OFFICIAL USE ONLY SENSITIVE Page 1 of 15 DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION 2. REPORT NUMBER 002 HB 4200-01 (37), Special Agent Handbook 3. TITLE GRACIDA CONTE, PABLO/Unknown/0109 Detainee/Alien - Death (Known Cause -Terminal Illness)/ELOY, PINAL, AZ 4. FINAL RESOLUTION Referred to Management 5. STATUS Closing Report 6. TYPE OF REPORT Investigative Findings 7. RELATED CASES 8. TOPIC Detainee Death Review- GRACIDA-Conte,Pablo (b)(6), (b)(7)(c) -Closing Report 9. SYNOPSIS On October 30, 2011, the Joint Intake Center, Washington, D.C, received notification regarding the death of U.S. Immigration and Customs Enforcement Detainee Pablo GRACIDA-Conte. GRACIDA, a citizen of Mexico, died on October 30, 2011, at the Tucson University Medical Center in Tucson, AZ. The Pima County Medical Examiner reported the cause of death as cardiomyopathy, a chronic disease of the heart muscle (myocardium) that causes it to become abnormally enlarged, thickened, and/or stiffened. On November 8, 2011, the U.S. Immigration and Customs Enforcement, Office of Professional Responsibility, Office of Detention Oversight initiated a Detainee Death Review of Pablo GRACIDA-Conte's death. This report documents the findings of the review. 10. CASE OFFICER (Print Name & Title) (b)(6), (b)(7)(c) 12. APPROVED BY(Print Name & Title) 14. ORIGIN OFFICE ICE OPR Office of Detention Oversight (ODO)-Phoenix 15-AUG-2012 Agent (b)(6), (b)(7)(c) 11. COMPLETION DATE - ICE-OPR Special 13. APPROVED DATE 15. TELEPHONE NUMBER 15-AUG-2012 No Phone Number - ICE-OPR Special Agent Supervisor THIS DOCUMENT IS LOANED TO YOU FOR OFFICIAL USE ONLY AND REMAINS THE PROPERTY OF THE DEPARTMENT OF HOMELAND SECURITY. ANY FURTHER REQUEST FOR DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTAINED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A COPY OF THE DOCUMENT. THIS DOCUMENT CONTAINS INFORMATION REGARDING CURRENT AND ON-GOING ACTIVITIES OF A SENSITIVE NATURE. IT IS FOR THE EXCLUSIVE USE OF OFFICIAL U.S. GOVERNMENT AGENCIES AND REMAINS THE PROPERTY OF THE DEPARTMENT OF HOMELAND SECURITY IT CONTAINS NEITHER RECOMMENDATIONS NOR CONCLUSIONS OF THE DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEMINATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE MADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 2 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE On October 30, 2011, the Joint Intake Center (JIC), Washington, D.C., received notification of the death of Detainee Pablo GRACIDA-Conte (Alien Number (b)(6), (b)(7)(c) ). GRACIDA, a citizen of Mexico born on March 9, 1957, died on October 30, 2011, at the Tucson University Medical Center (TUMC) in Tucson, AZ. GRACIDA was 54 years old when he died. At the time of his death, GRACIDA was in U.S. Immigration and Customs Enforcement (ICE) custody at the Eloy Detention Center (EDC) in Eloy, AZ. The EDC is owned and operated by Corrections Corporation of America (CCA). The EDC is a designated ICE facility that accommodates male and female ICE detainees of all security classification levels for periods in excess of 72 hours. EDC operates in accordance with an Intergovernmental Service Agreement (IGSA) between ICE and the City of Eloy. ICE Health Service Corps (IHSC) provides medical services to detainees at EDC. EDC maintains accreditation through the American Correctional Association (ACA). The Field Office Director (FOD), Office of Enforcement and Removal Operations (ERO), Phoenix, AZ, is responsible for ensuring EDC compliance with the ICE Performance Based National Detention Standards (PBNDS). An Assistant Field Office Director (AFOD) is physically located at EDC and oversees ICE detention operations at the facility. (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) On December 13-15, 2011, Special Agent (SA) and SA of the ICE Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO), Phoenix, AZ, conducted a Detainee Death Review regarding GRACIDA. ODO was assisted by subject (b)(6), (b)(7)(c) matter expert (SME), registered nurse (RN) . RN (b)(6), (b)(7)(c) is employed by Creative Corrections (CC), a national management and consulting firm contracted by ICE to provide subject matter expertise in detention management with a special emphasis on health care. As part of the review, ODO interviewed ICE ERO and EDC personnel. ODO also reviewed immigration, medical, and detention records pertaining to GRACIDA. The following is a time-line of events which occurred while GRACIDA was in ICE custody. On June 4, 2011, at 4:38 p.m., the Solano County Sheriff's Office arrested GRACIDA for selling alcohol to a minor, a misdemeanor in violation of California Penal Code Section 25658. Subsequently, GRACIDA was incarcerated at the Solano County Jail in Fairfield, CA. Solano County Sheriff's Officer(b)(6), (b)(7)(c) completed the Intake Health Screening Form for GRACIDA with no boxes marked that identified prior health-related issues (Exhibit 01). On June 4, 2011, ERO FOD San Francisco Immigration Enforcement Agent (IEA) OFFICIAL USE ONLY SENSITIVE (b)(6), (b)(7)(c) OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 3 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE encountered GRACIDA at the Solano County Jail. Law Enforcement Support Center, Law (b)(6), (b)(7)(c) Enforcement Specialist issued an ICE Form I-247, Immigration Detainer-Notice of Action, for GRACIDA. GRACIDA remained at the Solano County Jail until his release to ICE custody on June 9, 2011. On June 9, 2011, at approximately 9:00 a.m., Transport Officer (b)(6), (b)(7)(c) who is employed by ERO FOD San Francisco contract transportation company G4S, transported GRACIDA from the Solano County Jail to the ERO Office in Sacramento, CA, for processing. When GRACIDA arrived (b)(6), (b)(7)(c) at ERO Sacramento, IEA arrested GRACIDA for immigration violations. At the (b)(6), (b)(7)(c) time of arrest, IEA completed ICE Form I-213, Record of Deportable/Inadmissible Alien. The I-213 reflects that IEA (b)(6), (b)(7)(c) issued GRACIDA an ICE Form I-862, Notice to Appear, charging GRACIDA with inadmissibility pursuant to Section 212 (a)(6)(A)(i) of the Immigration and Nationality Act (INA), as an alien present without admission or parole (Exhibit 02). ERO made a determination to house GRACIDA at EDC. At approximately 3:00 p.m., ERO FOD (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) San Francisco G4S contract Transport Officers and ransported GRACIDA by detention bus from the ERO Office in Sacramento, CA, to ICE Air Operations in Oakland, CA. GRACIDA was searched after exiting the bus and prior to boarding the airplane. ICE Air Operations transported GRACIDA via airplane on the West Coast Loop Flight. The West Coast Loop Flight departed Oakland, CA, landed in San Diego, CA, and then continued to Williams Gateway Airport in Mesa, AZ. Upon arrival in Mesa, AZ, GRACIDA was transported via detention bus to a staging facility in Florence, AZ. GRACIDA was transported from the staging facility in Florence, AZ, to the EDC. GRACIDA was considered "in-transit" via land transportation and ICE Air Operations from the time he departed the ERO office in Sacramento, CA, on June 9, 2011, until arrival at EDC on June 10, 2011. On June 10, 2011, at 7:14 a.m., GRACIDA arrived at the EDC via Asset Bus (Exhibit 03). At (b)(6), (b)(7)(c) approximately 8:17 a.m., GRACIDA was booked into EDC by Officer and was classified as a Level I (lowest threat) detainee (refer to Exhibit 03). GRACIDA completed the booking process, and was housed in the receiving and discharge area of EDC until his intake screening. (b)(6), (b)(7)(c) On June 10, 2011, at 1:10 p.m., IHSC RN completed the initial intake screening as documented on Form IHSC-795-A (Exhibit 04). The intake screening form reflects that GRACIDA denied any past or current medical or mental health problems. The form documented GRACIDA's vital signs as temperature (T) 97.5 degrees, pulse (P) 56, respiration (R) 14, and blood pressure (BP) 112/68. Form IHSC-795-A specified that GRACIDA was 5'01" and 107 OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 4 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE pounds. RN (b)(6), (b)(7)(c) determined GRACIDA's screening was normal and the disposition is listed as general population. RN (b)(6), (b)(7)(c) reviewed the IHSC-795-A, which was also signed by provider and Assistant Health Services Administrator RN (b)(6), (b)(7)(c) RN (b)(6), (b)(7)(c) was not available for interview. RN (b)(6), (b)(7)(c) interviewed EDC medical staff concerning communication with GRACIDA. GRACIDA reportedly spoke Mixteco, a dialect of Spanish spoken in rural Mexico. Interviews determined that staff communication with GRACIDA was at a very basic level. EDC staff fluent in Spanish communicated with him in Spanish; non-Spanish speaking staff attempted to use the Interpretalk (b)(6), (b)(7)(c) translation service. RN interviewed RN (b)(6), (b)(7)(c) on December 15, 2011, at EDC. RN(b)(6), (b)(7)(c) stated she did not have face-to-face contact with GRACIDA. RN(b)(6), (b)(7)(c) stated staff is expected to enlist the services of a translator if they are unable to communicate effectively with a detainee. RN (b)(6), (b)(7)(c) , who conducted the intake screening, did not document the language used to complete that process, and as previously noted, RN (b)(6), (b)(7)(c) was not available for interview. No other remarkable activity occurred regarding GRACIDA until June 20, 2011. On June 20, 2011, at 2:40 p.m., RN (b)(6), (b)(7)(c) performed a physical examination/health appraisal within 14 days of arrival and documented the examination on Form IHSC 795-B (Exhibit 05). During the examination, GRACIDA stated he had no history of chronic illness. GRACIDA's vital signs were (T) 98.2 degrees, (P) 46, (R) 16, and (BP) 103/60. Medical records specify GRACIDA was 109.6 pounds at the time of this examination. The medical record, Standard Form (SF) 600, reflects that during the examination, IHSC officials irrigated a foreign body from GRACIDA's left ear. RN (b)(6), (b)(7)(c) interviewed RN (b)(6), (b)(7)(c) on December 13, 2011, at EDC. During the interview, RN (b)(6), (b)(7)(c) stated the foreign body removed from GRACIDA's ear was a moth. RN (b)(6), (b)(7)(c) could not provide any further details. No other remarkable activity occurred regarding GRACIDA until July 19, 2011. On July 19, 2011, at 1:05 p.m., GRACIDA went to the EDC medical clinic for vomiting and profuse (b)(6), (b)(7)(c) sweating. At 1:30 p.m., Dr. examined GRACIDA and treated him for his ailments. GRACIDA was given 600 cubic centimeters (cc) normal saline intravenously (IV), Phenergan 25 milligram (mg) IV, and Zantac 25mg IV (Exhibit 06). SA (b)(6), (b)(7)(c) SA (b)(6), (b)(7)(c) and RN (b)(6), (b)(7)(c) interviewed Dr. (b)(6), (b)(7)(c) on December 14, 2011. Dr. (b)(6), (b)(7)(c) dentified GRACIDA by photograph and remembered treating him. Dr. (b)(6), (b)(7)(c) stated she does not remember reviewing GRACIDA's physical examination because she reviews more than 200 physicals a week. Dr. (b)(6), (b)(7)(c) told ODO Agents that she speaks fluent Spanish, and she did not have any problems communicating with GRACIDA in the Spanish language. Dr. (b)(6), (b)(7)(c) stated that mid-level providers are able to care for chronic care patients. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 5 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE Dr. (b)(6), (b)(7)(c) stated that on July 19, 2011 at approximately 1:30 p.m., she manually checked GRACIDA's heart rate. Dr. (b)(6), (b)(7)(c) told ODO Agents the machine often gives inconsistent readings when compared to a manual check. Dr. (b)(6), (b)(7)(c) stated on this date she started him on intravenous (IV) fluids due to dehydration. Dr. (b)(6), (b)(7)(c) stated they rarely give IV fluids at the facility, but it is a more common practice in the summer months (refer to Exhibit 06). At 4:30 p.m., RN (b)(6), (b)(7)(c) drew a blood sample from GRACIDA for laboratory analysis that included a complete metabolic chemistry (CMC) and complete metabolic panel (CMP). The medical record documents GRACIDA's vital signs as (T) 97.5 degrees, (P) 42, (R) 20, (BP) 124/78, and 106.8 pounds (refer to Exhibit 06). On July 21, 2011, at 11:45 a.m., Dr. (b)(6), (b)(7)(c) reviewed GRACIDA's laboratory tests results (Exhibit 07). Dr. (b)(6), (b)(7)(c) documented in the medical record that GRACIDA's white blood cell count was 12.9 (normal range is 4-10.5), Neutrophils 81 (normal range is 40-74), and blood sugar 102 (normal range is 65-99). On August 5, 2011, GRACIDA completed a sick call slip requesting glasses to improve his vision (Exhibit 08). The sick call slip was received on August 6, 2011, and GRACIDA was seen by RN (b)(6), (b)(7)(c) on August 8, 2011 (refer to Exhibit 08). GRACIDA received reading glasses as a result of the examination. On August 10, 2011, GRACIDA submitted a sick call slip describing a decreased appetite (Exhibit 09). On August 12, 2011, RN (b)(6), (b)(7)(c) examined GRACIDA regarding his complaint of a decreased appetite (Exhibit 10). RN (b)(6), (b)(7)(c) recorded GRACIDA's vital signs as (T) 98.3 degrees, (P) 39 on machine (60 when taken manually), (R) 16, and (BP) 111/72. During the examination, GRACIDA denied any dizziness, and complained of loss of appetite. RN (b)(6), (b)(7)(c) assessment reflected "health maintenance" and her plan was to refer GRACIDA to the clinic in one to two days for a weight check to compare current and past weights. RN (b)(6), (b)(7)(c)documented that a weight scale was not available at the time of the examination. RN (b)(6), (b)(7)(c) plan was to refer GRACIDA to a provider if a significant change was observed in his weight. According to medical records, GRACIDA's weight on August 15, 2011, was 108.3 pounds, which was an increase of 1.5 pounds since July 19, 2011 (Exhibit 11). No other significant activity or interactions occurred with GRACIDA until October 1, 2011. On October 1, 2011, GRACIDA prepared a sick call slip for a runny nose, congestion, and a headache (Exhibit 12). The sick call slip was received on October 3, 2011, and GRACIDA was seen for his complaints on October 4, 2011, at approximately 11:25 a.m. (Exhibit 13). RN (b)(6), (b)(7)(c) OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 6 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE examined GRACIDA for his complaints and documented GRACIDA's vital signs as (T) 98.5 degrees, (P) 100, (R) 16, and (BP) 114/63. RN (b)(6), (b)(7)(c) documented that GRACIDA's throat was red, and he had a productive cough with clear sputum. GRACIDA was provided Chlorpeniramine maleate 4mg, which relieves symptoms of the common cold, to be taken every 4-6 hours as needed, and Tylenol 650 mg, to be taken every 4 hours as needed. On October 5, 2011, GRACIDA submitted a sick call slip for an upset stomach (Exhibit 14). At (b)(6), (b)(7)(c) 4:31 p.m., RN examined GRACIDA for complaints of nausea/vomiting, epigastric pain, and bloating (Exhibit 15). Per open source documents, epigastric pain is described as pain in the upper middle part of the abdomen (www.medical -dictionary.com). RN (b)(6), (b)(7)(c) documented GRACIDA's vital signs as (P) 85, (R) 16, (BP) 108/82, and 106 pounds. A urinalysis was performed, and all results were within normal limits. GRACIDA was provided MI Acid 20 ml (antacid) and referred to nurse practitioner (NP) (b)(6), (b)(7)(c) . NP(b)(6), (b)(7)(c)renewed GRACIDA's medications of Ranitidine 150 mg and added Metoclopramide 10 mg (heartburn relief medication) to be taken every morning as needed for 7 days. Per open source information, Reglan (Metoclopramide) is used to treat heartburn caused by gastric reflux (www.drugs.com). NP(b)(6), (b)(7)(c) scheduled a follow-up appointment for GRACIDA for the week of October 10, 2011. (b)(6), (b)(7)(c) On October 8, 2011, at 11:30 a.m., RN examined GRACIDA for burning abdominal pain and vomiting (Exhibit 16). RN (b)(6), (b)(7)(c) referred GRACIDA to NP(b)(6), (b)(7)(c). At 3:30 p.m., GRACIDA told NP(b)(6), (b)(7)(c)that since he arrived at EDC, the food had made him ill. GRACIDA stated the food made him vomit at least once a day and made him feel nauseating pain. GRACIDA stated there was no blood in his vomit or stool. Medical records reflect that GRACIDA stated he ate a routine diet of meat and tortillas prior to his arrival at EDC. NP(b)(6), (b)(7)(c)planned laboratory tests on October 11, 2011, for CBC, CMP, and H. Pylori (test to determine the presence of bacteria that can cause peptic ulcers), a urinalysis, and recommended a bland diet. (b)(6), (b)(7)(c) RN (b)(6), (b)(7)(c) interviewed NP on December 13, 2011, regarding her interactions with (b)(6), (b)(7)(c) GRACIDA. NP stated that an unknown correctional officer contacted the medical clinic to report that GRACIDA was vomiting after every meal. NP(b)(6), (b)(7)(c)documented that GRACIDA appeared to be older than his stated age, and that there was no translator available for GRACIDA' s native dialect of Mixteco Bajo (refer to Exhibit 16). NP(b)(6), (b)(7)(c)documented that GRACIDA spoke very little Spanish and no English. NP (b)(6), (b)(7)(c) charts reflect that GRACIDA's weight had increased by 3 pounds since October 05, 2011, and his heartbeat was "regular, no murmurs, rubs, gallops or CP." NP(b)(6), (b)(7)(c)also documented that GRACIDA's abdomen was "flat, non-distended, hyperactive BSx4, no rebound or guarding," and that GRACIDA had "warm, dry, intact pale skin, and moist mucous membranes." ODO verbal consultation with CC medical SME RN (b)(6), (b)(7)(c) OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 7 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE verified that flat, non-distended, hyperactive, with no rebounding or guarding is a normal finding when examining the abdominal area. BSx4 is described as normal bowel sounds in all four of the abdominal quadrants. GRACIDA's vital signs were (T) 97.6 degrees, (P) 53, (R) 16, (BP) 109/69. GRACIDA advised his pain level was 10 out of 10. Per open source information, a pain scale is a method used to measure pain so that health professionals can plan how to best manage and control it. Most pain scales use numbers from 0 to 10; 0 means no pain, and 10 describes the worst pain the person has ever known or felt (www.health.com). (b)(6), (b)(7)(c) On October 11, 2011, at approximately 11:20 a.m., NP(b)(6), (b)(7)(c)obtained a blood sample from GRACIDA for laboratory analysis. NP(b)(6), (b)(7)(c)provided GRACIDA instructions on his diet and the use of his medications (Exhibit 17). On October 14, 2011, at 8:59 a.m., GRACIDA presented to the clinic as a walk-in with complaints of a headache, nausea and vomiting (Exhibit 18). (Agent's note: the medical record was dated (b)(6), (b)(7)(c) 10/13/2011.) RN obtained GRACIDA's vital signs and recorded them as (T) 97.6 degrees, (P) 77, (R) 18, (BP) 112/81, and 109.9 pounds. GRACIDA listed his level of pain as eight out of 10. RN (b)(6), (b)(7)(c) interviewed RN (b)(6), (b)(7)(c) on December 13, 2011, regarding her interactions with GRACIDA. RN (b)(6), (b)(7)(c) stated the medical record entry was incorrectly dated as October 13, 2011. RN (b)(6), (b)(7)(c) stated GRACIDA presented to the clinic as a walk-in for headache, nausea and vomiting and abdominal pain. RN (b)(6), (b)(7)(c) advised that she is Guatemalan and spoke with GRACIDA in the Spanish language. RN (b)(6), (b)(7)(c) documented that GRACIDA complained of epigastric pain that had kept him from sleeping for one month. RN (b)(6), (b)(7)(c) stated that GRACIDA looked tired, and his color was odd. (b)(6), (b)(7)(c) At approximately 10:00 a.m., GRACIDA was referred to NP NP (b)(6), (b)(7)(c) examined GRACIDA (refer to Exhibit 18). During this visit, GRACIDA told NP (b)(6), (b)(7)(c) he had not felt well for two months and continued to have nauseating abdominal pain. GRACIDA told NP (b)(6), (b)(7)(c) he had diarrhea and sometimes vomited when he ate. NP (b)(6), (b)(7)(c) documented that GRACIDA was alert, oriented and appeared to be chronically ill. She also documented that GRACIDA had a soft tender abdomen and was epigastric in the left upper quadrant. NP (b)(6), (b)(7)(c) reviewed GRACIDA's laboratory results and determined they were abnormal (Exhibit 19). Laboratory results showed GRACIDA's Microalbumin as 51.2 (normal is 0.0-17.0) and GRACIDA's Microalbumin/Creatinine ratio was 40.3 (normal is 0.0-30.0). NP (b)(6), (b)(7)(c) documented that GRACIDA's weight appeared to be stable and discontinued his Reglan and Ranitidine medication. Per open source information, Ranitidine (Zantac) is used to treat and prevent ulcers in the stomach and intestines (www.drugs.com). NP (b)(6), (b)(7)(c) prescribed OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 8 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE Clarithromycin, Amoxicillin and Omeprazole. Per open source information, Clarithromycin (Biaxin) is used to treat bacterial infections affecting the skin and respiratory system, Amoxicillin is used to treat infections caused by bacteria, and Omeprazole (Prilosec) is used to treat gastroesophageal reflux disease (GERD) and other conditions caused by excess stomach acid (www.drugs.com). RN (b)(6), (b)(7)(c) interviewed NP (b)(6), (b)(7)(c) on December 13, 2011, at EDC. During the interview, NP (b)(6), (b)(7)(c) stated the medical entry (refer to Exhibit 18) was incorrectly dated as October 13, 2011, and stated the correct date was October 14, 2011. On October 18, 2011, at 10:20 a.m., NP (b)(6), (b)(7)(c) saw GRACIDA for a follow-up visit (Exhibit 20). NP (b)(6), (b)(7)(c) examined GRACIDA and documented that GRACIDA was feeling much better than during previous visits. GRACIDA stated his nausea, vomiting and diarrhea had subsided. NP (b)(6), (b)(7)(c) scheduled GRACIDA for labs on November 18, 2011, and another follow-up appointment on November 22, 2011. At the time of the visit, GRACIDA's vital signs were (T) 97.7 degrees, (P) 90, (R) 16, BP 102/60, and 110.9 pounds. On October 22, 2011, at 3:10 p.m., GRACIDA arrived at the EDC clinic with a complaint of shortness of breath and was examined by LPN (Exhibit 21). GRACIDA (b)(6), (b)(7)(c) reported having an increased level of pain and nausea during meals, pain when lying down, and (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) difficulty sleeping. LPN consulted with NP who advised to increase GRACIDA's fluid levels, continue with medications already prescribed, and schedule a follow-up visit next week with NP (b)(6), (b)(7)(c) GRACIDA's vital signs were (T) 96.9 degrees, (P) 90, (R) 24, BP 106/63, with an oxygen saturation of 100%. At 9:15 p.m., GRACIDA refused to report in to receive his evening medications. The medical record reflects that GRACIDA also refused to complete Refusal Form IHSC-820 (Exhibit 22). On October 23, 2011, GRACIDA completed a sick call slip requesting to discontinue his medications, because they made him feel ill (Exhibit 23). At 10:30 p.m., GRACIDA came to the evening pill line, but refused to take Clarithromycin 500mg and Amoxicillin. GRACIDA stated those medications made him very sick, and GRACIDA signed Refusal Form IHSC-820, which was witnessed by clinic staff (Exhibit 24). On October 24, 2011, at 6:18 a.m., GRACIDA again refused to take medications and refused to sign Refusal Form IHSC-820 (Exhibit 25). At 10:30 a.m., RN (b)(6), (b)(7)(c) examined GRACIDA at the EDC clinic due to the three consecutive refusals to take medications (Exhibit 26). GRACIDA complained of abdominal pain and a poor appetite. GRACIDA also reported persistent weakness and dizziness. GRACIDA stated he had not eaten for the preceding two months, and he could not recall his last meal. IHSC routinely monitored GRACIDA's weight, which remained stable. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 9 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE At 10:50 a.m., NP (b)(6), (b)(7)(c) examined GRACIDA at the EDC clinic (refer to Exhibit 26). GRACIDA complained that food and medication had made him sick. GRACIDA stated to NP (b)(6), (b)(7)(c) that he had a heart attack in the year 2000 while in CA. NP (b)(6), (b)(7)(c) documented GRACIDA had clear breath sounds, and GRACIDA stated he had no chest pain. NP (b)(6), (b)(7)(c) also noted GRACIDA had an "abnormal" Electrocardiogram (EKG) which was interpreted by a computer. NP (b)(6), (b)(7)(c) discontinued the antibiotic medication for GRACIDA and scheduled him for a follow-up visit the next day. NP (b)(6), (b)(7)(c) also noted that if GRACIDA remained in custody he would be referred to cardiology. During this visit, GRACIDA's vital signs were (T) 97.4 degrees, (P) 88, (R) 22, (BP) 89/58, with oxygen saturation on room air of 97%. (Agent's note: during her interview on December 14, 2011, Dr. (b)(6), (b)(7)(c) stated that GRACIDA's condition on October 24, 2011 should have been considered urgent, and he should have been referred to a cardiologist at that time.) On October 25, 2011, at 6:30 a.m., GRACIDA declined to come to the pill line for his "omeprazole" medication and refused to sign the Refusal Form IHSC-820 (Exhibit 27). At 3:15 p.m., GRACIDA arrived at the EDC clinic for his scheduled appointment. During this visit, NP (b)(6), (b)(7)(c) documented that GRACIDA was unable to complete a sentence without stopping for breath, and his breathing sounded "clear but diminished in bases" (refer to Exhibit 27). ODO consultation with CC medical SME RN (b)(6), (b)(7)(c) determined that "clear but diminished in bases" means there were no abnormal findings when listening to the lungs. GRACIDA exhibited an "abnormal EKG" and "pitting edema at lower extremities." IHSC referred GRACIDA to the Casa Grande Regional Medical Center (CGRMC) Emergency Room for evaluation at approximately 3:20 p.m. (refer to Exhibit 27). CGRMC medical personnel diagnosed GRACIDA with severe cardiomyopathy and possible pneumonia (Exhibit 28). Per open source documents, cardiomyopathy is a chronic disease of the heart muscle (myocardium) that causes it to become abnormally enlarged, thickened, and/or stiffened. Pneumonia is an infection of the lung that can be caused by nearly any class of organism known to cause human infections (www.medical-dictionary.com). IHSC personnel remained in contact with CGRMC medical personnel to track GRACIDA's progress (refer to Exhibit 28). (b)(6), (b)(7)(c) On October 27 and 28, 2011, Dr. (b)(6), (b)(7)(c) and Dr. of CGRMC, provided treatment to GRACIDA (refer to Exhibit 28). Dr. (b)(6), (b)(7)(c) noted in the physician's progress notes that GRACIDA was ailing from complex cardiac issues, and he would likely benefit from a higher level of medical care. Dr. (b)(6), (b)(7)(c) recommended GRACIDA for transfer to the Tucson University Medical Center (TUMC) (refer to Exhibit 28). GRACIDA remained in the care of CGRMC until he OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 10 of 15 1. CASE NUMBER 201201174 PREPARED BY REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE was transferred to TUMC on October 28, 2011. On October 28, 2011, at approximately 12:04 a.m., GRACIDA was discharged from the CGRMC and transferred to TUMC via air ambulance (refer to Exhibit 28). GRACIDA's arrival time at the TUMC was not documented. At approximately 2:36 p.m., GRACIDA was admitted to the TUMC Telemetry Unit (Exhibit 29). On October 30, 2011, at 12:57 a.m., GRACIDA was transferred to the TUMC Intensive Care Unit (ICU) as documented in the TUMC medical record (Exhibit 30). Dr. (b)(6), (b)(7)(c) examined GRACIDA in the ICU. At 2:27 a.m. and 2:30 a.m., Dr. (b)(6), (b)(7)(c) and Dr. (b)(6), (b)(7)(c)received notification that GRACIDA's blood pressure had dropped to a low reading of 60/45. At 3:13 a.m., the medical chart reflects that GRACIDA's blood pressure was 66/41. ICU personnel notified the resident doctor, who was not identified in medical records. The medical record reflects that attending medical personnel notified Dr. (b)(6), (b)(7)(c) at 3:22 a.m. that GRACIDA's condition was deteriorating. GRACIDA went into cardiac distress at 3:38 a.m. Medical personnel used an automated external defibrillator (AED) to shock GRACIDA with "150 joules" and initiated cardio pulmonary resuscitation (CPR). Medical personnel continued to provide emergency care to GRACIDA until Dr. (b)(6), (b)(7)(c) ordered all attempts at resuscitation to cease at 4:42 a.m. (refer to Exhibit 30). At approximately 6:47 a.m., the Tucson Police Department was notified of the incident. Tucson (b)(6), (b)(7)(c) Police Officer responded to the TUMC. TUMC RN (b)(6), (b)(7)(c) stated to Officer (b)(6), (b)(7)(c) hat GRACIDA died of complications consistent with heart failure. Officer (b)(6), (b)(7)(c) wrote in his report there were no signs of foul play or noticeable trauma to the body. The Tucson Police Report number is TPD 1110300281 (Exhibit 31). At approximately 2:30 p.m., GRACIDA's body was released to the Pima County Medical Examiner' s Office. GRACIDA's body remained in the University Medical Center morgue until it was transferred to the Pima County Medical Examiner's Office on October 31, 2011. Upon learning of GRACIDA's death, ERO notified the JIC and the Mexican Consulate. The ERO Detainee Death (b)(6), (b)(7)(c) Notification and Reporting Checklist documents that GRACIDA's daughter, received notification of her father's death from Consular Officer (b)(6), (b)(7)(c) Exhibit 32). SA (b)(6), (b)(7)(c) and RN interviewed ICE ERO Acting Officer in Charge (AOIC) on December 13, 2011. AOIC (b)(6), (b)(7)(c) stated she was first made aware of GRACIDA's situation on or about October 25, 2011, following his hospital admission due to shortness of breath and dizziness. AOIC (b)(6), (b)(7)(c) stated IHSC kept her abreast of GRACIDA's condition on a daily basis during his hospitalization. AOIC (b)(6), (b)(7)(c) prepared, reviewed and (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 11 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE forwarded documentation and notification to all appropriate parties within ICE concerning GRACIDA's medical condition. AOIC (b)(6), (b)(7)(c) stated that upon GRACIDA's death, she prepared written notifications, gathered documentation, and made notifications, as well as delegated these same tasks, as required by the PBNDS and ICE national policy. The State of Arizona Department of Health Services, Office of Vital Records generated a Certificate of Death for Pablo GRACIDA-Conte (Exhibit 33). The death certificate specifies the date of death as October 30, 2011. Cardiomyopathy is listed as the immediate cause. (b)(6), (b)(7)(c) On November 1, 2011, Forensic Pathologist D.O., conducted a postmortem examination of GRACIDA at the Forensic Science Center, in Tucson, AZ. The Pima County Medical Examiner's Office prepared autopsy report number ML 11-02140 (Exhibit 34). Dr. (b)(6), (b)(7)(c) wrote in the autopsy report that GRACIDA's death was caused by cardiomyopathy, and the manner of death was natural. On December 13, 2011, SA (b)(6), (b)(7)(c) and RN (b)(6), (b)(7)(c) nterviewed ICE ERO Deportation Officer (b)(6), (b)(7)(c) (DO) on December 13, 2011. DO (b)(6), (b)(7)(c) stated he was assigned GRACIDA' s immigration case and remembers it being unremarkable. DO (b)(6), (b)(7)(c) stated he did not receive any correspondence from GRACIDA during his detention and did not remember speaking to GRACIDA after the initial interview on June 10, 2011. GRACIDA did not file any detainee requests that would necessitate a visit from DO (b)(6), (b)(7)(c) MEDICAL COMPLIANCE REVIEW Creative Corrections (CC), a national management and consulting firm contracted by ICE to provide subject matter expertise in detention management with an emphasis on health care, reviewed the medical treatment of GRACIDA at EDC (Exhibit 35). CC concluded that EDC was not compliant with the ICE PBNDS for Medical Care. Specifically, CC determined that EDC failed to comply with ICE PBNDS Medical Care, section (II)(2), which requires that the healthcare needs of detainees be met in a timely manner. IHSC completed a Division of Immigration Health Services (DIHS) Root Cause Analysis Report regarding GRACIDA (Exhibit 36). The report lists problem areas, root contributors, improvement strategies, and strategies recommended for national implementation resulting from lessons learned relative to GRACIDA's death. The report states that IHSC will monitor abnormal heart rates and chart them with more regularity and states that patients with a heart rate of less than 50 and more than 120 beats per minute will be given an Electrocardiogram. The report also OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 12 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE addresses orientation of clinic staff in regards to abnormal heart rates and blood pressure monitoring. MORTALITY REVIEW (b)(6), (b)(7)(c) Dr. ., CC Chief Medical Officer, conducted a mortality review as part of the investigation of GRACIDA's death. Dr.(b)(6), (b)(7)(c)prepared a report detailing his findings and conclusion. Dr.(b)(6), (b)(7)(c)concluded GRACIDA's death might have been prevented if the providers, including the physician at EDC, had provided the appropriate medical treatment in a timely manner. Dr.(b)(6), (b)(7)(c)stated that GRACIDA did not receive appropriate or medically acceptable medical care while confined at EDC. Dr. (b)(6), (b)(7)(c) mortality review is attached to this report (Exhibit 37). IMMIGRATION AND DETENTION HISTORY Pablo GRACIDA-Conte, a native and citizen of Mexico, entered the United States without having been admitted or paroled after inspection by an Immigration Officer. On May 25, 1999, GRACIDA was arrested by the U.S. Border Patrol and booked into the DeKalb County Jail in Atlanta, GA. GRACIDA was voluntarily returned to Mexico. No additional information is available regarding this arrest. On June 4, 2011, ICE ERO encountered GRACIDA at the Solano County Jail in Fairfield, CA, pursuant to his arrest for the offense of Selling Alcohol to a Minor. On June 9, 2011, ICE officials issued a Notice to Appear charging GRACIDA with inadmissibility under Section 212(a)(6)(A)(i) of the INA, as an alien present without admission or parole. ICE ERO transferred GRACIDA to EDC pending removal proceedings. On October 25, 2011, an Immigration Judge granted GRACIDA voluntary departure under safeguards to Mexico, with an alternate Order of Removal to Mexico. CRIMINAL HISTORY The Solano County Sheriff's Office arrested GRACIDA and charged him with misdemeanor Selling Alcohol to a Minor, in violation of California Penal Code Section 25658, punishable by a maximum (b)(7)e $1000 fine and community service. GRACIDA's . GRACIDA did not OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 13 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE have any other known criminal arrests. The Law Enforcement Support Center confirmed all records for GRACIDA have been purged from NCIC. INVESTIGATIVE FINDINGS ICE took custody of GRACIDA on June 9, 2011, and GRACIDA was housed at EDC pending removal proceedings. This review determined that GRACIDA was not provided medical care in accordance with the ICE PBNDS while housed at EDC. This review also determined that GRACIDA complained about his health to IHSC officials; however, IHSC failed to provide him with timely and efficient health care. ICE PBNDS Medical Care standard, section (II)(2), requires that healthcare needs be met in a timely and efficient manner. ODO verified IHSC officials at EPC failed to comply with the PBNDS Medical Care standard. CC concluded that the following were deficiencies under the standard. RN (b)(6), (b)(7)(c) failed to re-take the pulse apically or consult a provider when GRACIDA's heart rate measured 46 at the time of the physical examination. IHSC staff did not reassess GRACIDA after his intravenous infusion was (b)(6), (b)(7)(c) completed on July 19, 2011. On October 22, 2011, NP did not opt to see GRACIDA despite complaints of shortness of breath. An RN failed to assess the cardiopulmonary status of GRACIDA. Dr. (b)(6), (b)(7)(c) failed to expedite interpretation of the detainee's EKG by the external cardiology group. ICE PBNDS Medical Care standard, section (II)(7), requires a detainee who needs health care beyond facility resources to be transferred in a timely manner to an appropriate facility where care is available. A written list of referral sources, including emergency and routine care, will be maintained as necessary and, at a minimum, updated annually. On October 24, 2011, Dr. (b)(6), (b)(7)(c) and NP (b)(6), (b)(7)(c) failed to send GRACIDA to the emergency room for evaluation after an abnormal EKG. AREAS OF CONCERN Dr (b)(6), (b)(7)(c) stated the clinic is understaffed, and she badly needs help. According to Health Services Administrator (HSA) (b)(6), (b)(7)(c) a quarter of the population at EDC has chronic care issues. RN (b)(6), (b)(7)(c) noted that the number of detainees requiring a higher level of care is increasing. RN (b)(6), (b)(7)(c) stated there is a staffing shortage at EDC. At the time of GRACIDA's death, RNs were staffed at 75 percent with five vacancies, midlevel practitioners (MLP) were staffed at 83 percent, OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 14 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE and physicians were staffed at 50 percent. EDC has been without a Clinical Director for four of the five years it has been open. Per the present staffing model, RNs are staffed at 95 percent, MLPs are at 83 percent, and physicians are at 50 percent. RN(b)(6), (b)(7)(c) stated sick call encounters range from 80 to110 per day with an average daily population of approximately 1,484 per the DIHS Operations Workload Report dated 10/1/2010 to 9/30/011. Dr. Dr. stated EDC needs a minimum of two additional MLPs as well as a Clinical Director. stated she has been asking IHSC for help for some time now. CC observed Dr. and HSA (b)(6), (b)(7)(c) were concerned about the unfilled vacancies. During the interview with , Acting Assistant Field Office Director (AFOD), the AFOD stated she had been (b)(6), (b)(7)(c) aware of staffing issues since assuming her post in April 2011. CC did not find that staffing levels had any direct bearing on the care provided to GRACIDA; however, CC determined that staffing levels within IHSC at the EDC are insufficient to meet ICE PBNDS, Medical Care, section (II)(29), which requires health care to be provided by a sufficient number of appropriately trained personnel. (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) CC has chosen not to cite EDC as non-compliant with ICE PBNDS Medical Care, section (II)(37), or section (V)(I), requiring translation assistance for non-English speaking detainees. Consensus among staff interviewed was that communication with GRACIDA succeeded, though at a very basic level. A number of staff, fluent in Spanish, communicated with him in Spanish, and the non-Spanish speaking staff attempted to use the Interpretalk translation service, albeit unsuccessfully due to the unavailability of an interpreter able to speak Mixteco Bajo. Apparent cultural barriers that prevented GRACIDA from grasping essential medical processes and concepts added to the complication presented by the detainee's obscure dialect, which has no parallels for certain medical terms. EDC medical personnel stated GRACIDA had difficulty understanding medication issues. ODO and CC conclude that language and cultural barriers were contributing factors in the failure of EDC staff to address GRACIDA's medical needs. EDC management stated that the Interpretalk service employs translators that speak Mixteco Bajo. Given GRACIDA's ongoing, unresolved symptoms, it would have been reasonable to expect EDC to take steps to arrange for a Mixteco Bajo interpreter. However, there is no evidence that this ever occurred. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 15 of 15 1. CASE NUMBER 201201174 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION Exhibit List HB 4200-01 (37), Special Agent Handbook 01- Solano County Sheriff-Coroner's Office Intake Health Screening Form 02- ICE Form I-213, Record of Deportable/Inadmissible Alien 03- EDC booking records 06/10/2011) 04- IHSC Initial Intake Screening Form IHSC-795-A 05- Physical Examination Form IHSC-795-B 06- EDC Medical Records (07/19/2011) 07- EDC Medical Records (07/21/2011) 08- IHSC Sick Call Request Slip (08/05/2011) 09- IHSC Sick Call Request Slip (08/10/2011) 10- EDC Medical Records (08/12/2011) 11- EDC Medical Records(08/15/2011) 12- IHSC Sick Call Request Slip (10/01/2011) 13- EDC Medical Records (10/04/2011) 14- IHSC Sick Call Request Slip (10/05/2011) 15- EDC Medical Records (10/05/2011) 16- EDC Medical Records (10/08/2011) 17- EDC Medical Records (10/11/2011) 18- EDC Medical Records (10/13/2011) 19- LabCorp Laboratory Results (10/14/2011) 20- EDC Medical Records (10/18/2011) 21- EDC Medical Records (10/22/2011) 22- IHSC Refusal Form (10/22/2011) 23- IHSC Sick Call Request Slip (10/23/2011) 24- IHSC Refusal Form (10/23/2011) 25- IHSC Refusal Form (10/24/2011) 26- EDC Medical Records (10/24/2011) 27- IHSC Refusal Form and EDC Medical Records(10/25/2011) 28- CGRMC Physician Progress Note (10/27-28/2011) 29- Tucson UMC Medical Records (10/28/2011) 30- Tucson UMC Medical Records (10/30/2011) 31- Tucson Police Department Report (10/30/2011) 32- ICE ERO Detainee Death Checklist (10/30/2011) 33- State of Arizona Certificate of Death (10/30/2011) 34- Pima County Arizona Autopsy Report (11/01/2011) 35- CC Medical Compliance Review 36- Division of Immigration Health Services Root Cause Analysis Report 37-CC Mortality Review OFFICIAL USE ONLY SENSITIVE 2. REPORT NUMBER 002 (b)(7)e (b)(6), (b)(7)(c) (b)(7)e (b)(7)(E) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(7)(E) (b)(7)(E) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) US. Department of Homeland Security Continuation Page for Form 1213 F?eNumb? (mwanm Event No: [)ate 06/09/2011 WCIDA-CONTE. Pablo Record of Deportable/Excludable Alien: Subject known as Pablo was encountered on June 04. 2011, pursuant to his incarceration at Solano County Jail in Fairfield, California. Subject was arrested for Misdemeanor BEP 25658 (A) SELL ALCOHOL TO MINOR. ALIENAGE ENTRY DATA: Subject is a native and citizen of Mexico. Subject entered the United States of America on an unknown time at an unknown place. Subject was not inspected or paroled by an Immigration Officer. IMMIGRATION HISTORY Subject received a Voluntary Return to Mexico on 5/25/1999. CRIMINAL HISTORY -sap 25658 (A) SELL ALCOHOL TO MINOR Turned over to ICE without prosecution. Subject did not claim to be a United States Citizen. Subject has no affiliation to the US military. Subject has no petitions or applications pending before C.I.S. Subject was advised of his consular rights. states . bject requests to have an Immigration Hearing before an Immigration Judge. RECOMMENDATIONS: SUBJECT is to be processed as a WANTA. 8' am T'tl My re Ie (W6), IHHIGRATION ENFORCEMENT AGENT 2 Form 1-831 Continuation Page (Rev. 08/01/07) U.S. Department of Homeland Security Notice to Appear In removal proceedings under section 240 of the Immigration and Nationality Act: subj 9a: In 3 FIN 30790 DOB: 03/09/1957 In the Matter of: Pablo GRACIDA-CONTE Respondent: currently residing at: Ill ICE CUSTODY (Number, street, city and ZIP code) (Area code and phone number) '3 I. You are an arriving alien. El 2. You are an alien present in the United States who has not been admitted or paroled. 3. You have been admitted to the United States, but are removable for the reasons stated below. The Department of Homeland Security alleges that you: 1. You are not a citizen or national of the United States; 2. You are a native of MEXICO and a citizen of 3. You arrived in the United States at or near UNKNOWN PLACE, on or about unknown date; 4. You were not then admitted or paroled after inspection by an Immigration Officer. 011 the basis of the foregoing, it is charged that you are subject to removal from the United States pursuant to the following provision(s) of law: 212(3) (6) (A) of the Immigration and Nationality Act, as amended, in that you are an alien present in the United States without being admitted or paroled, or who arrived in the United States at any time or place other than as designated by the Attorney General. This notice is being issued a?er an asylum of?cer has found that the respondent has demonstrated a credible fear of persecution or torture. Section 235(b)(l) order was vacated pursuant to: YOU ARE ORDERED to appear before an immigration judge of the United States Department of Justice at: To as 381' (Complete Address of Immigration Court, including Room Number. if any) on a date to be set a time to be set at to show why you should not be removed from the United States based on the (Date) (Time) thargds) set forth above SDDO {Signature and Title of Issuing O?icer) Dale: June 9 . 2011 ammo. on (City and State) See reverse for important information Form [-862 (Rev. 031mm?) Notice to Respondent Warning: Any statement you make may be used against you in removal proceedings. Alien Registration: This copy of the Notice to Appear served upon you is evidence of your alien registration while you are under removal proceedings. You are required to carry it with you at all times. Representation: If you so choose, you may be represented in this proceeding, at no expense to the Government, by an attorney or other individual authorized and quali?ed to represent persons before the Executive Of?ce for Immigration Review, pursuant to 8 CFR 3. l6. Unless you so request, no hearing will be scheduled earlier than ten days from the date of this notice, to allow you suf?cient time to secure counsel. A list of quali?ed attorneys and organizations who may be available to represent you at no cost will be provided with this notice. Conduct of the hearing: At the time of your hearing. you should bring with you any af?davits or other documents. which you desire to have considered in connection with your case. If you wish to have the testimony of any witnesses considered, you should arrange to have such witnesses present at the hearing. At your hearing you will be given the opportunity to admit or deny any or all of the allegations in the Notice to Appear and that you are inadmissible or removable on the charges contained in the Notice to Appear. You will have an Opportunity to present evidence on your own behalf, to examine any evidence presented by the Government, to object, on proper legal grounds, to the receipt of evidence and to cross examine any witnesses presented by the Government. At the conclusion of your hearing, you have a right to appeal an adverse decision by the immigrationjudge. You will be advised by the immigration judge before whom you appear of any relief from removal for which you may appear eligible including the privilege of departure voluntarily. You will be given a reasonable opportunity to make any such application to the immigrationjudge. Failure to appear: You are required to provide the DHS, in writing, with your full mailing address and telephone number. You must notify the Immigration Court immediately by using Form whenever you change your address or telephone number during the course of this preceeding. You will be provided with a copy of this form. Notices of hearing will be mailed to this address. If you do not submit Form EOIR-33 and do not otherwise provide an address at which you may be reached during proceedings, then the Government shall not be required to provide you with written notice of your hearing. If you fail to attend the hearing at the time and place designated on this notice, or any date and time later directed by the Immigration Court, a removal order may be made by the immigration judge in your absence, and you may be arrested and detained by the DHS. Mandatory Duty to Surrender for Removal: It" you become subject to a ?nal order of removal, you must surrender for removal to one of the offices listed in 8 CFR 24]. l6(a). Specific addresses on locations for surrender can be obtained from your local DHS of?ce or over the intemet at You must surrender within 30 days from the date the order becomes administratively ?nal. unless you obtain an order from a Federal court, immigration court, or the Board of Immigration Appeals staying execution of the removal order. Immigration regulations at 8 CFR 241.] de?ne when the removal order becomes administratively ?nal. I you are granted voluntary departure and fail to depart the United States as required, fail to post a bond in connection with voluntary departure, or fail to comply with any other condition or term in connection with voluntary departure, you must surrender for removal on the next business day thereafter. If you do not surrender for removal as required, you will be ineligible for all forms of discretionary relief for as long as you remain in the United States and for ten years after departure or removal. This means you will be ineligible for asylum, cancellation of removal, voluntary departure. adjustment of status. change of nonimmigrant status, registry, and related waivers for this period. If you do not surrender for removal as required, you may also be criminally prosecuted under section 243 of the Act. Request for Prompt Hearing To expedite a determination in my case, I request an immediate hearing. 1 waive my right to a 10-day period prior to appearing before an immigration judge. Before: (Signature ofRerpondenl) Date: {Signature and Title of Immigration O?icer) Certi?cate of Service This Notice To Appear was served on the respondent by me on in the following manner and in compliance with section 239(a)(1)(F) of the Act. in person by certi?ed mail, returned receipt requested Attached is a credible fear worksheet. El Attached is a list of organization and attorneys which provide free legal services. I: by regular mail [The alien was provided oral notice in the language of the time and place of his or her hearing and of the consequences of failure to appear as provided in section 240(b)(7) of the Act. (Signature of Respondent if Personally Served) (Signature and Title of of?cer) Form 1-862 Page 2 (Rev. U.S. Department or Homeland Security Warrant for Arrest of Alien File No. Event: NO: PINS 30790 Date: June 9; To any officer delegated authority pursuant to Section 287 of the Immigration and Nationality Act: From evidence submitted to me, it appears that: Pablo GRACIDA- corms (Full name of alien) UNKNOWN am an alien who entered the Umted States at or near on (Port) Unknown Date is within the country in violation of the immigration laws and is (Date) therefore liable to being taken into custody as authorized by section 236 of the Immigration and Nationality Act. By virtue of the authority vested in me by the immigration laws of the United States and the regulations issued pursuant thereto, 1 command you to take the above-named alien into custody for proceedings in accordance with the applicable provisions of the immigration laws and regulations. (Signature of Designated Immigration O?icer) .. (Print no me of Designated Immigration O?'Icer) SDDO - (Title) Certi?cate of Service Served by me at S?cmor ?13 on at . I certify that following such service, the alien was advised concerning his or her right to counsel and was furnished a copy of this warrant. (Signature of of?cer serving warrant) (Title of of?cer serving wam n_t) Form Io200 (Rev. 08/01/07) US. Department of Homeland Security Notice 0f ClIStOdz Determination Pablo enema-coma Event: No- File No Date: 06/09/2011 30790 Pursuant to the authority contained in section 236 of the Immigration and Nationality Act and part 236 of title 8, Code of Federal Regulations, I have determined that pending a ?nal determination by the immigration judge in your case, and in the event you are ordered removed from the United States, until you are taken into custody for removal, you shall be: detained in the custody of the Department of Homeland Security. El released under bond in the amount of El released on your own recognizance. El You may request a review of this determination by an immigrationjudge. El You may not request a review of this determination by an immigration judge because the Immigration and Nationality Act prohibits your release from custody. (W6), (Signature of authorizedot'?cer) SDDO (Title ot?authorized of?cer) SAW, CA (Of?ce location) I do El do not request a redetermination of this custody decision by an immigration judge. I acknowledge receipt of this noti?cation. (Signature of respondent) (Date) RESULT OF CUSTODY REDETERMINATION 0n custody status/conditions for release were reconsidered by: El Immigration Judge El DHS Of?cial El Board of Immigration Appeals The results of the No change - Original determination upheld. El Release - Order of Recognizance El Detain in custody of this Service. El Release - Personal Recognizance El Bond amount reset to El Other: (Signatureof of?cer) Form 1-286 (Rev. 0810 ?07) =orrn 795-A ICE Health Service Corps Intake. Screening (lHSp 795-A) ?oater ?anen: was identi?ed by {on ch 2 courses}: Arm Band Picture EJJVel-oally . . . . .. E: detainee was transferred :1 another famlny. old a medzcel lransrer summary mpany tne cetacnee7 No . ?re-,9 cf antral in camp. Time of inniai screening. 3 s. i Spanish Other I Name or INT 1: .1 What :anguaae do you sneak? English i Medical Screening co feei tooay" 113! can worosl 1 L: A O. .- I re- ycu currently harlan {my paln" Ves WM: Character of new .2: Location I -o-uyet}. cos-nolete oain assessment helm?- 3c. Durance /'id Inter-arty two pair. scales Be What fell-res :am or makes I: worseyou nave any sugnl?conl mectcal problems? Yes WM: yes. leuglem . . Do you take any medicallpn on a regular nettle including over the counter an: herb l7 {2 Yes ?V?c r25 1:31 meomucns HO 9 o? u?n- 5-: you have any allergre to :noluce allergles to medtcalton or food? Yes M: It yes not medncatmns . are now or nave you-eve? been treated bye doctor-fat a medical oonemon to rncluce hoopltallzanoos? Yes?jko If yes. exclam ,n dove you ever had a pa lent cough for re than three weers. coughed up blooc had a fever. moot Sweats. cr unexplain-e?ch I weight loss? Yes f? If yes. exptam. 311 a Are you pregnant? I: No awn (male) lfyes. date of 9?4 menstrual oen?od-_ :2 Have you had any recemlncute cnartge: with your vision? Yes WM: yes. exolatn -Ow-I?a? -. . . .. I-I- . .- 'l Oral Screening M. a. .. Are you havmg any dental problems? Yes h: yes. exolam f, -- . - - .- -.-Omnrnan-? a. . - . mental Health Screening '12 Have you ever mod to Inlli'yourself'? Ye; y-z-s. When Ola me onenrpl occur? Met-nod I ll attempt was wlutln the lad: 90 days. make referral Immediately and ensure I: - . .-J ?ansma E. "m Cut:an 5km - .4 9:33 Ozrer Are you currently :runlung Pboul lullmg or nan-rung yourself? Yes It Yes. make referral immoolotoly and ensure salary a- ois?qu?q .9 Nate 0 -U - - n-l? - A..- Furs: Name - ?mt.tencnullty . .g l: GARCIA-GOIFE.PABLO 081102011 ELOY Faculty ll 0512911 Page of 3 CM 3 ICE Health Service Corps Intake Screening (IHSC 795-A) (Continued) 3-: mu nave a husmr: :5 assaulung mad-mg othe a: have yet.- ever :een as? up far whzle ar natupnson?) veg I 13:2.- yc; ever teen -.- .asi prism as . 2* yes. men" n; was? 2.1 snack." V95 . Na lfves. mm: :5 :?rss :eman? lou- I 3-. win Rae-n if acmesne'm . 1' ?63. make referral Immodlamw and ensure safety . n? . 1: 529.1 :mngs cr peoale that s:he:s ?1:25 see. sr fel: amers re yes cantata: -E 51- now a: have :warg ?nu fa.- :2 ICE: eve' hear: James ma: ether peome dc-n No 7 "1372 3-39"- 5 31911931 03 have {01.5 :ngrag :r apnanen: reascn'i :1 yes . OII- Hw- - ca. .eer. .cspnahzed for asyafaamc 3330.13lle?mI-C Mn- u- -c ,es. N73: amass30!; me: a :l ph meal :r 591L132 nause'? Yes N: was. emiarr - -II.. .- I I It?- 9 til A, . I we: the: nu are :urreruv, 33:93: :f hem; :hssacau-g 2 sexually assaulted? was, egala 3ssaa:ize.: anyone? 1'95 a . -- ?Ok I .21.: 312were magma; umoona?: to mew aacu: jsur 'a?ngmus at when! beiaefs that we :cnaern desenzzr" 3? 1-35. exglar . - oo-o a our . . - Have 3:22. aver h-?id emits-'35 lea- If yes. exasam . 2mg 3: uncerszar .ng wn?aer. :fomazxcn" (EV-Substance UselAbuse Screening . L?m . . . 43:3..952: beer treated ?cr 1mg 2! aicche. creme-ms a: suffered withdrawal ?an-r. are; use? Yes Me 2? {55? ugh": .. m: ?aw cr have ?es?e' .;sed mme dank slam! at used drugs? yes. cure denim eelow Yes W: 5 1 9165 . . ..-. . . I - v- . I af'?se?? Date Lse .iwfgu?mgenaty Lag gee:feislm am: an berm-era to ccmmunicaticn. I. -- . g: .: spice-345 "awe normal unysdaher-ehzra33:53:: orientedllte :e'rSOr :Fa-z-z an: we . Fanen: app?:st NOT to be onemed .. are. Flag . .. ..-. . .V .. 535' Ina-5e fits: Name12-.- L: 3N3 a 3 I.- Dan-I- .-nn - v-oo - cm .- tare 2? Ar'rea? the.Sar (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) MEDICAL RECORD 2 3 JUN Luau? Amumuw I-uu we?; ?smug. CHRONOLOGICAL RECORD OF MEPICAL CARE entry) iLijfss SCREENING FORM Ar: you curre?} wil. ream. 93' mm threat? YES Efch. how :21 q; c1455? lives. \vhigi: an: prescuz?.? ll 10 OI [11? cough 01? 50?? mmat ass a zever QT Dim fact 30 pruvmcr {Cf further evaluation. UCE FORM i itching viz-A's ilJD nics scalp iEChing I I I cues-rec Rayon: recent hiswry of exposure In others win :rtfl'simi-F nu (J: I-Iiair examined fur lice using . faisuai inspwaim? Ewwc?: isms .. - - . - Inc: {0110ng .c 5 [Maui scale with no signs uI'm-dicuicsis Ftcnizh Maintenance ?iXoaudmonn! mlcn-cmiun required . 1 Lie-.- as per guideliz es and per ?m 2 7; SM: gcperalcd for linen and uniibrm change out UR MEDCAL FACILITY ?54555? 5 we .--, - ans-sauna: emu 3.3.91.3. 9 I Log-?nn-m-rH-I?va? ?rag (W6), T?ums i ms? 1 Ek"s DEhT?cA?ac {For new or warm intuit. sin. Mr- M: ?rst. 0 no or m; an; [Rt-23:315. no (W6), GRACIDA-CDNTE. PABLO 0310911957; MEXICO 9! chm- ?z-nxu?ueh:HacrecLu Sac-v. MEDICAL CARL- F3331 we: I: .f'pa'uu: -HMR ..- 051101201 1 ELOY ICE Health Service Corps Physical Examinatioanealth Appraisal (Continued) Mental Health! Substance PmbIemaIAbueelpevelopmentat l-ltstaory 7 Patient regatta history of Manic annexes El Vlolenoe towards others medicaltons Substance abuse treatment 2 Mental neattn hosoltallzauort l: Sutotde Dmglalcehol 1] actual abuse Drugaraloonol emblems - Severe anxiety :1 Learning difficulttee i: Deh'esaten .r I.- f? Expiam a" A v~ Current Mental Health Issues? Yes No lf yes explain problem and date proble began: ?Jur'enl Stgm?cam Dental Problerns? Yes 52$: 5 It yes, explain problem and date problem began: O: Vital Sign: ("ll Hie, - .1189.-. gamet?it .. .- . General Physical Exam - A. near: [Home . Abnormal Refused Not Evaluated 5; 'wfi Eyes E?oma- Abnormal REE-sad I a Not EJ303166 - at?; E, .laWM'Ears Name: by Abnormal Refused Not Evaluated ?emit?7"" "m Abnormal a {gang Not Evaluated 1 :thraat Abnormal Refused 5 Not Evaluated 5911: Us It: FRI, _Moutt:rl'eelh T: Normal 9 Abnormal Refused Not Evaluated I 3 a 5 Meet Jaime! :l Abnormal Refused Not Evaluatee :Chest :Z'Normet 3 Abnormal I: Refused :g'Not Evaluated longs galore-at 3 Elmonormal Refused Not Evaluated J-iear. Z?nnal Abnormal Refused :1 Not Evaluated tAudemel't ??at-mat '5 ngbnomal [j Refused Not Evaluated Eer?alyRectat Normal 3 Cl Abnormal [j Refused Not Evaluated Normal Abnermaf Refused Not Evaluated 95km ,6 Normal Abnormal Remain Not Evaluated (W6), DETEWON CENTER gawk to? ate 'Turie StampIPnntee Name -. oe?t-ch?n?u- . . . Fuatt'laate 335;. at?" i inate :fCamp ArnvattDCAI - 005 I - . Meow Cum: I- iSexForm 795-8 0312011 Page 2 of 3 i .g . ICE Health Semce Corps ;iPl1ysical Examinatioanealth Appraisal (Continued) Mental Statue Exam (check 5ft bozo: inai apply: -- - .. wu? Mill-E-"? 1-1 A- 0.. up .. -.. Comments She-methi? Patient was, glen and oriented to person. place. and time? Yes yo Normal? {Zines No Perceptual disturbances." Yes t'No gamed llyes ?odrtor; Ha??i?lof?s 3 Visual Hallucinations? {j Deiusmne um - tannearance Weigh: ZNem-ial Obese Overweight Thin Underweign: - _m . Grooming Normal Disheveled :3 Other _m gm meg?; Erec: 5mm balm 13mg; great: .3 Shame a cm Movement martial Tics [j Repetitive Rigid Agitated Slow Other in .- Mood mpfO?e f] Laeite Relaxed [3 Happy Ant-3;" [j SadlDepreseed a FearlullAl-ixious irritanie Other it's?llude Elwproprlate Cooperative Threatening [j Evasive Speech Z'Nonna Coherent fjpressured D?apid germ? Slotted Mumbled [j Tentative Loud Soft Other - ?lnlelligeti-oe Wee? Manual Appears developmentally delayed or mildly retarded good Impaired Poor ii A: exemil'ealth appraisal shows no signi?cent-rnedtcat, menial heailh. or dental issues currently Physical ex 'eallh ahcws the following signi?cant issues . . ,giver} the Saying-geelthy and Clinic and Health Onenlalionel Brochure in patients language Patient was vere?lly gnen instruction on dental nygiene Patient was provided instruction appropriate to detainees heailr needs Patient Verbalized understanding of any teaching or instruction _2 Pattern was if he or she had any questions. and any questions were addressed 3 - - . . . Return to medie?al clinic as needed Return to clinic for openintmeni. Other - - . . BSN RN - -.. Time were; 7 5 liensi Name 13? :aie ol Camp Arrival i 5 553's? Meant 'Citnzc. Eloy Sex - A- IHSC Form res-e 0312011 Page 3 of a I I . Division of Immigration Health Services .i Body Diagram Form 137:: Diagrams as appropnaxe and describe amencr and pasta-nor scars. sruases. conzusmns and baceraucns - . .Orzgm Cam: mr misuse; Can-m; 06/10 jam i. ELOY ?20? SHE Form 802 92908 ?age 1 a! . . . . - 0- .1 .- .cthB-o MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE . 1-. - . - A. EXAM 802 Emaf?kwm?inn-w-mnoon-.im?s 953*. new.? has: lawns?7:0. Tam?"?nousrn? 'sro?m ca. cl Wolm EEqu N2. N: a! 0' Sc: RECSRC Cit" 3.. - .uu smuvau Form 5 -- mmomsjmo kw. 2.1-: cam-54!: at cm: 091012011 MEXICO ELOY RECORD . 0F CARE . IN- IVE..- 3.5: 5.thqjig-1: I . F): RR IEMPLH Health Maintenance . P: Char: to Prnvidcr '1 Hf . 1? I e/ ?Rm' 4:51 a M45 Lw??crLila: ?1 31L W: . .. gJ?aig'Ci?m? fr; ?air??um. 31-21; Chis). I ail-1;. mWaJ. I I. . T. Mug-n ,gL-?u Gigi?4414-64Fiji fad-L?- Wu? ?4 Ifc-?Iu c- .h J?C?i-?ff: ?1&1 I . - 6 fir/iv Iii?!" {1 v? .- LC: 2:43: ram-s: d??'url gen-mu. .u'urrc- Luna .1: GARCIA-CONTE. PABLO I . .. 5-7.1? .. 331E9H35: I .- bxr?wh-Ichu_ -: MEXICO ELDY . .. .. 1,1 - 333353515. .. I I- - .I rFlum A . .. LE: 1 Iq??lel 1' U. h?Ei'C?T?t. . Lg; I. ung 1 12?1 AFDC 1?Ev- Lia-H?! - If L..- -- .Lgi?'rg?niidgL't? in! ELM-ilk and. a I. 351A552- 1-1: 42:? .- ., .. . . .1- ran.? 3C5- 5. 2:anal-.9 Mama.1--. .. . 42;, I- I . 3:511? ELOY Ch?? I '1er (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) C3 IMMIC RTION HEALTH SICK CALL REQUEST SLIP SOLICITUD PARA SERVICIOS MEDICOS - HOUSING 21 mm BR H: Fig.5; .3 3 -- Hit; 0F ARRIVAL. DATE DELLEGADA: jib/.5. Cf FECHA DE HOY: MEDICAL COMPLAINT Hasaes?'p For? MEDICO: - . f9 933:1ch Signature/F igrma; FOR CLINIC USE ONLY DA is - Lu 1 .3 .mrr; DATE SCHEDULED: . SignamreII-?innaz' 1 HEALTH SERVICES (?3510 SICK CALL REQUEST SLH i PARA SERVICIOS NAME I HOUSING UNIT NOMBRE: ?722ALIEN DOB: I) DATE OF ARRIVAL DATEMEDICAL COMPLAINT ?75 Sci/1:! 7" 1" are? i DE 35'} 9.3.FORCLINICUS ONLY . 7 - DATE RECEIVED: i . DATE-SCHEDULEDX) A ?i . Lg DATE 1 .. . A . -AI. .1 I -A eacr: entryan: .lxii ?(val-l.) '1 . (1 refIt. fine/~31 {1451? . . . (anf?lf" (/11 I L?jrt? r: (ting-?l 4 q. . I I anuLiz-?7?- 4/ Li! in? (Ii(Li-.11c7?- 34,- I hid-"W UD I'lm f\ s?mmnn FORM 500 men. SACK - u- REIRCSLICT .ah MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE DAT: aacn carryPresents for clinic 1 vigil r2: 5390:139? ?R?v 1? RR l?uin a 1n i A: Health Maintenance "Ac. P: Chart to Provider 5. "Han ETATLJS IDEPART Jul?m?thH-T :i M111: MU. I: q. as. pvt. fu'd?ld - as: or 5:31 Lat: +1335? h: GARCLA- HTE. PABLO cnaouomszcu HECGRD 0F cane Monica! Human: STANDARD FORM 505 mn- Lag-:- I'ne-cuac: :rv 55.1.1534? FEAR M1 CPR: 251-1132? 1'35? 963105101 1 DATE DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry) ED FROM PREVIOUS PAGE P: to Clear order "Mark "it" In ifwriting an order II I APPOINTMENT: I LAB: 1 NURSING: NURSING: i a . it; OTHER: . ?4 . Edhcated Patient RE: 5 - _!_Assessment and Plan of Care Provider Signature _;Name. Purpose, Use a. Side Effects of Medication lug": EngIIsh Spanish_0ther I Ingerpreter 8 lntlerpreter On-Slte Name: Provider Stamp Payout Verbalhes understanding of above cw?: STANDARD FORM and M. 5.97; ants . .u _aa?mpjo: Imr?z 9590: 9% mmOCmma man wetn?cu up?? ngnOm . - . .4 an. up no?? lxocm?zm pmm?zamz? n. - r. I. Pu 6:9. 6:23 Em om .u 4.9.3. i am cm FmopmmEmma? noznrz? 1:32 3, En; m. 3039,3535? turn?at. up: ?but hit; by. On n7. 35.9. 01w mOmnEzzu Cmm02r< .nxsu. .L x: Q?m mnlmucrmma .il. Q?m now?wmme J. .. .. .uim mmnm?mo 2m! .. _a . .1 . - 4" "Laura. .'(zr'thL'uC. aa- CPEONOLQGEAL RECORD OF MEDICAL CARE - - ve- -- MEDICAL RECORD: gn cam . DamsDetainee Idenn?cd by: SQ Name?! Date 0: 13111}: LE Picture ngAhen Rumour - . -.-- .Ll-?b 3 cv \1'd Is ?no Inn" Lilli-L": 1 r3.ql? "nnin? aw? 1 nu-lun13252-.. --.. .. HutII- C-JI. I Inn-l", 1-. . Il?q"_ a quHH $254-4: -le? I .. -.- I - .at??niaSV?l-" . . L. x-v?Ivdih- I 3" 1 1 A- vl'h I-l - -- fl-Jun-Egg Ad - -- uh-H?I-o .- 1? - .3..- - - . - 7 Non-moduc?ve .- I I Red flag? in refer tn [Wm-Eden Drmiing m- ;1 never" headache . i312- . 1. - - -. .2431 v-j (Continued un back} [math-'5 - r.-haw; . [332:3 x: TL: :29 mm .A'rL-s ?nal a sud-Tan alarms. one- Wrm- as; rr?Hciu; .D #m $3 I: 54:. 59- N: "32.13: v: Jr? :?hrrn' GAECIA-CCNTE. OAELO 5-: ?#35195? I: . gain-9:? I I 2 2'1: . . Ed. 1.. . . 93 two .23 23.3 .- 228,35 - um. Fame; .19 ZONIH you: mauzwh . . .. ..Ibl.unarhrhuLuUHU . . a ..Ilntilildl Il??ilun) .I .141. I I.II. i . .1. .qu3d I . . I.n. ll. .dli .I-I. .II . tidall . .I II I . Illrul . into-.1 an?, a . . Lt?: inc?lntii (I . . .. whluru?rhn." ..I?lnll . all.lliaJI. ..hul. ..J.. ..IIJ .- ll . "v.71. 1. - ?Ibqu 31.1..h?wlf. . .. -4. HINT: ill I . . - I.I-t: I. InQatari-.. .. l. Irv]! I1. I..fnw. VI ?uru?ujov! r-I-l. . . . ..I.. . I..JJMIJIH . . . . 1.. [Irvowl-0' 1 I'll--.. - . . -uu mrn; . u. in. .. 33m nmsutuon: - Es. mmTlre ICE Of?ce of Policy shall provide a copy of the media release to nongovernmental organizations (NGOs) via the eo-chairs. consulate has been noti?ed of a detainee?s death but the next-of-kin have not been located yet efforts to locate them continue, noti?cations to Congress. the media or NGOS shall include information that efforts to reach next-of-kin are ongoing. ONCOING REPORTING REQUIREMENTS. 8.2. Detention Management Division. Upon the death of a detainee in a detention facilitx, the BRO Assistant Director for Management (ADM) shall require: ?i?lrne Person making Status Date: Time: Zone: Noti?cation: Person Noti?ed: ?Mn coordination with OPR, an internal review of all facility inspection records for the detention facility at which the death occurred. review of all contract documentation for the detention facility where the death occurred. @If the death occurs at a medical facilig or while the detainee is Emit, the ADM shall require such review at the facility where the decedent was last held in custody. U.S. IMMIGRATION AND CUSTOMS ENFORCEMENT DIRECTIVE TITLE: NOTIFICATION AND REPORTING OF DETAINEE DEATHS INDIVIDUAL INCIDENT CHECKLIST b) The ADM shall submit the records within 14 calendar days of the death of the detainee to: Time Person matting Status: Date: Time: Zone: Noti?cation: Person Noti?ed: ICE senior management OPR for inclusion in mortality review CRCL 010 (if the investigation is being conducted by the 016). c) The ADM shall provide autopsy and toxicology results (if applicable), a copy of all treatment authorization requests (TAR), a copy of the death certi?cate and all other relevant documents state and local law enforcement investigatory information), as soon as they become available to: Time Person making Status: IDate: Time: Zone: Noti?cation: Person Noti?ed: I OHA for inclusion in Ol-lA?s mortality review CRCL 016 (if the investigation is being conducted by the 010). (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) PAB LO GRACIDA-CONTE MI. 1 1.02140 REPORT PIMA COUNTY. ARIZONA TUCSON POLICE DEPARTMENT I "0300218 I NOVEMBER 1.2011 Page]- ML [-02 I40 Re: PABLO Page 2 DIAGNOSIS: l. Cardiomyonatlty OPINION: In consideration or the circumstances surrounding his death. a review of the medical records. and external examination of the body. the death of this adult male. Pablo Oneida-Cattle. is ascribed to cordiomyolaothy. MANNER: Natural. (W6), DI). Forensic Pathologist (W6), ML 1 I-02l40 Re: PABLO Page 3 MEDICOLEGAI. OF DEATH: The deemed is a 54-year-old male inmate who was taken to the hospital and subsequently expired. He was at the scene by Dent 0442 on hours on October 30. ZOI l. The postmortem examination is periitnued under the authorization of the Pima County Medical Examiner's (mice. IDENTIFICATION: The body of Pahla is identi?ed by Department of Corrections' staff. 3 MI. I [-02l4tl Re: PABLO Page 4' EXAMINATION 0F 'l'HIi Al 'l'he postmortem examination of l?ahlo is performed at the Forensic Science Center. 2825 l5. District Street. Tucson. Arizona conttnencini at I445 hours on November I. b) 6), 20l I. Assisting in the examination are I and (mm) GENERAL INSPECTION: The unclad. uncmbalmed body is received in a body hag. CLOTHING AND PERSONAL None. EXTERNAL RIit?liN'I? MEDICAL 'I'l I) Protruding limit the mouth is an cndotmcheal tube which is held in place with tape. 2) Protruding from the right side of the neck is an intravaseular catheter. 3) Iincireling the leli wrist is a hospitl identi?cation tug labeled ?Pablo 4) Protruding front the left anterior wrist is an intravuseular catheter which is held in place with tape. 5) 0n the Ieli posterior hand is a who puncture whiclt is em cred witlt gauze. 6) Eneircling the right wrist is a hospital identi?cation tag labeled "Pablo (iracida-Conte". 7) 0n the body there are electrocardiograms leads. 8) from the right ntedial amt is an intravascular catheter which is held in place with tape. EXTERNAL The body is that of a normally-developed. adequately-nourished ntediunt-complected male measuring on inches and weighing Ill-l pouttds. The body is cold to the touch. Rigor mortis is present to an equal extent in all joints. l-?ised lividity is developed posteriorI}. Head and Neck: The head hair is black with the longest hairs measuring 2 cm. The eyes are closed. The irides are brown. The pupils are symmetrical. 'l'here are no petechial hemorrhages present. The bony structures of the nose are intact. The face is unsltaven. The teeth are natural and in good repair. MI. I l-02140 Re: PABLO Page 5 The cans are symmetrical. The neck is free of trauma and the trachea is in the midline. Trunk: The chest is symmetrical. The abdomen is flat. The external genitalia are that oh: male. The testicles are descended bilaterally. 'l'he pubic hair is black and normal in distribution and amount. The back and buttocks are not remarkable. Extremities: The upper extremities are symmetrical. 'l'he ?ngernails are medium in length. The lower extremities are symmetrical. 'I'he toenails are short. IDENTIFYING SCARS. MARKS. None identi?ed. EXTERNAL EVIDENCE INJURY: None. INTERNAL-EXAMINATION: Nut perfomted. (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) A a 4:30 In RN (bus), discontinued the detainee received 600 cc of Normal Saline; blood was drawn as ordered; and the detainee was released to return to his room. New orders for pill line medications were transcribed. COMMENT: The detainee was not reassessed before he was sent back to his room, two hours and 45 minutes after receiving IV ?uids and last vital signs check. Because detain was returned to general housing without being reassessed, CC cites non-compliance with ICE Medical Care, section requiring that detainees? ?health care needs will be met in a timely and ef?cient manner.? July 21, 201 1 11:45 am . Progress Note documents Dr. (bra). reviewed the results of the lab tests previously ordered, though there is no documentation of a patient encounter. She noted 12.9[While Blood Cowu. with normal being 4-10. Neutro 81[Nentropils with normal being 40-74], BS ?102 [Blood sugar with normal being 65-99j.? Her assessment was ?deferred;? her plan was ?as schedule.? Other tests results out of the normal range were as follows: 0 Absolute neutrophils were 10.4 (normal range is I .8-7. 8) . AST (SGOT) was 42 (indicator of liver damage; normal is 0-40) All other tests were within normal limits (WNL). August 5, 2011 Sick call slip was submitted in Spanish requesting reading glasses. Per the medical record the sick call slip was received on August 6, 2011, and he was seen by RM on August 8, 201 1. COMMENT: It is assumed this and subsequent sick call requests were written by other detainees on behalf, given his documented inability to write. All sick call slips case were reviewed for compliance with ICE Medical Care, section which requires sick call health services requests to be received and triaged within 48 hours after submission. Compliance is met. Upon interview, RN stated she gave the detainee a simple reading test to determine the level of magni?cation he wo need. She did not obtain an interpreter because the testing sheet was written in Spanish, though she stated she would have called the Interpretalk translation service if needed. ?He verbalized understanding in Spanish of process to return reading glasses.? August 10, 2011 The detainee submitted a sick call slip in Spanish complaining of no appetite and stomach pain. It was received on August 11 2011 and detainee was seen on August 12, 2011, by RN The medical record documents, ?Detainee presents of not having appetite; States he eats very little at meal time for one year now; Detainee states he worked doing heavy lifting and since has lost his appetite." Vital signs were as follows: 0 Temperature- 98.3 0 Blood pressure -11 1/72 DETAINEE DEATH REVIEW: Pablo Page 5 Section 1 - Medical Compliance Review Creative Corrections. LLC f" 0 Pulse- 39 taken with machine (heart rate is lower than the previous 60); 60 when retaken manually (normal lower range] COMMENT: The discrepancies between the pulse rates determined by machine and the manual pulse rates of 46, 42 and 39, respectively, should have prompted evaluation of the accuracy of the blood pressure machines, procaiures for taking manual pulse rates, and follow-up protocols. The detainee denied dizziness, nausea or vomiting, and only complained of loss of appetite. The weight scale was unavailable, so referred him to the clinic for a weight check in one or two days to compare current and past weights. Signi?cant change would result in referral to a provider. August 15, 2011 Detainee presented to the clinic for a weight check. Licensed Practical Nurse (LPN), documented vital signs as follows: Temperature- 98.4 Pulse- 52 (low) Blood pressure- 102/55 (low) Weight-108.3 (an increase of 1.5 pounds since July 19. 20]] reading) The note was signed by Dr. same but not dated. October 1, 2011 A sick call slip submitted in Spanish indicated a cold with cough, fever, headache and inability to sleep. The sli was received on October 3 and the detainee was seen on October 4, 2011 at 11:?uent in Spanish. The Nursing Guidelines form used by nursing staff as protocols for Sick Call noted congestion, runny nose and sore throat for two days. His throat was red; he had a productive cough with clear sputum. His pain was scored three of ten. Vital signs were as follows: 0 Temperature- 98.5 0 Pulse- 100 (Per RN Garcia it is not uncommon to have an elevated pulse rate with an upper respiratory infection.) a Blood pressure-1 14/63 (increase ?'om the previous reading but low) Per the Nursing Guidelines protocol, the detainee was given Chlorpheniramine maleate 4mg (relieves of the common cold) every 4-6 hours as needed and Tylenol 650 mg every four hours as needed; follow-up as needed. The detainee ?verbalized understanding of instructions.? october 5, 201 1 Detainee submitted a sick call slip in English complaining he had no appetite for the last three weeks and when he did eat, throw up.? ?Can you please help me?? DETAINEE DEATH REVIEW: Pablo Page 6 Section 1 - Medical Compliance Review Creative Corrections. LLC (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) October 8, 20 11:30 am Medical record entry by RNdocumented she saw detainee after he was sent to the clinic by the pod of?cer with burning abdominal pain and vomiting not relieved by medication. He stated he had a decreased appetite and denied blood with vomiting. The vital signs as follows: 0 Temperature-97.6 0 Pulse- 53 (low) 0 Blood pressure-109169 (low) 0 Weight-109.6 (a 3. 6 pound weight gatn?'om October 5. 20] 1) Upon examination she noted ?pain with pressure over epigastric region; pale, sallow color.? His pain severity was rated ten of ten. 3:30 -m were referred the detainee to NPor evaluation and treatment. Per interview with NP a correctional of?cer called the clinic to report detainee was ?vomiting after every meal.? ?Dif?cult translation as does not speak English or much Spanish? was noted. She attempted to obtain an interpreter, however had been told the detainee only spoke the native dialect of Masteko Bajo (Mixteko), and there were no Interpretalk service translators available at the time. Instead, she used an Interpretalk Spanish interpreter to ?speak Spanish slowly.? She noted that something was de?nitely lost when trying to communicate over a speaker phone and that the detainee kept putting his hands on his mouth. Through the interpreter, the detainee stated that ever since he came to ?this place the food does not agree with me. food is damaging my stomac She remembers all he wanted to talk about were tortillas saying tortillas and meat were the only things that didn?t hurt his stomach. He vomits once a day, but is nauseous after all food. He denied blood in his vomit or stool. He stated his pain was ten of ten, but that he did not appear to be in a signi?cant amount of pain at the time as would be exhibited by objective signs such as grimacing. COMMENT: As noted in the Nursing Guidelines protocol form, signs of pain such as grimacing can be culturally linked. Therefore, the detainee may have been experiencing a signi?cant amount of pain, but his cultural background may have prevented him from showing it. NP documented the detainee was a ?thin male, appears older than stated age.? She remembers his examination was essentially negative, including a normal heart auscultation as documented in her medical note. Her assessment was nausea and plan was as follows: - Labs 10-11-2011 0 CBC (Complete Blood Count) 0 CMP (Comprehensive Metabolic Panel) 0 H. Pylori (test to determine the presence of the bacteria that can cause peptic ulcers) 0 Urinalysis Bland diet DETAINBE DEATH REVIEW: Pablo Page 8 Section 1 - Medical Compliance Review Creative Corrections, LLC Discontinue previous Metoclopramide order 0 Replace above order with Motoclopramide 10 mg three times daily before meals via pill line (call up with diabetic patients). ?Patient verbalizes understanding of above? per standardized block entry. October 11, 2011 Bloodwas drawn for lab tests. October 14, 2011 8:59 am (Note: Per interview, entry was incorrectly dated October 13, 2011 in the medical record.) Detainee presented to the clinic as a walk-in for headache, nausea and vomiting and abdominal pain. He was checked in by RNRN who upon interview, stated her ?rst language is Guatemalan. She reported she spoke to the detainee in ?purely Spanish,? and ?not for one second did 1 think he didn?t understand.? RN \bxe). documented the detainee complained of epigastric pain that does not let him sleep for duration of one month. He has a poor appetite and sometimes vomits when he cats, and has diarrhea in small amounts times a day. A UA dipstick was done with results WNL except: Protein 30 mg/dL; Bilinibin moderate; and color dark amber. El remarked during interview the detainee ?looked color was odd.? CO who interpreted for RN lye), (owl stated the detainee ?always looked pale.? His vital signs were as follows: Temperature-97.6 Pulse- 77 Blood pressure-l 17/81 Weight-109.9 [a .3 pound weight gain ?-om October 8, 201]] The detainee was referred to the provider. Lab results received and signed by provider. The CBC, CMP, and Urinalysis, were all WNL except as follows: Test Result Normal Range RDW (Random Distribution Width) 15.5 (High) 11.7-15.0 Glucose 103 (High) 65-99 Creatinine 1.34 (High) 0.76.1.2? Carbon Dioxide 19 (Low) 20-32 Protein 5.9 (Low) 6.0-8.5 Albumin 3.0 (Low) 3.5-5.5 AIG Ratio 1.0 (Low) 1.1-2.5 AST (8601') 41 (High) 0-40 Urine Appearance Turbid Clear Protein 1+ (Abnormal) Negative -- DETAINEE DEATH REVIEW: Pablo Page 9 Section 1 - Medical Compliance Review Creative Corrections. LLC Trace Present NIA More than 8 0.0-0.8 1.23 0.00-0.88 0.86 0.00-0.79 10:00 am NP evaluated detainee She stated in interview she was ?90% ?uent in Spanish? but would call a translator if needed. She felt there was ?total understanding? both ways. Detainee stated he had not felt well for two months and ?appeared chronically ill.? He had no appetite, and had nausea and pain level of eight/ten which does not let him sleep. She said, ?All he wanted was chili relenos and tortillas." He reported having used alcohol daily for ?ve years but had none since 2009. performed a ?focus exam? of the abdomen because of his presenting The medical record entry noted his abdomen was soft with tender epigastric and left midquadrant hyperactive bowel sounds; weight was stable; lab results were reviewed with the detainee. Her assessment was abdominal pain; diahrrea; H. Pylori positive; abnormal labs. She added in interview that she was looking speci?wa at the RDW which was high and would indicate anemia; the platelet count, which would identify liver issue, was normal; the creatinine level was elevated, possibly indicating the kidneys were not working properly; there was protein in the urine; and the detainee was positive for H. Pylori bacteria. She would prescribe a two week regimen of the triple therapy Omeprazole and antibiotics to eradicate the H. Pylori bacteria. NPplan was documented as follows: Metoclopramidc discontinued due to increased creatinine level Change Ranitidine to Omeprazole 20 mg twice daily for 14 days, then once daily Clarithromycin 500 mg twice daily for 14 days Amoxicillin 1 gm twice daily for 14 days Encourage ?uid intake Check mine microalbumin/Creatinine ratio Follow-up next week The results of the ordered urine check for microalbumin/Creatinine ratio were WNL except: Microalbumin, 51.2 (normal is and Microalbumin/Creat Ratio, 40.3 (normal is 0.0- 30.0). The elevated results could be an early indication of kidney failure. The medical record documented ?[Patient] verbalizes understanding of above.? October 18, 2011 10:40 am conducted a follow-up lab review with detainee She stated, on interview, he looked better, was hungry and had no nausea, vomiting or diarrhea. His abdomen was not tender. His vital signs were as follows: DBTAINEE DEATH REVIEW: Pablo Page 10 Section 1 - Medical Compliance Review Creative Corrections. LLC (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) October 25, 2011 6:30 am Detainee re?ised to come to pill line for his Omeprazole and refused to sign a refusal form. 3:15 pm The detainee presented to the clinic for follow-up after court as ordered. His vital signs were as follows: Temperature-97.5 Pulse- 74 Blood pressure-l 07/77 Respiration-16 Sa02 97% Weight-112.4 Pain level 4/10 Medical record documentation by NP noted the Maalox helped the detainee?s heart and let him sleep, but the pills make him worse. He did not want any more of the Omeprazole pills; feels ?short of breath" and needs to rest; denies chest pain but is dizzy; thinks he may leave tonight or tomorrow. During interview, NP stated she could tell detainee ?was in failure? as soon as he came to the clinic after court. He couldn?t talk ?without stopping to breathe? and was ?dizzy.? He said the Maalox helped but the pills made him worse; she observed his color was gray; he had 2+ pitting edema (observable swelling that pits when pushed in and persists caused by ?uid accumulationjon both lower extremities; and his apical pulse was irregular. 3:26 pm Another ECG was performed with the following results: 0 Sinus with occasional premature ventricular complexes and possible premature atrial complexes with aberrant conduction Possible left atrial enlargement; Rightward axis Pulmonary disease pattern Septal infarct age undetermined wave abnormality, consider lateral ischemia Ventricular rate-96 Abnormal EKG Additional ?ndings on examination re?ect the detainee?s skin was warm and dry and gray in color; breath sounds are clear upper lobes; diminished in bases right less than le?; apical pulse irregular; EKG abnormal; abdomen soft with tenderness around the umbilical cord and with no guarding or rebound; clubbing of ?ngernails present. Her assessment was questionable my; DETAINEE DEATH REVIEW: Pablo Page 15 Section 1 - Medical Compliance Review Creative Corrections, LLC a Conestive Heart Failure, cardiac or pulmonary issues. Her plan indicated consultation with Dr. ammo} and transport to the emergency room via ambulance. COMMENT: This is the ?rst observation of clubbing documented in the medical record. '7 :00 pm Detainee was admitted to Casa Grande Regional Medical Center Per report from the hospital diagnosis was ?abnormal abdominal pain; rule out cholecystitis (in?ammatlon of the gallbladder); plural effusion possible in?ltration (excess ?uid that has accumulated in the lungs) cardiomegaly (enlarged heart). October 27, 2011 Per report from the Intensive Care nurse at detainee was ?more stable.? A CAT scan and Echocardiogram were done earlier. ?The provisional diagnosis is now Chagus Disease.? COMMENT: Per the Mayo Clinic, Chagus Disease is ?an in?ammatory, infectious disease caused by a parasite found in the feces of the triatomine bug commonly found in the rural areas in Mexico, South and Central America ?It is most often diagnosed in children and ?if left untreated, it can cause serious heart and digestive problems.. ..Signs and of the chronic phase may occur 10 to 20 years a?er initial infection or they may never occur.? The of the chronic phase are as follows: Irregular heartbeat In?amed enlarged heart Congestive heart failure Sudden cardiac arrest Dif?culty swallowing due to enlarged esophagus Abdominal pain due to enlarged colon October 28, 2011 Detainee was airli?ed to the University Medical Center (UMC) in Tuscon for a higher level of care due to the complexity of his cardiac issues. Per UMC medical record, the detainee was admitted to the telemetry unit. Noted by the resident was the patient is ?Full Code.? October 29, 201 1 9:20 pm UMC medical record documents an emergency response with successful de?brillation. October 30, 2011 12:57 am Detainee was transferred to the UMC Intensive Care Unit where he com lained ?he can?t take a doe breath.? DEATH REVIEW: Pablo Page 16 Section 1 - Medical Compliance Review Creative Corrections. LLC A -- - - 7. 3:38 am (m Per UMC MR advanced cardiac life support efforts were initiated with multiple de?brillations, intubation, emergency drugs and cardiopulmonary resuscitation. 4:42 am Detainee expired. Per the death certi?cate, the Immediate Cause of Death was cardiomyopathy. Per interview with AFOD she has good communication with HSA we), was apprised of detainee hospitalization and death. She also stated she was aware a postmortem examination was to take place. The Supervisory Detention and Deportation Of?cer noti?ed the family. All other appropriate noti?cations were made by Immigration and Enforcement Of?cers. November 1, 2011 2:45 pm An autOpsy was performed by the Pima County Medical Examiner?s Of?ce. Per the autopsy report, ?In consideration of the circumstances surrounding his death, a review of the medical records, and external examination of his body the death of this adult male Pablo Gracida- Conte is ascribed to cardiornyOpathy.? An internal examination was not performed. COMMENT: CC notes the external examination perfomied during autOpsy noted, ??ngernails are medium in length.? There was no mention of clubbing of the ?ngernails. MEDICAL COMPLIANCE REVIEW CONCLUSIONS The ICE Medical Care, ensures that detainees have access to emergent, urgent, or non- emergent medical care so that their health care needs are met in a timely and ef?cient manner. CC ?nds that EDC failed to comply with this standard. As discussed in the above timeline, de?ciencies were found in the following: 0 ICE Medical Care, section (II) (2) requiring that detainees? healthcare needs be met in a timely manner. 0 At the time of the physical examination We), to re-take the pulse apically or consult a provider when the detainee?s heart rate was found to be 46. 0 After the detainee?s infusion was completed on July 19, 2011, he was not reassessed before sending him back to his room. 0 NP refused to see the detainee even though he came to the clinic complaining of shortness of breath on October 22, 201 l. The RN failed to assess the detainee?s cardiopulmonary status despite complaints of shoMess of breath on October 22, 2011. 0 Dr. (taxes), ll ailed to expedite interpretation of the detainee?s EKG by the external cardiology group. a (Wk i DETAINBE DEATH REVIEW: Pablo Page 17 Section 1 - Medical Compliance Review Creative Corrections. LLC (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) m, CC concludes language and cultural barriers were contributory factors in the failure of BBC staff to address detainee medical needs. Though unavailable for two medical encounters, CC was informed the Interpretalk service does employ translators in the Mixteko language. Given his unresolved, ongoing approximately four months in duration, BDC should have taken steps to arrange the availability of a Mixteko interpreter to bridge the cultural gap. . -- DEATH REVIEW: Pablo Section 1 - Medical Compliance Review Creative Corrections, LLC (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) .n P?s October 28, 2011 . Detainee was airlifted to the University Medical Center (UMC) in Tucson to receive a higher level of care due to the complexity of his cardiac condition. October 30, 2011 Detainee was transferred to the UMC Intensive Care Unit where he complained ?he can?t take a deep brea The detainee's medical condition became unstable and a code was called. The detainee was de?brillated (shocked); intubated (arti?cial airway inserted), and expired. November 1, 2011 An autopsy was performed by the Pima County Medical Examiner?s Of?ce. Per the autopsy report, ?In consideration of the circumstances surrounding his death, a review of the medical records, and external examination of his body, the death of this adult male Pablo Gracida-Conte is ascribed to cardiomyopathy.? An internal examination was not performed. Findings 1. LanguageICultural Barrier: Staff interviews revealed detainee spoke Mixteko, and dialect of Spanish spoken in rural Mexico. He reportedly did not read or write Spanish. Medical encounters were conducted by or through Spanish-speaking staff who indicated they believed they were able to communicate at a very basic level. Non- Spanish speaking staff reported they attempted to use the Interpretalk language service which does employ translators who speak Mixteko; however, interpreters were not available. Beyond the language barrier, Creative Corrections was made aware evidence of a cultural barrier was apparent, further interfering with successful communications and possibly contributing to failure to properly treat the detainee. According to the HSA, Interpretalk interpreters may serve as ?cultural brokers? as well as translators. Use of lnterpretalk for this purpose should have been arranged to assure effective, complete and accurate communications, particularly as the detainee?s condition worsened. 2. Inspection of Equipment: There was a considerable discrepancy in results when the heart rate was taken manually (60) versus by way of an automated blood pressure machine which also checks for heart rate (39). This warranted an instrument inspection and a review of provider training to validate the accuracy of the heart rate when manually checked. It is unusual for these readings to vary by this degree. 3. Documentation and Health Records: 0 There are discrepancies in the detainee?s date of birth as documented in the EDC medical record, the detainee?s sick call slips, and the UMC medical records. It is possible the dates of birth reflected on the sick call slips were inaccurate because other detainees wrote them on behalf of detainee though that is not documented in the record. His year of birth on the slips ranges from 1957 to 1971. Section 2 - Mortality Review Creative Corrections LLC It is customary and necessary for medical providers to sign and date medical records upon review. There were entries in the medical records that were stamped and initialed as being reviewed; however, the date is not documented. 4. Timeliness and Quality of Care: a Dr. failed to schedule a follow-up appointment for the detainee after receiving abnormal lab results which might have indicated an acute intraabdominal infection may be ensuing. An appointment with the physician should have been scheduled instead of documenting a ?follow-up as scheduled?. CAPT NP ne 2 lected to evaluate the detainec?s complaint of being short of breath. Instead, NP gave a verbal order to ?increase ?uids, continue meds, and refer to NP for follow-up next week.? The complaint of shortness of brea necessitated a thorough physical exam, possible chest x-ray and labs. Frequently, an appropriate evaluation for shortness of breath will also include an EKG to rule out the possibility of cardiac disease. 0 An abnormal EKG was faxed to a local cardiology group and was not identified as ?urgent? which resulted in the interpretation being received by BBC three days later. - Providers failed to properly assess and follow up the urine abnormalities which were consistent with liver and kidney dys?mction. Indicators for the detainee having cardiac disease were not identi?ed: 1) recurrent low heart rate, 2) persistent weight gain, 3) shortness of breath, 4) an elevated RDW (abnormality in the shape of the red blood cells which might indicate a risk for cardiovascular event), and 5) an abnormal EKG. - The detainee?s medical record continually documented a recurrent, potentially life threatening, low heart rate which should have prompted an urgent cardiology consultation. An echocardiogram would have been of bene?t to assess a baseline cardiac ?mction of the detainee?s heart. Conclusion: The detainee arrived to BBC on July 10, 2011 with no known documented signi?cant past medical history. He was not taking any prescribed medications. He voiced no medical concerns which would have necessitated further evaluation on arrival, though the initial intake physical form documented a low heart rate. This abnormality was not identi?ed by the provider as being a concern which usually requires further evaluation. Subsequently, the detainee presented to the clinic on numerous occasions with various and a documented very low heart rate. This ?nding did not prompt the providers to refer the detainee for appropriate outside consultation cardiology) in an attempt to identify the cause(s) for this recurrent abnormality. Also, various cardiac risk factors and/or markers were not identi?ed by providers which indicated the detainee was at a high risk for having a cardiovascular event. The detainee?s cause of death per autopsy report was cardiomyopathy which is a deterioration and enlargement of the heart muscle. If the providers. including the staff physician, would have provided the appropriate medical treatment in a timely manner, the detainee?s untimely demise might have prevented. DETAINEE DEATH REVIEW: a I. I Pe Section 2 Mortality Review Creative Corrections LLC A A. Therefore, it is my professional opinion that the detainee did not receive appropriate and medically acceptable medical care while con?ned at BBC. Dr. MD Creative Corrections, LLC ETNEE DEATH Pablo GCIDA-CONT I. Pe Section 2 - Mortality Review . Creative Corrections LLC