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email identifying the cellmate requirement; and the statements of multiple witnesses who told the OIG that Epstein’s cellmate requirement was widely disseminated verbally by MCC New York leadership. B. MCC New York Staff Failed to Conduct Mandatory Rounds and Inmate Counts Resulting in Epstein Being Unobserved for Hours Before His Death The OIG’s investigation and review revealed that on August 9 and 10, 2019, MCC New York SHU staff did not conduct the mandatory rounds and inmate counts during their shift in the SHU. The failure to undertake these required measures to account for inmate whereabouts and wellbeing—and the supervisors’ failure to properly supervise the SHU staff, as discussed further below—resulted in Epstein being unobserved for hours before his death, which compounded the failure of MCC New York staff to ensure that Epstein had an appropriate cellmate. 1. Failure to Conduct Rounds and Inmate Counts in the SHU Federal regulations require that employees “use official time in an honest effort to perform official duties.””! Additionally, BOP standards of conduct required that employees “[c]onduct themselves in a manner that fosters respect for the Bureau of Prisons, the Department of Justice, and the U.S. Government.””* Because “[i]Jnattention to duty in a correctional environment can result in escapes, assaults, and other incidents,” BOP standards of conduct also require employees “to remain fully alert and attentive during duty hours.” BOP policy also requires “[c]ontinuous inmate accountability,” which is accomplished through rounds and inmate counts.’”? Among other things, rounds and inmate counts enable staff to observe inmates and ensure that they are safe and secure in their cells and are in good health. BOP policy and MCC New York SHU Post Orders set out the requirements for these inmate accountability measures, specifying that correctional staff must conduct rounds on an irregular schedule at least twice each hour, no more than 40 minutes apart. BOP policy and MCC New York SHU Post Orders further specify that at least two MCC New York SHU staff members must conduct inmate counts at 12 a.m., 3.a.m., 5a.m., 4 p.m., and 10 p.m. daily, and also at 10 a.m. on weekends and federal holidays. The OIG's investigation and review revealed that an inmate (Inmate 4) was internally transferred from the SHU to Receiving and Discharge at approximately 3:15 p.m. on August 9, 2019; however, this inmate transfer was not documented until approximately 12:35 a.m. on August 10, 2019. Based on this internal transfer, BOP records, and witness statements, the OIG determined that the 4 p.m. and 10 p.m. SHU inmate counts on August 9 were erroneous. In addition, the OIG reviewed the available SHU security camera video, which did not show COs walking up or down the stairs leading to the various SHU tiers during the count times, a process that is necessary to conduct an accurate count of inmates.”* During their OIG interviews, the Evening Watch SHU Officer in Charge, the Material Handler, CO Tova Noel, and Material Handler Michael Thomas each admitted that they did not conduct all of the mandatory rounds and inmate counts in the SHU 5 C.F.R. 8 2635.705(a); see also 5 C.F.R. § 2635.101(b)(5). 7 BOP Program Statement 3420.11. ® BOP Program Statement 5500.14. ™ As discussed in Chapter 5, the OIG found that the security camera video was of low quality. Therefore, the OIG analyzed the video in conjunction with BOP records and witness statements regarding the personnel in the SHU and their activities. 102 DOJ-OGR-00023469