BUTNER — In-house watchdogs in the U.S. Department of Justice say quarantine problems, staff movement and limited use of early release programs have all had a part in the severity of the COVID-19 outbreak at the Butner federal prison.

Above all, the open-floor dormitories and communal bathrooms of three units — including the prison’s satellite camp — “contributed, in part, to over 1,000 inmates” of those units contracting the virus, a report issued Thursday by the department’s Office of the Inspector General said.

The report was one of two the office released Thursday that examined major COVID-19 outbreaks at Federal Bureau of Prisons facilities. The other addressed the Milan federal prison in Michigan.

The ongoing situation Butner is the most serious COVID-19 outbreak in the region, and one of the most serious in the federal prison system. As of Friday, 28 inmates and a guard have perished because of the coronavirus.

By the Federal Bureau of Prisons’ count, 1,255 inmates of Butner and 150 of the prison’s staff have had COVID-19 at one point or another since the pandemic began last spring.

The authors of Thursday’s report said they did the legwork for it, in manner of speaking, between May 6 and July 25, when the outbreak at Butner was at its peak.

They termed their work a “remote inspection” of the facility that relied on telephone interviews with key officials at Butner and in the Federal Bureau of Prisons, document reviews, data analysis, the response Butner employees gave to a nationwide survey of federal prison-system staff, and a “consideration of complaints” from inmates and Butner staff to the inspector general’s hotline.

Some of the most serious problems the watchdogs identified occurred at Butner’s satellite camp, a portion of the sprawling facility that’s in Durham County. The prison’s other units are in Granville County.

While most units at Butner were quick to implement social-distancing orders the Federal Bureau of Prisons handed down on March 13, beyond making its food service carry out the camp didn’t “further restrict inmate movements” until April 16, a day after one of its inmates tested positive for COVID-19.

Combined with the open-floor dorm layout, the “delays in tightening controls on inmate movements likely contributed to the spread of COVID-19 there,” the report said.

The prison as a whole “lifted or loosened some inmate movement restrictions in May, and its minimum-security unit — which also manages the camp — didn’t reimpose them even after its own outbreak began.

Prison managers implemented quarantine measures, but in April two inmates developed COVID-19 shortly after being moved to the minimum-security unit’s general population. That “development likely contributed to the spread of COVID-19” in the unit, inspectors said, adding by July 25 it had “the highest number of COVID-19 positive inmate cases at” Butner.

Moreover, inmates who tested negative for the virus but afterward were likely exposed to known COVID-positive inmates “were not quarantined as close contacts” in line with Federal Bureau of Prisons and U.S. Centers for Disease Control guidance, they said.

A big problem was that in the minimum-security unit and one of the prison’s medium-security units, “space availability issues” meant there wasn’t room to quarantine everyone who had the virus, they said.

Butner officials believed that “nearly all” of the medium-security unit’s inmates “had been in close contact with suspected or confirmed COVID-19 inmates,” the inspectors said.

In addition to lacking space, quarantining inmates of that particular medium-security unit was problematic for security reasons. Its population includes “high security inmates, gang members, civilly committed sex offenders” and some inmates who require “enhanced outpatient” treatment of mental-health problems, the inspectors said.

Another big problem throughout the prison was that it “was unable to fully comply” with higher-level advice to limit the movement of prison staff within the facility.

Because of factors that included COVID-related absences, guards in some of the units had to or were allowed to change posts, “which likely increased the spread of COVID-19” in the affected units, the inspectors said.

In the minimum-security unit, some “worked posts at which they were in contact with COVID-19 positive inmates, as well as posts at which they were in contact with COVID-19 negative inmates.”

And while there’s been extensive testing of inmates, at no time prior to July 25 did Butner’s managers test staff for the virus, and even as of Dec. 3 the Federal Bureau of Prisons didn’t require its facilities to test staff.

In June, the bureau’s medical director — Jeffrey Allen, though he wasn’t named in the report — told inspectors that “staff are the primary vulnerability for introduction of COVID-19 into institutions and that testing staff could help mitigate the spread of the disease in institutions.”

But he also said the bureau “cannot mandate staff COVID-19 testing as a condition of employment, and added that “testing all staff would be labor intensive.”

Butner’s wardens have dealt with the situation by making sure workers knew they could get tested through a variety of community based care providers. Given testing’s “widespread availability” in the Tri-County and Triangle, there hasn’t been a need for the Butner prison to capitalize on a staff-testing contract the Federal Bureau of Prisons signed in July.

Prison officials learned of the first known case of COVID-19 at the Butner prison on March 24. It involved a “staff member had been exposed to the virus while traveling outside of North Carolina and then worked” at the prison hospital “without any symptoms for a few days before learning of the exposure.”

The first positive among inmates surfaced on or about March 27, and involved a medium-security inmate who “did not self-report symptoms.” He was hospitalized after his fellow inmates reported that he had flu-like symptoms, and on April 11 he became the prison’s first inmate to die from the virus. The report didn’t name him, but the Federal Bureau of Prisons previously reported that convicted kidnapper and rapist Charles Richard Rootes, 81, succumbed to COVID-19 on April 11.

Inspectors also examined and found wanting Butner’s use of the expanded home-confinement program — house arrest, in essence — that former U.S. Attorney General William Barr authorized last spring to get some inmates out of the virus’ line of fire.

The Federal Bureau of Prisons last spring gave Butner officials lists that included more than 600 inmates who might be eligible for transfer to home confinement, but as of July 6, Butner officials had referred only 87 for transfer.

Three inmates deemed eligible for transfer died while awaiting it. The report didn’t name them, but the dates given for their deaths coincided with those of inmates William Walker Minto, Bobby Lee Medford and John Dailey.

Minto, Medford and Dailey had been in prison for dealing marijuana, racketeering and health care fraud, respectively. Medford was a former sheriff of Buncombe County, and his family has criticized the way prison officials handled his prospective release. Dailey was one of the inmates who, with help from civil-rights groups, sued prison officials over their handling of the pandemic.

Inspectors said a first-brush screening by data analysts suggests that as of April 12, 1,070 of the 1,829 minimum- or medium-security inmates could’ve qualified for a move to home confinement.

Another 86 inmates had received “compassionate release” from the federal court system as of June 30, the report said.

A case manager at Butner told inspectors that many inmates “had high recidivism risk scores or were sex offenders and therefore did not meet home confinement eligibility.” Others “may not have had a viable release plan” for transfer outside prison walls.

But in their separate report on the Milan prison, inspectors also told of talking with a bureau executive who stressed the “responsibility to ensure that inmates who pose a risk to public safety are not released into the community.

He “noted that many inmates housed in minimum and low security facilities may appear to present minimal risk to the community based on their current institution security level but that some have criminal histories, including violence and sex offenses, that preclude them from home confinement placement,” inspectors said in the Milan report.

Both the Milan and Butner reports said that the Office of the Inspector General is conducting a broader review of the bureau’s “use of early release authorities, especially home confinement,” and will report on its findings separately.

Contact Ray Gronberg at rgronberg@hendersondispatch.com or by phone at 252-436-2850.

Contact Ray Gronberg at rgronberg@hendersondispatch.com or by phone at 252-436-2850.