Blackburn v. N.C. Dep't of Pub. Safety ( 2016 )


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  •               IN THE COURT OF APPEALS OF NORTH CAROLINA
    No. COA15-556
    Filed: 15 March 2016
    Caldwell County, No. 14 OSP 5988
    SHAWN BLACKBURN, Petitioner,
    v.
    N.C. DEPARTMENT OF PUBLIC SAFETY, Respondent.
    Appeal by petitioner from the Final Decision entered 23 January 2015 by
    Administrative Law Judge Selina M. Brooks in the Office of Administrative Hearings.
    Heard in the Court of Appeals 3 November 2015.
    Merritt, Webb, Wilson & Caruso, PLLC, by Joy Rhyne Webb, for petitioner-
    appellant.
    Attorney General Roy Cooper, by Assistant Attorney General Tamika L.
    Henderson, for respondent-appellee.
    ZACHARY, Judge.
    Shawn Blackburn (petitioner) appeals from the decision of the Administrative
    Law Judge (ALJ) upholding his termination as a correctional officer employed by the
    North Carolina Department of Public Safety (DPS or respondent) for grossly
    inefficient job performance. On appeal, petitioner argues that the ALJ erred by
    denying his motion in limine to exclude certain evidence from the hearing; that some
    of the ALJ’s findings of fact are not supported by the evidence; and that the ALJ erred
    by concluding that respondent established by a preponderance of the evidence the
    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    existence of just cause to terminate petitioner. We are aware that our correctional
    officers perform a difficult job, and we are sympathetic to the challenges faced by
    correctional officers in a prison setting. Nonetheless, after careful review of the facts
    and the relevant law, we conclude that the ALJ did not err and that the decision of
    the ALJ should be upheld.
    I. Background
    Petitioner was hired by DPS as a correctional officer in 1999, was promoted
    through the ranks, and in March 2014 petitioner was a Correctional Captain at DPS’s
    Alexander Correctional Institution (“Alexander”). As a Correctional Captain,
    petitioner was responsible for interpreting, developing, and following prison
    procedures, as well as reviewing the work performed by others to ensure its
    compliance “with the goals and the missions of the . . . Department of Public Safety,”
    including DPS’s goals of ensuring “the safety of the inmates” and “the humane
    confinement of inmates.” On 8 and 9 March 2014 petitioner was, in addition to being
    a Correctional Captain, Alexander’s “officer in charge” or “OIC.” Petitioner testified
    that the OIC was the person who was “left in charge of the daily running of the
    institution and the safety and welfare of the staff and the inmates at that institution.”
    Petitioner’s dismissal arose from the circumstances surrounding the death of
    Michael Kerr, an inmate housed at Alexander in March 2014. Mr. Kerr had a history
    of mental illness for which he had received medication. In February 2014 Mr. Kerr
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    was housed “in ‘administrative segregation’ or, as it is better known, solitary
    confinement[,]” Davis v. Ayala, __ U.S. __. __, 
    135 S. Ct. 2187
    , 2208, 
    192 L. Ed. 2d 323
    , __ (2015), initially for mental health observation. At this time Mr. Kerr was
    “placed on nutraloaf,” which petitioner described as “a management meal that is
    given to inmates for disciplinary reasons to manage their behavior.” At first Mr. Kerr
    was given milk with the nutraloaf, but on 8 March 2014 petitioner ordered that Mr.
    Kerr no longer receive milk, because Mr. Kerr had used the milk cartons to stop up
    the toilet in his cell. Pursuant to petitioner’s orders, there was a sign on Mr. Kerr’s
    cell reading “Do not give him milk per Captain Blackburn.” The sign remained in
    place until Mr. Kerr’s death, and was visible to staff on all shifts.
    Alexander’s “Medical Emergency Response Plan” defines a “Code Blue” as “a
    medical emergency . . . requiring the immediate assistance of medical personnel.” On
    8 March 2014 Sergeant Johnson, a correctional officer at Alexander, called a Code
    Blue for Mr. Kerr because Mr. Kerr was not responding to correctional staff. When
    petitioner arrived at Mr. Kerr’s cell, medical personnel were present and Mr. Kerr
    was lying on his bed in leg restraints and metal handcuffs. After medical personnel
    determined that Mr. Kerr did not require immediate medical treatment, petitioner
    allowed Mr. Kerr’s leg restraints to be removed, but ordered that Mr. Kerr’s handcuffs
    should not be removed until Mr. Kerr walked to the door and asked for their removal.
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    Mr. Kerr remained in handcuffs from the time that the Code Blue was called
    until his death on 12 March 2014. Petitioner admitted that after he ordered on 8
    March 2014 that Mr. Kerr no longer receive milk, the only way Mr. Kerr could obtain
    any fluid would be to use his handcuffed hands under the faucet. On 9 March 2014,
    petitioner entered Mr. Kerr’s cell with Ms. Sims, Alexander’s staff psychologist.
    Although Mr. Kerr did not speak or sit up while petitioner and Ms. Sims were in Mr.
    Kerr’s cell, petitioner left Mr. Kerr in handcuffs. Ms. Sims asked petitioner if a Code
    Blue should be called and petitioner said no. At the end of petitioner’s shift, he
    completed a report on the day’s events, called an “OIC report.” Petitioner failed to
    note in his OIC reports for either 8 or 9 March 2014 that a Code Blue had been called
    for Mr. Kerr or that Mr. Kerr was still in handcuffs at the end of the 9 March 2014
    day shift.
    Petitioner was not at work on 10 or 11 March 2014. When petitioner returned
    to work on 12 March 2014, he directed Sergeant Johnson to prepare Mr. Kerr for
    transport to Central Prison. When Sergeant Johnson entered Mr. Kerr’s cell, he
    found Mr. Kerr’s handcuffs filled with embedded fecal matter, and saw cuts and
    abrasions on Mr. Kerr’s wrists resulting from wearing the mechanical cuffs for an
    extended period of time. Petitioner directed his staff to use bolt cutters to remove the
    handcuffs, and Mr. Kerr was transported to Central Prison. Mr. Kerr was pronounced
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    dead upon his arrival at Central Prison. The coroner determined that Mr. Kerr’s
    cause of death was dehydration.
    Following Mr. Kerr’s death, DPS conducted an investigation which included
    interviewing witnesses, including petitioner, and reviewing documents. DPS
    conducted a pre-disciplinary conference with petitioner on 4 April 2014, and on 7
    April 2014 petitioner received a letter from DPS informing him that he was being
    terminated from employment for grossly inefficient job performance, and stating that:
    . . . Management has decided to dismiss you, effective April
    7, 2014 based on Grossly Inefficient Job Performance[.] . . .
    This decision was made after a review of all of the
    information available, including prior disciplinary action,
    the current incident of Grossly Inefficient Job
    Performance, and the information you provided during the
    pre-disciplinary conference. The specific conduct reason(s)
    for your dismissal [are] as follows:
    On March 18, 2014, you were interviewed as part of [an
    investigation] . . . into the death of inmate Michael Kerr.
    You were also interviewed on April 1, 2014 as part of an
    internal investigation into this same matter. During both
    interviews, you stated that you were notified on March 8,
    2014 of a Code Blue . . . for inmate Kerr. . . . You stated
    you told inmate Kerr to remain on the bed until all staff
    were out of the cell and the door was secured. You indicated
    that once the door was secured, you ordered inmate Kerr to
    come to the door to take off the restraints and he refused.
    You further indicated that you informed Sergeant Johnson
    to have staff check Kerr every 15 minutes and offer Kerr
    the opportunity to have the restraints removed. You also
    stated, “Due to him being a segregated inmate, I was not
    going to risk staff safety by removing the handcuffs while
    staff was in his cell. He had to be behind a secured door.” .
    ..
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    Records indicate that you also worked on March 9, 2014. .
    . . You indicated that you were aware of [Mr. Kerr’s] mental
    state and you had notified mental health staff.
    Investigators determined that inmate Kerr remained
    handcuffed for a period of five (5) days based on your
    instructions to staff to have [the] inmate remain cuffed
    until he was willing to submit to removal of the restraints
    through the cell door.
    At no time during your assigned working hours on March
    8, 2014 did you communicate the status of inmate Kerr, his
    refusal to submit to handcuff removal, or the fact that
    inmate Kerr’s condition was deteriorating to the Assistant
    Superintendent for Custody and Operations.
    You failed to Initiate an Incident report for a documented
    Code Blue Emergency.
    According to the Division of Prisons’ Policy and Procedures
    Manual, F.1504 (h)(1-2), . . . The use of instruments of
    restraint, such as handcuffs . . . are used only with approval
    by the facility head or designee.
    (1) Instruments of restraint will be utilized only as a
    precaution against escape during transfer, [to] prevent
    self-injury or injury to officers or third parties, and/or for
    medical or mental health reasons. . . . “
    The Office of State Human Resources Policy Manual,
    Section 7, page 2, states, “Grossly Inefficient Job
    Performance is the failure to satisfactorily perform job
    requirements as set out in the job description, work plan,
    or as directed by the management of the work unit or
    agency, and the act or failure to act causes or results in:
    Death or serious bodily injury or creates conditions that
    increase the chance for death or serious bodily injury to an
    employee(s) or to members of the public or to a person(s)
    for whom the employee has the responsibility;”
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    Your willful violation of these policies constitutes grossly
    inefficient job performance. . . .
    After a review of the information provided, to include the
    Pre-Disciplinary Conference, I saw no mitigating factors
    regarding your actions in this matter that would warrant
    action less than dismissal. . . .
    Petitioner appealed his termination to DPS, and on 16 July 2014 he received a
    letter from DPS informing petitioner that the letter was a final agency decision to
    uphold termination of petitioner’s employment. The letter stated that:
    On March 8, 2014, a Code Blue (Medical Emergency) was
    called because segregation staff observed inmate Kerr to be
    unresponsive in his cell. . . . You ordered inmate Kerr to
    come to the door to have the handcuffs removed and he did
    not. You then told inmate Kerr that until he got up and
    came to the cell door and asked to have his handcuffs
    removed his handcuffs would not be removed. At that time,
    you were aware that inmate Kerr had serious mental
    health issues. . . .
    There was no record of proper medical evaluation during
    the time inmate Kerr was in restraints over the next five
    days. . . . Reports indicated that one time inmate Kerr was
    observed standing; other reports indicated that he
    appeared to be asleep, or awake on his bunk. . . .
    Nevertheless, you did not remove inmate Kerr’s handcuffs
    because inmate Kerr did not come to the door to have the
    restraints removed. Your shift was scheduled off for the
    next two days. You left the correctional institution with
    your order regarding the procedure for removal of the
    handcuffs still in place.
    On March 12, 2014, four days after your original order that
    inmate Kerr remain in handcuffs until he asked to have
    them removed, you came back on shift as the OIC and you
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    instructed Correctional Sergeant William Johnson to
    prepare inmate Kerr for transfer to Central Prison.
    Sergeant Johnson went to the Segregation Unit and found
    inmate Kerr in his cell with his pants and underwear down
    around his ankles. He had urinated and defecated on
    himself. . . .
    Staff could not unlock the handcuffs because they were
    clogged with dried feces. . . . Staff observed cuts and bruises
    on inmate Kerr's wrists. . . . Inmate Kerr was not seen by
    medical staff on March 12, 2014 prior to leaving for Central
    Prison. Inmate Kerr left Alexander Correctional
    Institution at approximately 8:30 AM and arrived at
    Central Prison around 11:30 AM. When he was received at
    Central Prison, he had expired.
    ...
    You were the OIC responsible for the fact that inmate Kerr
    remained in handcuffs for five days. There was no valid
    reason for inmate Kerr to have remained in handcuffs for
    five days. . . . In addition, it should have been obvious that
    inmate Kerr was not a threat to any custody staff, that no
    restraints were necessary, and that he was in need of
    medical attention. . . . It was your obligation to remove the
    restraints; it was not incumbent upon inmate Kerr to ask
    you to do so. It was obvious from the video footage taken on
    March 12, 2014, that after five days inmate Kerr was so
    incapacitated that he was not ambulatory and could not get
    himself into a wheelchair from the bed, and yet the
    restraints were still not removed. . . . The medical
    testimony indicated that the cumulative evidence of
    inmate Kerr’s behavior shows he was nonresponsive and
    not being intentionally noncompliant.
    As mitigation you argued that all of the other captains at
    Alexander had been returned to work and that you were
    the only Captain terminated. I find that you were
    differently situated from all of the other Captains because
    your behavior in ordering that inmate Kerr be handcuffed
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    until he could ask to have them removed was particularly
    culpable behavior and may have played a role in inmate
    Kerr’s death. Because there was no superintendent at
    Alexander Correctional Institution at this time, it was
    particularly incumbent upon you to be aware of the risks
    to inmates and staff and to obtain adequate guidance and
    supervision. . . .
    [A]t no time did you seek medical advice about Inmate
    Kerr’s condition on March 10-12, 2014. In addition, you
    were responsible for knowing the consequences of your
    order to keep inmate Kerr in handcuffs and for ensuring
    that he was able to take care of his personal needs,
    including exercise and taking nourishment.
    Inmate Kerr was about 5'9" tall, weighing around 300
    pounds, and medically determined to be obese. . . . You
    attempted to place the responsibility on another
    employee[.] . . . You also argued that you could not have
    ordered inmate Kerr’s handcuffs to be removed[.] . . .
    During your dismissal appeal hearing you . . . stated that
    inmate Kerr was in handcuffs for disciplinary reasons[.] . .
    . [T]he use of handcuffs was inappropriate for disciplinary
    reasons. . . . When questioned as to how inmate Kerr was
    supposed to handle his bodily functions if he was left in
    handcuffs, you indicated that essentially it was inmate
    Kerr’s problem for not coming to the door to have his
    handcuffs removed. You also admitted that it appeared to
    you that that inmate Kerr’s health was deteriorating over
    the two days you were off work, yet instead of sending
    inmate Kerr for medical care at the closest medical facility,
    he was transported three hours away to Central Prison,
    where he arrived dead. There appears to be no valid
    reasons for the restraints to have been put on initially
    when the inmate Kerr was examined as a result of the Code
    Blue. There were no valid reasons that the handcuffs were
    not removed when the exam was concluded. And there was
    no valid reason inmate Kerr did not receive medical care.
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    I have also considered as an aggravating circumstance your
    complete lack of remorse or belief that you did anything
    wrong with regard to inmate Kerr. . . . Your belief that you
    did nothing wrong in the face of this inmate’s death is
    evidence that you cannot continue to be employed by the
    Department of Public Safety. No other level of disciplinary
    action is sufficient to protect the inmates in the custody of
    the Department of Public Safety and address your conduct
    and behavior.
    In conclusion, you were the Officer in Charge (OIC) at
    Alexander Correctional Institution on March 8, 2014. A
    Code Blue was called that inmate Michael Kerr was
    nonresponsive. Your staff responded to the Code Blue and
    medical staff examined inmate Kerr. After the exam, the
    leg restraints were removed but not the handcuffs, and
    staff exited the cell. . . . You then ordered that inmate Kerr
    remain in handcuffs until he asked to have them removed
    and came to the door for that purpose. You did not ensure
    that the restraint policies were complied with. As a result
    of your order, inmate Kerr remained in the handcuffs for
    five days. On March 12, 2014, prior to inmate Kerr being
    transported to Central Prison, [Mr. Kerr’s] handcuffs had
    to [be] cut off because they were encrusted with fecal
    matter. When he arrived at Central Prison, inmate Kerr
    was found to be unresponsive. He was pronounced dead on
    arrival at Central Prison.
    On 7 August 2014 petitioner filed a petition for a contested case hearing with
    the North Carolina Office of Administrative Hearings. A three day hearing was
    conducted before the ALJ beginning on 2 December 2015. During the hearing
    petitioner acknowledged that as a correctional captain he was “required to have
    considerable knowledge of the department’s rules, policies, and procedures
    concerning the custody, care, treatment and training of inmates” and that his position
    required “the exercise of good judgment and discretion” given that a particular
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    situation might not be addressed in the written policies. Petitioner admitted that the
    responsibilities of an OIC included a duty to “take corrective action on any condition
    that may affect the security, safety, or welfare of a variety of people, including
    inmates,” and “to document all unusual and important activities in the OIC shift
    report.” Petitioner also conceded that he was familiar with the “[DPS] Division of
    Prisons, Alexander Correctional Institution Standard Operating Procedure Section
    .0427, Restraint Procedures” which governed the correctional officers’ use of
    restraints, including handcuffs. These regulations state that:
    Restraints may be used as a precaution against escape
    during transfer for medical reasons, [to] prevent self-
    injury, to protect staff or others or [to] prevent property
    damage or manage disruptive behavior where other means
    have failed. Restraints are never to be applied for
    punishment, and must be removed as soon as possible as
    directed by the circumstances requiring application.
    Regarding the conditions of Mr. Kerr’s confinement, petitioner agreed that Mr.
    Kerr was initially placed in handcuffs on 8 March 2014 to “secure him so medical staff
    could go in and evaluate him.” Petitioner also admitted that he and Ms. Sims entered
    Mr. Kerr’s cell unaccompanied by “an extraction team” and that petitioner did not
    carry a shield. Petitioner testified that he knew that Mr. Kerr “had been at one time
    [in] residential mental health,” and that Mr. Kerr had never acted violently towards
    prison staff. Petitioner also admitted that during the 15 minute checks ordered by
    petitioner, the prison staff did not enter Mr. Kerr’s cell or check to see if the cuffs
    were hurting Mr. Kerr.
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    The ALJ also heard testimony from several prison officials. Stephanie Leach
    testified that she was employed by DPS to investigate events such as the death of an
    inmate, and that she led the investigation into Mr. Kerr’s death. Ms. Leach reviewed
    records indicating that Mr. Kerr had not been observed in a standing position after 8
    March 2014. Ms. Leach testified that, based upon her review of a videotape and Mr.
    Kerr’s medical records, Mr. Kerr was not capable of walking to the cell door, and was
    not intentionally refusing to do so, and that the coroner determined that Mr. Kerr’s
    cause of death was dehydration.
    Marvin Polk testified that had worked for DPS for over thirty years and that
    he conducted internal investigations into employee misconduct. In over thirty years’
    experience with DPS, he had never heard of an inmate being restrained in handcuffs
    for five days. Mr. Polk concluded that respondent “did not use sound judgment and
    reasoning” by leaving Mr. Kerr handcuffed for five days, and that it was the
    responsibility of the OIC to ensure that an inmate received necessary medical
    treatment. Kenneth Lassiter, DPS’s Deputy Director of Operations, testified that an
    OIC has the authority to make decisions that are necessary for an inmate’s health or
    safety. Mr. Lassiter did not think handcuffs should have been applied to Mr. Kerr.
    When handcuffs were applied, custodial staff should have checked every fifteen
    minutes to make sure the handcuffs weren’t causing any injury, because mechanical
    handcuffs of the kind used on Mr. Kerr had the potential for a serious risk of harm to
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    an inmate, because of the risk of fluid retention. Mr. Lassiter also testified that it was
    “rare that metal restraints are on an inmate for more than four hours,” and that he
    had never heard, in more than twenty-five years of working for DPS, of another
    instance of an inmate left in handcuffs for such “an extended amount of time.”
    George Solomon testified that he was DPS’s Director of Prisons, that he had
    been employed by DPS for over thirty-five years, and that DPS’s “mission is to
    maintain the public safety and safe and humane treatment of our stakeholders, our
    inmate population, [and] make sure we take care of them[.]” Mr. Solomon was
    responsible for the decision to fire petitioner, based on a review of interviews and
    petitioner’s statements.    Mr. Solomon testified that petitioner’s acts of leaving
    handcuffs on Mr. Kerr and not providing Mr. Kerr with milk might have contributed
    to Mr. Kerr’s “decompensation and deterioration.”
    On 23 January 2015 the ALJ entered a Final Decision that affirmed DPS’s
    decision to uphold petitioner’s termination. The ALJ concluded that respondent had
    shown by the preponderance of the evidence that it had just cause to terminate
    petitioner for grossly inefficient job performance.       The ALJ’s conclusions were
    supported by more than eighty findings of fact, which were based based on a
    voluminous transcript of over 600 pages and hundreds of pages of exhibits.
    Petitioner has appealed the ALJ’s Final Decision to this Court.
    II. Standard of Review
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    The standard of review of an administrative agency’s decision is set out in N.C.
    Gen. Stat. § 150B-51 (2013), which provides that
    (b) The court reviewing a final decision may affirm the
    decision or remand the case for further proceedings. It may
    also reverse or modify the decision if the substantial rights
    of the petitioners may have been prejudiced because the
    findings, inferences, conclusions, or decisions are:
    (1) In violation of constitutional provisions;
    (2) In excess of the statutory authority or jurisdiction of the
    agency or administrative law judge;
    (3) Made upon unlawful procedure;
    (4) Affected by other error of law;
    (5) Unsupported by substantial evidence admissible under
    G.S. 150B-29(a), 150B-30, or 150B-31 in view of the entire
    record as submitted; or
    (6) Arbitrary, capricious, or an abuse of discretion.
    (c) . . . With regard to asserted errors pursuant to
    subdivisions (1) through (4) of subsection (b) of this section,
    the court shall conduct its review of the final decision using
    the de novo standard of review. With regard to asserted
    errors pursuant to subdivisions (5) and (6) of subsection (b)
    of this section, the court shall conduct its review of the final
    decision using the whole record standard of review.
    “Under the whole record test, the reviewing court must examine all competent
    evidence to determine if there is substantial evidence to support the administrative
    agency’s findings and conclusions.” Henderson v. N.C. Dep’t of Human Resources, 
    91 N.C. App. 527
    , 530, 
    372 S.E.2d 887
    , 889 (1988) (citation omitted). “ ‘[T]he whole
    record test is not a tool of judicial intrusion; instead, it merely gives a reviewing court
    the capability to determine whether an administrative decision has a rational basis
    in the evidence.’ ” N.C. Dep't of Env't & Natural Res. v. Carroll, 
    358 N.C. 649
    , 674,
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    
    599 S.E.2d 888
    , 903-04 (2004) (quoting In re Rogers, 
    297 N.C. 48
    , 65, 
    253 S.E.2d 912
    ,
    922 (1979)). Therefore, the whole record test “does not permit the reviewing court to
    substitute its judgment for the agency’s as between two reasonably conflicting
    views[.]” Lackey v. Dep't of Human Resources, 
    306 N.C. 231
    , 238, 
    293 S.E.2d 171
    , 176
    (1982).
    “Where the petitioner alleges that the agency decision was based on error of
    law, the reviewing court must examine the record de novo, as though the issue had
    not yet been considered by the agency.” Souther v. New River Area Mental Health,
    
    142 N.C. App. 1
    , 4, 
    541 S.E.2d 750
    , 752 (internal quotation omitted), aff'd per curiam,
    
    354 N.C. 209
    , 
    552 S.E.2d 162
    (2001). “Under a de novo review, the court considers
    the matter anew and freely substitutes its own judgment for that of the [ALJ].” In re
    Appeal of the Greens of Pine Glen Ltd. P’ship, 
    356 N.C. 642
    , 647, 
    576 S.E.2d 316
    , 319
    (2003) (citing Mann Media, Inc. v. Randolph Cty. Planning Bd., 
    356 N.C. 1
    , 13, 
    565 S.E.2d 9
    , 17 (2002)). In addition, “[a]n administrative agency’s interpretation of its
    own regulations is entitled to deference unless it is plainly erroneous or inconsistent
    with the regulation’s plain text.” Total Renal Care or N.C. v. North Carolina HHS,
    __ N.C. App.__, __, 
    776 S.E.2d 322
    , 327 (2015) (citing York Oil Co. v. N.C. Dep’t of
    Env’t, 
    164 N.C. App. 550
    , 554-55, 
    596 S.E.2d 270
    , 273 (2004)).
    III. Denial of Petitioner’s Motion in Limine
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    Petitioner argues first that the ALJ erred by denying his motion in limine
    seeking “to restrict the respondent from producing evidence of anything other than
    the reasons that were [stated] in [petitioner’s] April 7, 2014, dismissal letter as far as
    reasons to justify his termination.” Petitioner argues that the ALJ violated the notice
    requirements of N.C. Gen. Stat. § 126-35 by considering facts and circumstances that
    were not specifically discussed in petitioner’s pre-disciplinary letter. We conclude
    that petitioner’s argument lacks merit.
    In this case, petitioner makes only one challenge to evidence admitted over his
    objection, consisting of petitioner’s assertion that the ALJ admitted evidence of a
    prior disciplinary warning against petitioner over petitioner’s objection. We hold that
    evidence of petitioner’s prior disciplinary history was properly considered as part of
    the ALJ’s review of the level of discipline imposed against petitioner. See 
    Carroll, 358 N.C. at 670
    , 599 S.E.2d at 901 (including, as part of its review of whether the
    discipline imposed was appropriate, the fact that the petitioner “has been a reliable
    and valued employee . . . for almost twenty years with no prior history of disciplinary
    actions against him.”). “Career state employees, like petitioner, may not be
    discharged, suspended, or demoted for disciplinary reasons without ‘just cause.’ N.C.
    Gen. Stat. § 126-35(a). This requires the reviewing tribunal to examine . . . “whether
    [the petitioner’s] conduct constitutes just cause for the disciplinary action taken.”
    Warren v. Dep’t of Crime Control, 
    221 N.C. App. 376
    , 379, 
    726 S.E.2d 920
    , 923
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    (quoting Carroll at 
    665, 599 S.E.2d at 898
    (internal quotation omitted), disc. review
    denied, 
    366 N.C. 408
    , 
    735 S.E.2d 175
    (2012). In Wetherington v. N.C. Dep’t of Pub.
    Safety, __ N.C. __, __ S.E.2d __ (2015 N.C. LEXIS 1259 *14-15) (18 December 2015)
    our Supreme Court addressed the issue of an agency’s discretion to determine the
    appropriate discipline:
    Just cause “is a flexible concept, embodying notions of
    equity and fairness, that can only be determined upon an
    examination of the facts and circumstances of each
    individual case.” . . . [The employee’s supervisor] confirmed
    that he [believed that he] could not impose a punishment
    other than dismissal for any violation, apparently
    regardless of factors such as the severity of the violation,
    the subject matter involved, the resulting harm, the
    trooper's work history, or discipline imposed in other cases
    involving similar violations. We emphasize that
    consideration of these factors is an appropriate and
    necessary component of a decision to impose discipline
    upon a career State employee[.]
    Wetherington, __ N.C. at __, __ S.E.2d at __ (quoting 
    Carroll, 358 N.C. at 669
    , 599
    S.E.2d at 900-901 (internal quotation omitted)) (emphasis added).
    We have also reviewed petitioner’s challenges to the admission of evidence that
    was not the subject of an objection at the hearing. N.C. Gen. Stat. § 126-35(a) requires
    that if disciplinary action is contemplated against a State employee, “the employee
    shall, before the action is taken, be furnished with a statement in writing setting
    forth the specific acts or omissions that are the reasons for the disciplinary action and
    the employee’s appeal rights.”
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    This Court has interpreted section 126-35(a) as requiring
    the written notice to include a sufficiently particular
    description of the “incidents [supporting disciplinary
    action] . . . so that the discharged employee will know
    precisely what acts or omissions were the basis of his
    discharge.” Failure to provide names, dates, or locations
    makes it impossible for the employee “to locate [the]
    alleged violations in time or place, or to connect them with
    any person or group of persons,” thereby violating the
    statutory requirement of sufficient particularity.
    Owen v. UNC-G Physical Plant, 
    121 N.C. App. 682
    , 687, 
    468 S.E.2d 813
    , 817 (quoting
    Employment Security Comm. v. Wells, 
    50 N.C. App. 389
    , 393, 
    274 S.E.2d 256
    , 259
    (1981)), disc. review improvidently allowed, review dismissed, 
    344 N.C. 731
    , 
    477 S.E.2d 33
    (1996).
    In this case, petitioner received a pre-disciplinary letter on 7 April 2014 that
    set out the “names, dates, [and] locations” pertinent to his dismissal. This letter made
    it clear that the “specific acts or omissions” leading to petitioner’s termination were
    petitioner’s acts or omissions as related to Mr. Kerr’s conditions of confinement in
    March 2014, and specifically as pertaining to petitioner’s role in allowing Mr. Kerr to
    remain in handcuffs for five days without appropriate attention to his physical and
    medical condition.
    On appeal, petitioner argues that the ALJ “erred as a matter of law when she
    allowed Respondent to present reasons other than those listed in the 7 April 2014
    dismissal letter and made findings of fact and conclusions of law based on those
    additional reasons by which she found just cause for the termination of Petitioner’s
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    employment.” Petitioner fails, however, to identify any evidence considered by the
    ALJ that was not directly related to petitioner’s role in Mr. Kerr’s conditions of
    confinement during March 2014, and our own review indicates that the evidence
    challenged by petitioner consisted entirely of the facts and circumstances
    surrounding Mr. Kerr’s death and petitioner’s actions or inactions relevant to Mr.
    Kerr’s death. Petitioner is apparently arguing that he is entitled to notice, not only
    of the acts and omissions that were the basis of his termination, but also to notice of
    every item of evidence pertaining to these acts and omissions. Petitioner cites no
    authority for his vastly expanded view of “notice” and we know of none. We conclude
    that petitioner is not entitled to relief on the basis of this issue.
    IV. Factual Support for the ALJ’s Findings of Fact
    Petitioner argues next that certain of the ALJ’s findings of fact are not
    supported by substantial evidence. The majority of the ALJ’s findings are not
    challenged and thus are conclusively established on appeal. Koufman v. Koufman,
    
    330 N.C. 93
    , 97, 
    408 S.E.2d 729
    , 731 (1991) (“Where no exception is taken to a finding
    of fact by the trial court, the finding is presumed to be supported by competent
    evidence and is binding on appeal.”) (citation omitted). Moreover, after careful review
    of the record and the ALJ’s order, we conclude that in order to determine whether the
    ALJ properly ruled that respondent established by a preponderance of the evidence
    that respondent had just cause to terminate petitioner’s employment, it is not
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    necessary for us to assess the evidentiary support for all of the findings challenged
    by petitioner. We will, however, review the evidence supporting those findings that
    we find to be material to the ALJ’s decision.
    We review a challenge to the ALJ's findings to determine
    whether the findings are supported by substantial
    evidence. N.C. Gen. Stat. § 150B-51(b), (c). “Substantial
    evidence is such relevant evidence as a reasonable mind
    might accept as adequate to support a conclusion.” Even if
    the record contains evidence that could also support a
    contrary finding, we may not substitute our judgment for
    that of the ALJ and must affirm if there is substantial
    evidence supporting the ALJ's findings.
    Renal Care, __ N.C. App. at __, 776 S.E.2d at 328 (quoting Surgical Care Affiliates v.
    N.C. Dep’t of Health & Human Servs., __ N.C. App. __, __, 
    762 S.E.2d 468
    , 470 (2014)
    (internal quotation omitted), disc. review denied, 
    368 N.C. 242
    , 
    768 S.E.2d 564
    (2015)).
    We first review petitioner’s challenge to Finding No. 26, which states that
    “[t]he evidence indicates that Inmate Kerr was not refusing to have his handcuffs
    removed but was unresponsive due to his mental health and/or physical condition.”
    This finding is supported in part by Ms. Leach’s testimony, including the following:
    Q: Based on your review, did you determine if Mr. Kerr was
    refusing orders or just not responding?
    MS. LEACH: Mr. Kerr was just not responding, which is
    different from refusing.
    Q: Based on your experience as a registered nurse, did it
    appear to you that Mr. Kerr was capable of walking on his
    own accord?
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    MS. LEACH: No.
    This finding is further supported by Mr. Lassiter’s testimony that “Mr. Kerr’s
    condition, from everything that I've read and could understand, prevented him from
    coming to the door.” Petitioner acknowledges this testimony, but argues that the
    validity of these witness’s testimony was impeached on cross-examination. “It is for
    the agency, not a reviewing court, ‘to determine the weight and sufficiency of the
    evidence and the credibility of the witnesses, to draw inferences from the facts, and
    to appraise conflicting and circumstantial evidence[,] if any.’ ” Carroll at 
    674, 599 S.E.2d at 904
    (quoting State ex rel. Utils. Comm’n v. Duke Power Co., 
    305 N.C. 1
    , 21,
    
    287 S.E.2d 786
    , 798 (1982)). We conclude that this finding is supported by substantial
    evidence.
    Petitioner also challenges the evidentiary support for Finding No. 40, which
    states that the ALJ “finds as fact that Petitioner did not view Inmate Kerr as a threat
    to the safety of Ms. Simms or himself on March 9.” Petitioner argues that the fact
    that he entered Mr. Kerr’s cell on 9 March 2014 without an extraction team or a safety
    shield “does not prove that [Mr. Kerr] was not considered to be a threat.” We are not
    required to determine, however, whether this evidence “proves” petitioner’s state of
    mind, but whether it adequately supports the ALJ’s inference in this regard. We hold
    that the fact that petitioner entered Mr. Kerr’s cell with Ms. Simms without
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    employing the institutional safety precautions supports the ALJ’s finding that
    petitioner did not regard Mr. Kerr as a threat.
    We next review petitioner’s challenge to Finding No. 46 that “[n]o evidence was
    offered that Petitioner ensured that custody staff actually performed checks to see if
    the handcuffs were too tight or causing any harm to Inmate Kerr.” Petitioner does
    not dispute the factual accuracy of this finding, and acknowledges his own testimony
    that petitioner “did not instruct custody staff to perform checks on the restraints to
    see if they were too tight or causing injury to Inmate Kerr[.]” Instead petitioner
    contends that such safety checks were not his responsibility. However, the scope of
    petitioner’s responsibility is not relevant to the accuracy of the ALJ’s finding that
    petitioner did not ensure that custody staff monitored Mr. Kerr’s condition with
    respect to the handcuffs. Petitioner also argues that this finding “shifted the burden
    of proof” to petitioner. Finding No. 46 does not address or shift the burden of proof,
    but simply notes that the evidence of petitioner’s failure to supervise appropriate
    safety checks was uncontradicted by any other evidence. We hold that this finding is
    supported by substantial evidence.
    Petitioner next challenges Finding No. 47, which states that petitioner
    “concedes that in his experience no inmate had ever been left in handcuffs for more
    than a few hours even when the inmate was refusing to have the handcuffs removed.”
    On appeal, petitioner argues that he did not concede that no inmate had ever been
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    left in handcuffs for more than a few hours, but only that such a situation was
    “unusual.” Assuming, arguendo, that the ALJ should have found that petitioner
    conceded it was “unusual” for an inmate to be in handcuffs for an extended period of
    time, we hold that this does not require reversal of the ALJ’s order.
    Petitioner next challenges the evidentiary support for Finding No. 51, which
    states that “Petitioner’s belief that Inmate Kerr was faking and being defiant was the
    basis of his decision to leave him in handcuffs until he came to the cell door to have
    them removed.”     We hold that this finding is amply supported by substantial
    evidence. For example, petitioner testified as follows:
    Q: Okay. And I believe you testified earlier that you did not
    believe initiating any type of disciplinary action against
    Mr. Kerr would change his behavior.
    PETITIONER: Disciplinary action -- yes, ma’am, I testified
    to that.
    Q: What behavior did you want him to change?
    PETITIONER: His behavior of not coming to the door.
    Refusing to come to the door and be left in handcuffs. I
    wanted the handcuffs removed from him.
    (emphasis added). Petitioner’s own testimony expressly indicates that he viewed Mr.
    Kerr as acting defiantly, and thus supports the ALJ’s finding.
    Petitioner also challenges Finding No. 54, which states that on 12 March 2014
    Sergeant Johnson “found Inmate Kerr lying in his own urine and feces with his pants
    and underwear around his ankles. He was not responsive to verbal commands but
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    appeared to be semi-conscious.” Petitioner’s challenge is limited to the ALJ’s use of
    the phrase “semi-conscious.”       It is undisputed, however, that Mr. Kerr was
    unresponsive, said nothing beyond repeating the word “Please,” and fell over when
    placed in a wheelchair. This finding is supported by substantial evidence.
    Petitioner next challenges Findings Nos. 84 and 85, which state that:
    84. Based upon all of the admissible evidence, the
    Undersigned finds as fact that Petitioner did not report a
    Code Blue incident or ensure that subordinate staff
    completed a report.
    85. Based upon all of the admissible evidence, the
    Undersigned finds as fact that Petitioner did not complete
    the daily OIC reports as required of an Officer In Charge.
    Petitioner admits that he did not report the Code Blue incident, but offers the
    excuse that other correctional officers also failed to do so, a fact which if true does not
    change the factual accuracy of the finding. Regarding petitioner’s failure to complete
    daily OIC reports, petitioner asserts that this was not specifically mentioned in his
    pre-disciplinary letter.   As discussed above, however, petitioner’s neglect of his
    responsibility to complete OIC reports was a part of petitioner’s acts and omissions
    as specifically related to Mr. Kerr’s conditions of confinement in March 2014. The
    ALJ did not err by making these findings.
    Finally, petitioner challenges Findings Nos. 86, 87, and 88, which state that:
    86. Based upon all of the admissible evidence, the
    Undersigned finds as fact that Petitioner did not exercise
    the discretion or good judgment required of a Correctional
    Captain.
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    87. Based upon all of the admissible evidence, the
    Undersigned finds as fact that Petitioner did not ensure
    the safe and humane treatment of Inmate Kerr.
    88. After considering all of the documentary and
    testimonial evidence admitted in this contested case,
    taking particular note of the Petitioner’s written
    statements and testimony, the Undersigned finds as fact
    that Petitioner fails to accept any personal responsibility
    for his actions or inactions that caused harm to Inmate
    Kerr.
    Findings Nos. 86 and 87 are supported by the ALJ’s other findings of fact that
    are either unchallenged or which we have determined to be supported by substantial
    evidence. Petitioner argues that his failure to accept personal responsibility was not
    listed as a reason for termination in his pre-disciplinary letter.        We conclude,
    however, that this circumstance was relevant to the ALJ’s review of the level of
    discipline imposed. For the reasons discussed above, we conclude that the challenged
    findings were supported by substantial evidence, and that petitioner is not entitled
    to relief on this basis.
    V. Just Cause for Petitioner’s Termination
    Petitioner’s final argument is that the ALJ erred by finding and concluding
    that respondent had just cause to terminate petitioner for grossly inefficient job
    performance. We disagree.
    N.C. Gen. Stat. § 126-35(a) provides that “[n]o career State employee subject
    to the North Carolina Human Resources Act shall be discharged, suspended, or
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    demoted for disciplinary reasons, except for just cause. . . . The State Human
    Resources Commission may adopt, subject to the approval of the Governor, rules that
    define just cause.” Pursuant to this grant of authority, the North Carolina Office of
    State Human Resources has stated that “[t]here are two bases for the discipline or
    dismissal of employees under the statutory standard for "just cause" as set out in G.S.
    126-35. These two bases [include] (1) Discipline or dismissal imposed on the basis of
    unsatisfactory job performance, including grossly inefficient job performance.” 25
    N.C.A.C. 1J .0604(b)(1). In this case, petitioner was discharged for grossly inefficient
    job performance, which is defined by 25 N.C.A.C. 1J.0614(5) as follows:
    (5) Gross Inefficiency (Grossly Inefficient Job Performance)
    means a type of unsatisfactory job performance that occurs
    in instances in which the employee: fails to satisfactorily
    perform job requirements as specified in the job
    description, work plan, or as directed by the management
    of the work unit or agency; and, that failure results in
    (a) the creation of the potential for death or serious bodily
    injury to an employee(s) or to members of the public or to a
    person(s) over whom the employee has responsibility[.] . . .
    In order to review the ALJ’s determination that respondent had established
    that respondent had just cause to terminate petitioner, we must consider petitioner’s
    acts and omissions in the context of the duties of his position. As a Correctional
    Captain, petitioner was responsible for interpreting, developing, and implementing
    standard operating procedures and emergency plans, as well as reviewing the work
    performed by others to ensure its compliance “with the goals and the missions of the
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    . . . Department of Public Safety,” including DPS’s goals of ensuring “the safety of the
    inmates” and “the humane confinement of inmates.” During the hearing petitioner
    admitted that his position required “the exercise of good judgment and discretion”
    given that not every situation would be addressed in the written policies.
    In addition to his rank as a Correctional Captain, petitioner acted as the OIC
    on 8 and 9 March 2014. Petitioner testified that the OIC is “the individual that's left
    in charge of the daily running of the institution and the safety and welfare of the staff
    and the inmates at that institution.” Mr. Polk testified that the duties of an OIC
    include the following:
    The officer-in-charge of each facility within the Division of
    Prisons or his or her designated representative will conduct
    a daily inspection of the facility for the purpose of detecting
    and eliminating all hazards to the security, health,
    sanitation, safety, and welfare of staff and inmates at the
    facility. No condition which constitutes a threat to the
    sanitation, safety, or security of the prison facility will be
    permitted to exist.
    Mr. Polk also testified that it was the responsibility of the OIC to ensure than
    an inmate received necessary medical care. In addition, Mr. Polk explained that, as
    OIC, petitioner had a responsibility to follow up on petitioner’s orders regarding Mr.
    Kerr by communicating with the Alexander staff on 10 and 11 March when petitioner
    was not at the facility:
    Q. Now, how can Mr. Blackburn be responsible for what
    happened on March 10th and 11th if he wasn’t at work that
    day?
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    MR. POLK: Because on March 9th, he left the institution
    knowing that the inmate was still handcuffed inside the
    cell, and he had a duty to follow up to find out what his
    situation was. He was the officer-in-charge that placed
    those procedures in effect that no one should remove the
    handcuffs until he got up and walked to the door.
    We conclude that petitioner had a highly placed supervisory role at Alexander,
    in which he gave orders to other correctional staff and had a great deal of
    responsibility. As a correctional captain and the OIC, petitioner was required to
    exercise good judgment and make discretionary decisions to further the health and
    safety of both the correctional staff and the inmates.
    We next consider the ALJ’s findings of fact to determine whether they support
    the ALJ’s finding and conclusion that there was just cause to terminate petitioner for
    grossly inefficient job performance. The ALJ made the following findings of fact which
    are either unchallenged on appeal or which we have determined to be supported by
    substantial evidence:
    1. Petitioner was employed by Respondent North Carolina
    Department of Public Safety (DPS) for fourteen (14) years
    with promotions through the custody ranks from a
    Correctional Officer to a Correctional Captain.
    2.   At the time of his dismissal, Petitioner was a
    Correctional Captain, the second highest rank at the
    Alexander Correctional Institution (“Institution”)[.]
    3. Petitioner testified that he was aware of and familiar
    with the position description of a Correctional Captain
    which states that “[t]he Correctional Captain is responsible
    for interpreting, developing and implementing Standard
    Operating Procedures, Post Orders, and Emergency Plans
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    which are needed to carry out the custody assignments of
    the facility.” The Correctional Captain also “assume[s] the
    responsibilities of the Assistant Superintendent for
    Custody and Operations in the absence of the Assistant
    Superintendent for Custody and Operations.”            The
    Correctional Captain “has the responsibility of reviewing
    work performed and ensuring that it is in compliance with
    the goals and missions of the Department of Corrections.”
    An important goal of DPS is to ensure the safety and
    humane confinement of inmates.
    4. Petitioner would regularly perform duties as the Officer
    In Charge (“OIC”) of the Institution during his 12-hour
    duty assignment. An OIC has “the authority to make
    spontaneous decisions regarding Institution operational
    issues, while maintaining the safety and security of Staff,
    agents, volunteers, visitors, and inmates throughout the
    Institution areas of control . . . [and] will directly supervise
    and/or monitor all areas of the Institution regarding
    enforcement of orderly conduct, sanitary conditions, and
    safety.”
    5. Petitioner testified that as OIC he was responsible for
    the daily running of the Institution and for the safety and
    welfare of inmates and prison staff and to document all
    unusual and important activities in the OIC shift report.
    6. Petitioner was familiar with DPS’s policies and
    procedures governing the treatment and confinement of
    inmates. . . .
    ...
    8. Petitioner testified that he was aware that DPS’s
    policies allow a considerable amount of discretion and use
    of judgment by a Correctional Captain because every
    scenario that prison staff may encounter is not covered by
    written policies and procedures.
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    9. Petitioner testified that in February 2014, he knew that
    Inmate Kerr “had been at one time residential mental
    health.” He also testified that he did not know whether
    inmate Kerr was on administrative segregation or
    disciplinary segregation status, or whether he was there
    for mental health observation.
    10. Over time, [Mr. Kerr’s] segregation status was
    continued for disciplinary reasons for various non-violent
    infractions such as being loud in his cell and throwing
    water on the floor.
    ...
    15. Inmate Kerr had been tearing up the milk cartons and
    putting the pieces in his toilet thereby flooding the cell so
    Petitioner ordered that [Mr. Kerr] no longer be provided
    the milk with the nutraloaf.
    16. An unidentified individual put a note on Inmate Kerr’s
    cell door “NO MILK PER CAPTAIN BLACKBURN.”
    Petitioner testified . . . that he knew the note was posted.
    17. Inmate Kerr was no longer provided milk with the
    nutraloaf after Petitioner’s order was given, even during
    the shifts when Petitioner was not on duty.
    18. “Code Blue” is defined as any medical situation in the
    confines of the Institution requiring the immediate
    assistance of Medical Personnel.
    19. On March 8, 2014, Petitioner was the Correctional
    Captain on duty as the OIC when a Code Blue was called
    because segregation staff observed Inmate Kerr to be
    unresponsive in his cell.
    20. When Petitioner arrived at Inmate Kerr’s cell, he was
    lying on his bed with leg restraints on and his hands cuffed
    in front. Inmate Kerr lay in the bed awake, not talking or
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    moving and, at one point, staff could not tell if he was
    breathing.
    ...
    22. Petitioner then ordered Inmate Kerr to come to the cell
    door to have the mechanical handcuffs removed. Petitioner
    informed Inmate Kerr that his handcuffs would not be
    removed until he got up and came to the cell door.
    23. Petitioner directed the subordinate custody staff not to
    remove the handcuffs until Inmate Kerr came to the door
    and asked that the handcuffs be removed. . . .
    24. Petitioner directed custody staff to perform 15-minute
    safety checks on Inmate Kerr’s handcuffs. The safety
    checks consisted of looking through the cell door at Inmate
    Kerr. Neither Petitioner nor his subordinate staff checked
    to see if the handcuffs were too tight or causing physical
    harm to Inmate Kerr.
    25. Custody tablet reports indicate that at times staff
    would simultaneously report that Inmate Kerr appeared to
    be sleeping and [also that Mr. Kerr] refused to have his
    handcuffs removed.
    26. The evidence indicates that Inmate Kerr was not
    refusing to have his handcuffs removed but was
    unresponsive due to his mental health and/or physical
    condition.
    27. Petitioner did not complete an incident report for the
    Code Blue for Inmate Kerr on March 8, 2014 or report that
    Inmate Kerr was in restraints at the end of his shift on
    March 8, 2014. . . .
    28. Petitioner noted the incident in the Shift Narrative for
    March 8 including the order not to remove the handcuffs
    until Inmate Kerr came to the cell door.
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    ...
    30. As OIC, Petitioner failed to note on the OIC report on
    March 8, 2014 that Inmate Kerr was still in handcuffs.
    31. Petitioner did not call Assistant Superintendent Moose
    or any other resource available to him, such as the division
    duty officer, on March 8, 2014 to receive any type of
    guidance on what to do regarding Inmate Kerr. As OIC,
    Petitioner did not notify the Administrator (Moose) that
    Inmate Kerr remained in handcuffs at the end of shift.
    32. Petitioner was the OIC on March 9, 2014.
    ...
    36. On March 9, 2014, Petitioner entered Inmate Kerr’s cell
    with staff psychologist Dara Simms without an extraction
    team, the required number of custody staff, or the shield
    for protection.
    ...
    38. Inmate Kerr remained on his bed unresponsive even
    after Petitioner tried to rouse him with his hand and by
    pulling Inmate Kerr’s blanket out of his hands.
    39. Ms. Simms asked Petitioner if a Code Blue should be
    called, but Petitioner responded that a Code Blue was not
    necessary. They exited the cell and left Inmate Kerr in the
    handcuffs.
    40. The Undersigned finds as fact that Petitioner did not
    view Inmate Kerr as a threat to the safety of Ms. Simms or
    himself on March 9.
    41. Petitioner’s notes in the Shift Narrative for March 9
    record Inmate Kerr in handcuffs.
    - 32 -
    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    42. At the end of his shift on March 9, 2014, Petitioner did
    not include in the OIC report that Inmate Kerr remained
    in handcuffs.
    43. Petitioner took his scheduled off-duty days on March 10
    and 11, 2014 leaving in place his order that Inmate Kerr
    remain in handcuffs.
    44. Inmate Kerr remained in handcuffs from March 8
    through March 12, 2014. Segregated Unit Shift Narratives
    completed by the OIC for each day record that Inmate Kerr
    remained in handcuffs in his cell.
    45. Neither Petitioner nor any of the other OICs noted that
    Inmate Kerr was still in handcuffs on their OIC reports for
    March 8, 9, 10, or 11, 2014.
    46. No evidence was offered that Petitioner ensured that
    custody staff actually performed checks to see if the
    handcuffs were too tight or causing any harm to Inmate
    Kerr.
    47. Petitioner concedes that in his experience no inmate
    had ever been left in handcuffs for more than a few hours
    even when the inmate was refusing to have the handcuffs
    removed.
    ...
    49. Despite the fact that Petitioner asserted that Inmate
    Kerr was simply refusing to obey his commands to come to
    the door to have the handcuffs removed, neither Petitioner
    nor any other custody staff ever initiated any type of
    disciplinary action against Inmate Kerr for his supposed
    refusal.
    50. The Undersigned finds as fact that Inmate Kerr was
    not in handcuffs due to violent behavior or any other
    behavioral reason.
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    51. Petitioner’s belief that Inmate Kerr was faking and
    being defiant was the basis of his decision to leave him in
    handcuffs until he came to the cell door to have them
    removed.
    52. Petitioner had the authority to simply order that the
    handcuffs be removed.
    53. On Mach 12 2014, Petitioner instructed Correctional
    Sergeant William Johnson to prepare Inmate Kerr for
    transport to Central Prison for mental health care.
    54. When Sergeant Johnson went to Inmate Kerr’s cell he
    found Inmate Kerr lying in his own urine and feces with
    his pants and underwear around his ankles. He was not
    responsive to verbal commands but appeared to be semi-
    conscious.
    55. The Undersigned reviewed a video of Inmate Kerr being
    prepared for transport to Central prison: correctional staff
    physically put clean pants on Inmate Kerr; an additional
    officer was called to retrieve a wheelchair and then lifted
    Inmate Kerr into the wheelchair; he appeared to be
    slumping in the wheelchair.
    56. Sergeant Johnson informed Petitioner that the
    handcuffs could not be unlocked because they were caked
    with feces. Petitioner ordered Sergeant Johnson to use bolt
    cutters to remove the handcuffs.
    57. Various staff observed cuts and bruises on Inmate
    Kerr’s wrist[s] from being in handcuffs for an extended
    period of time. Custody staff gave Inmate Kerr bandaids.
    58. Corrections Officer James Quigley stated in written
    statements dated March 18, 2014 and April 1, 2014 that
    when he assisted with dressing Inmate Kerr, he observed
    “open wounds on his right wrist.” In his written statement,
    Sergeant Johnson noted “cuts” on Inmate Kerr’s wrist
    caused by the handcuffs.
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    59. No evidence was offered that Inmate Kerr ever got up
    from his bunk after the evening of March 8, 2014 until he
    was physically removed from his cell on March 12, 2014.
    60. Inmate Kerr did not see medical staff before leaving the
    Institution at 8:30 a.m. and was dead upon arrival at
    Central Prison at 11:30 a.m.
    61. As a result of Inmate Kerr’s death, a Sentinel Event
    team conducted an investigation at the Institution into his
    death and submitted a report to DPS.
    62. As a result of that report, DPS’s Professional Standards
    Office conducted internal investigations into the conduct of
    several employees, including Petitioner.
    63. Marvin Polk, an investigator with the Professional
    Standards Office with DPS, conducted the internal
    investigation regarding Petitioner’s conduct and submitted
    a report dated April 5, 2014 to DPS management which
    recommended disciplinary action against Petitioner.
    64. Mr. Polk testified that in his thirty years working for
    the department he had never known an inmate to have
    been left in handcuffs for five days. He testified that
    handcuffs should have been removed from Inmate Kerr by
    assembling a team with a shield, removing the handcuffs
    and backing out of the cell.
    65. Kenneth Lassiter, Deputy Director of Operations for
    DPS, has been employed by DPS for twenty-five years and
    is familiar with the DPS’s policy and procedures related to
    the care and confinement of inmates. He testified that
    handcuffs can create the potential for a serious risk of harm
    and, therefore, custody staff are trained to ensure that the
    handcuffs are not embedded or cutting into an inmate’s
    skin.
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    66. During the internal investigation, Petitioner gave three
    written statements.
    67. On March 18, 2014, Petitioner stated that he had dealt
    with Inmate Kerr a couple times on the segregation unit
    and mental health unit.
    68. On April 1, 2014, Petitioner stated that on March 9,
    2014, he discussed with Nurse Triplett that he was aware
    of Inmate Kerr’s mental state and that he “had notified
    Mental Health Staff.”
    69. In another statement on April 1, 2014, Petitioner stated
    that a Code Blue was called on March 8, 2014 for Inmate
    Kerr.
    ...
    71. On April 4, 2014, Petitioner attended a Pre-
    Disciplinary Conference wherein the reasons supporting
    discipline were given to him. Petitioner was given an
    opportunity to respond orally and in writing. Petitioner
    gave verbal and written statements[.] . . .
    72. On April 4, 2014, Petitioner submitted a written
    statement “to fully explain my thought process and
    decision making for the events that occurred over the
    weekend.” He wrote that on March 8, he did not know
    Inmate Kerr’s mental health status “or that his medical
    status had changed or that he needed any further medical
    assistance or needs.”
    ...
    74. After the Pre-Disciplinary Conference, Director
    Solomon reviewed the Sentinel Event Report, Internal
    Investigation report, witness statements and all available
    information including Petitioner’s prior active written
    warning and years of service, making a decision to
    discipline Petitioner. On July 18, 2013, Petitioner had
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    received a written warning for Unacceptable Personal
    Conduct for falsely recording time on his timesheets. In
    that written warning Petitioner was directed to review
    department, division and facility policies and procedures
    specific to his responsibility as a Correctional Captain, and
    also was warned that if any further performance or conduct
    incidents occurred that he would be subject to discipline up
    to and including dismissal.
    75. On April 7, 2014, Petitioner was dismissed based upon
    Grossly Inefficient Job Performance.
    76. Respondent’s dismissal letter dated April 7, 2014,
    states the specific conduct as reasons for the dismissal.
    77. Respondent’s dismissal letter dated April 7, 2014, is
    based upon the Division of Prison’s Policy and Procedures
    Manual, P .1504(h)(1-2) which states:
    . . . . The use of instruments of restraint, such as
    handcuffs, leg cuffs, waist chains, black boxes and
    soft restraints are used only with approval by the
    facility head or designee.
    (1) Instruments of restraint will be utilized only as a
    precaution against escape during transfer, [to]
    prevent self-injury or injury to officers or third
    parties, and/or for medical or mental health reasons.
    ...
    78. Petitioner appealed his dismissal to the Employee
    Advisory Committee where he was given the opportunity
    to speak and present evidence to the committee.
    79. In his Step 2 Grievance Filing, concerning Inmate Kerr
    “Remaining In Handcuffs,” Petitioner stated that Inmate
    Kerr “remained in cuffs of his own free will” and “these
    orders were only for Saturday 3/8/14 morning and thru [sic]
    end of shift on Sunday 3/9/14.”
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    80. In his Step 2 Grievance Filing, Petitioner submitted a
    written “Closing Statement” excusing his actions because
    of “[t]he lack of a clear procedure deprived me of a concise
    understanding of what was expected during this type of
    incident.” He also complained that “[n]o one else did
    anything different [from] what I did but I am the one
    sitting here with no job while the other OIC’s are back to
    work.”
    81. [Respondent] presented evidence that as a result of
    Inmate Kerr’s death and the events surrounding it, a total
    of twenty-five employees faced discipline: nine were
    dismissed (including an Assistant Superintendent); one
    was reassigned down (Region Director); one was demoted
    (Assistant Superintendent); ten received a written
    warning; two received a TAP entry; and two resigned.
    82. On June 3, 2014, the Employee Advisory Committee
    unanimously recommended that the dismissal be upheld.
    83. On July 16, 2014, a Final Agency Decision was issued
    by Commissioner W. David Guice upholding the dismissal.
    84. Based upon all of the admissible evidence, the
    Undersigned finds as fact that Petitioner did not report a
    Code Blue incident or ensure that subordinate staff
    completed a report.
    85. Based upon all of the admissible evidence, the
    Undersigned finds as fact that Petitioner did not complete
    the daily OIC reports as required of an Officer In Charge.
    86. Based upon all of the admissible evidence, the
    Undersigned finds as fact that Petitioner did not exercise
    the discretion or good judgment required of a Correctional
    Captain.
    87. Based upon all of the admissible evidence, the
    Undersigned finds as fact that Petitioner did not ensure
    the safe and humane treatment of Inmate Kerr.
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    88. After considering all of the documentary and
    testimonial evidence submitted in this contested case,
    taking particular note of the Petitioner’s written
    statements and testimony, the Undersigned finds as fact
    that Petitioner fails to accept any personal responsibility
    for his actions or inactions that caused harm to Inmate
    Kerr.
    To summarize, the undisputed evidence and the ALJ’s findings establish the
    following material facts and circumstances:
    1. In March 2014 petitioner was a Correctional Captain
    and acted as the OIC at various times. Petitioner’s position
    required that he not only know and follow prison rules and
    regulations, but that he respond with discretion and good
    judgment to situations that were unexpected or were not
    addressed in written guidelines.
    2. On 8 and 9 March 2014 petitioner was the OIC at
    Alexander, a position that placed him in a supervisory role
    over the institution and made him responsible for the
    exercise of good judgment by him and by the staff in order
    to promote the health and safety of staff and inmates.
    3. On 8 March 2014 petitioner ordered that Mr. Kerr must
    remain in handcuffs until he walked to the door of his cell
    and asked for their removal. On 8 March 2014 petitioner
    also ordered that Mr. Kerr should no longer be given milk,
    leaving Mr. Kerr with no way to drink any liquid unless he
    could use his handcuffed hands to drink from the sink in
    his cell.
    4. Petitioner did not ensure that the custodial staff checked
    Mr. Kerr’s condition, or that they removed the handcuffs
    periodically to allow Mr. Kerr to drink or to use the toilet
    in his cell. Mr. Kerr was not observed to be standing or to
    have moved from his bed after 8 March 2014.
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    5. No evidence was presented that Mr. Kerr had ever
    behaved violently towards custodial staff or that he
    presented a danger to petitioner or to other staff.
    5. Petitioner had the authority to order the handcuffs
    removed. Procedures existed that would have reduced or
    eliminated any risk associated with removing Mr. Kerr’s
    handcuffs.
    7. Petitioner’s action of allowing Mr. Kerr to remain in
    metal handcuffs for five days was not in accordance with
    DPS’s or Alexander’s guidelines for use of restraints.
    Based on the evidence, the ALJ’s findings of fact, and the undisputed crucial
    facts, we conclude that petitioner’s actions of (1) allowing Mr. Kerr to remain lying
    on his bed in handcuffs for five days, (2) without receiving anything to drink during
    this time, and (3) without any attention to Mr. Kerr’s condition, was a violation of
    applicable rules, a breach of petitioner’s responsibility as a senior correctional officer,
    and contributed directly related to Mr. Kerr’s death on 12 March 2014. The ALJ did
    not err by finding and concluding that respondent had properly determined that it
    had just cause to terminate petitioner for grossly inefficient job performance.
    Petitioner’s arguments for a contrary result are primarily technical in nature
    and ignore the degree of responsibility associated with his position. For example,
    petitioner argues that the ALJ did not make a finding tracking the statutory language
    that petitioner “failed to satisfactorily perform job requirements as specified in his
    job description, work plan, or as directed by management.” We first note that as a
    Correctional Captain, petitioner was management. Secondly, the ALJ’s findings
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    establish that petitioner’s acts and omissions meet the standard for grossly inefficient
    performance, and the ALJ’s order need not be reversed for omitting an additional
    finding that tracks the statutory language.
    Similarly, petitioner contends that the ALJ did not make a finding specifically
    quoting the definitional language that petitioner’s “actions or inactions resulted in
    the creation of the potential for death or serious bodily injury to Inmate Kerr.” The
    evidence was undisputed that at the time of Mr. Kerr’s death he had been in
    handcuffs for days, with nothing to drink, was lying in his own urine and feces, and
    was determined to have died of dehydration. In the face of this overwhelming and
    disturbing evidence, petitioner nonetheless argues that respondent “failed to present
    sufficient evidence to establish such potential of serious bodily injury or death.” We
    hold that the evidence and the ALJ’s findings established not only a potential for
    serious injury or death but death itself.
    Petitioner also contends that the “only specific findings that ALJ Brooks made
    that Petitioner failed to satisfactorily perform his job requirements were those
    relating to his failure to complete an incident report for the Code Blue incident and
    his failure to document that Inmate Kerr remained handcuffed at the end of his shift
    on his daily OIC report.” (PtrBrf 25-26) Petitioner fails to acknowledge the most
    important “job requirement” of his position, that of exercising good judgment in a
    supervisory position of great responsibility.
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    BLACKBURN V. N.C. DEP’T OF PUB. SAFETY
    Opinion of the Court
    Petitioner also asserts that his conduct, even if it constituted grossly inefficient
    job performance, did not warrant dismissal. We again note that petitioner’s position
    required him to exercise supervisory authority and good judgment. We conclude that
    the ALJ’s findings support the conclusion that respondent had shown that it had just
    cause to terminate petitioner for grossly inefficient job performance.
    We have considered petitioner’s remaining arguments and conclude that they
    are without merit. For the reasons discussed above, we conclude that the ALJ did
    not err and that its order should be
    AFFIRMED.
    Judges BRYANT and CALABRIA concur.
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