institutional count and housing unit count slips and informed SHU staff of the correct number of inmates in the SHU at that time. Senior Officer Specialist 5 told the OIG that prior to his departure from the SHU at approximately 4 p.m., he told the Evening Watch SHU Officer in Charge what the SHU count should be. In addition, the Day Watch SHU Officer in Charge told the OIG that SHU staff maintain a “cheat sheet,” which lists the number of inmates believed to be in the SHU at any given time. When interviewed by the OIG, the Day Watch SHU Officer in Charge reviewed the 4 p.m. SHU count slip from August 9, 2019, which was signed by the Evening Watch SHU Officer in Charge and CO Noel. Based on his review, the Day Watch SHU Officer in Charge told the OIG that the Evening Watch SHU Officer in Charge and Noel probably did not count the inmates in the SHU. He said they likely wrote down the numbers they thought should have been entered for the count because the count slip inaccurately included an inmate (Inmate 4) among the number of inmates in the SHU after that inmate had been transferred to another housing unit. According to what he told the OIG and wrote in an email on August 9, earlier that afternoon the Day Watch SHU Officer in Charge observed Inmate 4 attempt to retrieve an unknown item from his visitor in the MCC New York SHU visiting room. The Lieutenant’s Log from August 9, 2019, reflected that following this incident, Inmate 4 was removed from the SHU at 3:15 p.m. and transferred to the Receiving and Discharge dry cell, which is a secure location where inmates are taken for observation when they are believed to have ingested or secreted contraband on their person. According to the Day Watch SHU Officer in Charge, the inaccurate 4 p.m. count slip told him “that the count was not done and they just assumed and went by the cheat sheet because the body wasn't even there,” referring to Inmate 4, who was transferred from the SHU to Receiving and Discharge. The Day Watch SHU Officer in Charge told the OIG that if the 4 p.m. SHU count had been accurately conducted, then the Evening Watch SHU Officer in Charge and the SHU staff should have realized that Inmate 4 was no longer in the SHU. In his interview with the OIG, the Evening Watch SHU Officer in Charge acknowledged that neither he nor any other SHU staff member conducted the 4 p.m. SHU count on August 9. The Evening Watch SHU Officer in Charge verified that it was his handwriting and signature on the 4 p.m. SHU count slip and said he had prepared the count slip ahead of time because “[t]here was so much going on” in the SHU that day. The Evening Watch SHU Officer in Charge confirmed that Noel’s name and signature also appeared on the 4 p.m. 62 DOJ-OGR-00023429