Two Iowa jails have made reforms after an ombudsman report found the facilities were restraining people with mental illnesses in chairs for long periods of time.
Webster County Jail provided staff with additional training and upgraded its systems for surveillance, documentation and tracking policy changes. Boone County built a padded cell as an alternative to restraint. Now, the facilities say they have reduced restraint use and duration, even as they acknowledge ongoing challenges to providing adequate mental health care.
“If you need to fix it, fix it. And that’s the approach we took here,” said Webster County Jail Administrator Mark Gargano.
The Iowa Office of Ombudsman is an independent agency in the state’s legislative branch that investigates complaints against government agencies. The developments come after the office found the two jails failed to comply with state law, county policies and manufacturer recommendations when they restrained people in chairs as “de facto mental health treatment.”
The report identified a host of issues at the jails, including a lack of mental health evaluations, inadequate documentation and monitoring, restraint chairs used as punishment, and failure to report incidents to the state jail inspector. The report also recommended changes to jail policies and state regulations.
The recent probe comes years after an earlier report from the office identified many of the same findings and recommendations in 2009 — but stopped short of calling for changes to state regulations.
How three states are addressing the use and abuse of restraint chairs in jails.
Pennsylvania: How public data led to a ban on restraint chairs in Allegheny.
Iowa: How a watchdog investigation spurred reform in two jails.
California: After a mentally ill man died his family’s advocacy led to statewide changes.
“Our goal is really to prevent history from repeating itself by codifying our recommendations in the administrative rules so that … the issues that we identified in this report can be really resolved for all time,” Ombudsman Bernardo Granwehr said.
Restraint chairs abused at Iowa two jails
The ombudsman’s 2009 report identified unmet mental health needs as a key factor underlying the widespread use and abuse of restraint chairs in county jails. It laid out more than a dozen recommendations.
Over a decade passed before the office began receiving new complaints on the issue.
“To some extent, a resurgence of complaints could be expected as personnel changes, retirements, and local elections create turnover over time,” the new report said. “Memories fade, institutional knowledge is lost, and we sometimes fail to learn from past mistakes.”
The office said it began investigating again after receiving a complaint in 2020 about Boone County Jail, followed by three successive complaints about Webster County Jail. To probe the claims, the office requested records from the jails, interviewed jail staff, and toured Webster County Jail.
But the jails could not provide some of the requested records. Webster County Jail could not locate its restraint chair manual, and staff admitted certain incident reports were never created, the report said. Staff at both jails also could not provide some videos of the incidents, according to the report.
During their tour of Webster County Jail, investigators reported seeing a large sign on the restraint chair that read: “WARNING Do not leave detainees in this chair for more than TWO hours.” But staff restrained people for longer than that.
In 2022, one man was restrained 13 times in seven weeks, with one incident lasting nearly 14 hours. Later that year, another man was restrained for eight hours without medical intervention or breaks to stretch or use the bathroom. In 2023, a third man was restrained seven times in three weeks, including a five-hour incident in which he was naked and didn’t receive breaks.
“In several cases, inmates placed in restraint chairs were not promptly evaluated for mental health issues, despite exhibiting signs of distress or self-harm. These failures often led to prolonged and repeated use of restraint chairs,” the report said.
Investigators discovered that, at Boone County Jail in 2019, one man was restrained repeatedly over multiple days, including one incident lasting more than 14 hours, with the exception of a break for a phone call. The man was upset because the jail had run out of his medication, resulting in him “headbutting his door” and “punching himself in the face,” the report said.
Staff “failed to obtain a mental health evaluation during or immediately after his arrival,” the report said. “Aside from risking injury to the inmate and staff, the jail risks violating the inmate’s Eighth Amendment rights and increases its liability when it ignores the signs and symptoms of severe mental illness,” the report said.
Both jails also “showed inconsistencies in documenting the need for restraint, the checks performed during restraint, and the conditions of the inmates,” the report said. In some incidents, staff used chairs “not as a response to immediate threats but as punishment for disruptive behavior.”
Some of the incidents weren’t reported to the state jail inspector, as required by Iowa law, so the jails “missed an opportunity for oversight and, possibly, corrective action by the chief jail inspector,” the report said.
A statewide sweep in Iowa
To put the two jails in context, investigators also obtained information from more than a dozen other Iowa jails regarding the number of restraint chair uses in 2022.
At least five jails did not report using a restraint chair at all that year, according to the report. One, Muscatine County, reported no use in the last four years, “as the jail also utilizes the padded cell for difficult inmates,” the report said.
A padded cell, historically used in psychiatric hospitals, is a room with soft walls and flooring that is intended to prevent self-harm. The report noted that a padded cell may be used “as a less restrictive alternative” to restraint chairs that “gives the inmate a chance to calm down.”
But the ombudsman’s office acknowledged the approach also has limitations. “The padded cell is not a substitute for mental health treatment and may in fact exacerbate mental health and aggression in an inmate, making a restraint chair use inevitable,” the report said.
Johnson County held more inmates than did Webster County and had fewer restraint chair uses that year, the report found. Investigators noted that the facility employs a full-time nurse and social worker, and inmates receive medical and mental health services from nearby hospitals and clinics.
“When you deal with other counties that don’t have that type of resource, as far as mental health and hospitals, to respond to somebody with a mental health crisis, it’s obviously going to be very difficult for them,” said Johnson County Jail Administrator John Good.
Ombudsman recommends changes
The ombudsman laid out a series of recommendations for county jails and the department of corrections, building on the initial action items outlined more than a decade earlier.
The report recommended jails ensure staff adhere to policy, are properly trained in the use of restraint chairs — with annual refresher courses — and report incidents to the state jail inspector.
It also recommended the Iowa Department of Corrections update the administrative rules governing Iowa’s jails. The department is charged with adopting rules for the administrative code and ensuring compliance through the jail inspector.
The ombudsman had previously approached the department before, back in 2017, and sent a memo to the Iowa State Sheriffs’ and Deputies’ Association about potential rule changes. But discussions stalled as the COVID-19 pandemic emerged and the office shifted priorities.
Recommendations by the Iowa Office of Ombudsman
The new report returned to the issue and outlined eight recommendations that would require jails to:
- Implement comprehensive mental health screenings to promptly identify inmates needing mental health evaluations
- Consider less restrictive alternatives and, when those alternatives are not used, to document the reasons why
- Check for any adverse medical conditions during 15-minute personal visual observations
- Conduct periodic reviews (at least hourly) to determine whether an inmate can be released and document if the inmate was released or the reason for ongoing restraint
- Require direct, in-person medical reviews every two hours
- Contact a mental health professional whenever an inmate with a known or suspected mental health condition is restrained, or whenever any inmate is restrained longer than a few hours
- Improve documentation to include the reason the inmate was placed in restraints, who ordered the restraint, observations during 15-minute checks, observations of medical reviews, and the decision to release or keep the inmate in restraints
- Ensure all restraint incidents are video recorded and retained for at least two years
The Iowa Department of Corrections declined to comment on the report or the proposed changes.
The report did not go so far as to set a limit on restraint duration or recommend banning the use of restraint chairs.
“Restraint chairs have their place,” Granwehr said, “but not as a first resort. Other alternatives, other less restrictive alternatives, should be considered. And if you use it there should be procedures in place to make sure it’s used responsibly and in a limited fashion.”
Boone County Jail builds a padded cell
In response to the report, Boone County initially issued a critical written reply. But the sheriff says the facility has still taken action based on the recommendations.
In Iowa, if the ombudsman substantiates a complaint, the office then tries to persuade the agency in question to take corrective action. But that’s not always successful. The office produces public reports in “rare cases” when informal efforts have been unsuccessful. In those cases, the office is required to consult with the involved agencies and attach their written replies in the report.
In his response, Boone County Chief Deputy Cole Hoffman expressed concern about the probe’s “biased view,” the exclusion of certain jails from its analysis, and the length of the investigation, noting that it took multiple years to conduct.
Hoffman acknowledged that staff failed to report incidents to the state. But he defended some of the missing documentation. “Given the responsibility of jail staff, including 20-45 inmates with varying levels of mental health issues, documentation can sometimes fall short,” he wrote.
Hoffman said he hadn’t seen recommendations from the 2009 report and called on the ombudsman to regularly update training and oversight bodies about best practices. “Considering the importance of these issues, as noted in the report, it seems reasonable to establish a routine of sharing recommendations to help address and prevent future concerns,” he wrote.
In response to the report, Boone County Sheriff Andy Godzicki said the jail spent $30,000 to convert an existing room into a padded cell, which is now the facility’s “go-to” when people are engaging in self-harm. “It’s far less restraining,” said Godzicki, who became sheriff in 2022, after the restraint incident at issue in the report.
In the jail’s first month with a padded cell, staff used it twice to contain people who were self-harming, Godzicki said. One of those people, he said, still needed to be restrained in a chair to be medically evaluated before being transported to a psychiatric facility 20 minutes away.
“We do maintain the chair, and it does have its place. But now it’s stored off in one corner of our jail,” Godzicki said. When staff do use a chair, he said, they focus on documenting it, adhering to protocols and reporting to the state. Data provided by the jail shows staff have used a chair at least twice so far in 2025.
Godzicki applauded the ombudsman’s emphasis on the challenges jails face in providing care for people who are mentally ill. But Godzicki said the report didn’t fully capture the realities of crisis situations that staff face. When someone is “freaking out,” it can be difficult to calm them down and engage them with mental health resources in the moment, he said.
Godzicki said the jail contracts with a local on-call nurse and offers telehealth services to anyone who requests a therapist or counselor. In extreme cases, the jail seeks a court order to commit someone to a psychiatric facility.
“The restraint chair use, since the padded cell, has most certainly gone down, and I expect it to go down. However, it probably won’t be zero,” he said, adding, “The padded cell — it’s not a solution for everything.”
Webster County Jail upgrades systems
In his response, Webster County Sheriff Luke Fleener thanked the ombudsman for bringing the 2009 report to his attention, calling it a “useful resource.” He noted that much of the jail staff is new and was unaware of the report.
Fleener said that, after the report, staff received training on restraint chairs, and “yearly competency training is being conducted and properly documented.” The jail also shifted from a paper to an electronic system that tracks inmate interactions and maintains records “indefinitely,” he wrote.
“We document all the checks — that the restraints were checked, that they were offered a bathroom break, water,” said Gargano, the jail administrator. “That’s been helpful.”
Gargano, who became jail administrator in late 2022, said two of the three incidents covered in the report happened before his time.
The jail’s previous surveillance system was “terrible,” he said, so the facility invested $70,000 in new cameras. “Not a lot of jails have that option to have a supportive Board of Supervisors that gave us the money to do it. And it helped reduce the potential for liability,” Gargano said.
Gargano noted that the jail’s new system for tracking policy updates informs staff of changes in law. “Over the years here and in other jails, people probably just did what they thought was the best thing, and some of them probably just — not made up the rules — but didn’t have that reference to make sure that they were following state and federal law,” Gargano said.
The jail now follows manufacturer guidelines on restraint chair use and limits restraint to two hours in most cases, he said. “Anything beyond that is not helpful,” Gargano said. “If it goes beyond the two hours, we’ve had occasions where we’ve had to take them to the emergency room because it was a mental health crisis.”
In the report, Fleener indicated concerns about mental health resources at the jail. He noted the facility does not have on-site medical services and relies on a community health organization. “When a mental health issue is identified, we are given an appointment time which unfortunately can be a week or more out,” he wrote.
When the jail faces an “immediate need for mental health issues,” staff must transport people to a regional health center or contact a telehealth partner using a tablet, Fleener said.
In an interview with Illinois Answers in April, Gargano said the jail has also been considering the possibility of implementing on-site medical care. “Jails have become the new mental health triage centers, and that’s very messed up,” Gargano said.
Fleener attributed the jail’s lack of reporting to the state to the “complete transition of the Administrative Jail Staff and staff shortages.” Now, restraint chair use “is flagged so proper and timely notification is made,” he wrote.
As a result, chair use is “down a lot,” Gargano said. Recent data provided by the jail shows that use peaked in 2022, when staff used the device two dozen times. So far in 2025, staff have used a chair just once.
The jail also has a padded cell, he said, but someone ripped it apart, costing $26,000 in repairs. The facility is working on retrofitting a cell to make it into an additional padded cell, Gargano said.
“It can help if you have people trained in de-escalation. Then it doesn’t always result in a fight,” he said. “But then there are always people that are going to do what they are going to do.”
‘There’s always room for improvement’
Granwehr, the ombudsman, said he hopes the report will also prompt jails to focus on providing treatment to people with mental illness before resorting to restraint.
“One of the big takeaways from this report is to acknowledge the reality that mentally ill people end up getting funneled into the correctional system, and jails should be prepared for that influx,” Granwehr said. “Restraint chairs are not a first resort in dealing with that, but treating mental illness is.”
Rita Bettis Austen, legal director for the ACLU of Iowa, said the report’s findings are “troubling” and echoed calls for reform. The organization has supported abolishing restraint chairs, writing that the device is “widely viewed as a form of torture by international human rights experts.”
“The reforms recommended by the Ombudsman are important if the use of restraints continues. But it’s now past time to simply get rid of these dangerous devices and practices,” Austen said in a statement.
Good, the Johnson County jail administrator, said the report has helped educate jails on best practices, identify problems and improve care for detainees.
He said it’s also an important reminder to jails to limit restraint to the shortest duration possible and to involve medical personnel. “Once you put them in there, you need to get them out as fast as possible,” he said. “Two hours — that’s really pushing it.”
Asked about the ombudsman’s recommendations for updating state regulations, officials in Boone and Webster counties voiced support. “Clearly, any of that stuff is worth looking at,” said Gargano, the Webster County jail administrator. Godzicki, the Boone County sheriff, called the recommendations “productive.”
“There’s always room for improvement,” Godzicki said.
![[Video] Strapped Down: Investigating Restraint Chairs in Illinois Jails](https://i0.wp.com/illinoisanswers.org/wp-content/uploads/2024/05/B0011836.jpg?fit=1200%2C9999&ssl=1)
