OFFICIAL USE ONLY SENSITIVE Page 1 of 21 DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION 2. REPORT NUMBER 002 HB 4200-01 (37), Special Agent Handbook 3. TITLE Mandza, Evalin Ali/Unknown/0108 Death-Detainee/Alien (Unknown Cause)/AURORA, ADAMS, CO 4. FINAL RESOLUTION 5. STATUS Closing Report 6. TYPE OF REPORT Detainee Death Review 7. RELATED CASES 8. TOPIC Detainee Death Review of Evalin MANDZA 9. SYNOPSIS On April 12, 2012, the Joint Intake Center, Washington D.C., received notification regarding the death of U.S. Immigration and Customs Enforcement Detainee Evalin Ali MANDZA. MANDZA, a citizen of Gabon, died on April 12, 2012, at the Aurora Medical Center South, in Aurora, Colorado. The treating physician, Dr. (b)(6), (b)(7)(c) reported MANDZA died of anterior myocardial infarction, and severe left main coronary artery stenosis. On April 17, 2012, the U.S. Immigration and Customs Enforcement, Office of Professional Responsibility, Office of Detention Oversight, initiated a Detainee Death Review of MANDZA'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)-Houston 16-OCT-2012 Supervisor (b)(6), (b)(7)(c) 11. COMPLETION DATE - ICE-OPR Special Agent 13. APPROVED DATE 15. TELEPHONE NUMBER 16-OCT-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 21 1. CASE NUMBER 201207288 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 April 12, 2012, the Joint Intake Center (JIC), Washington, D.C., received notification regarding the death of U.S. Immigration and Customs Enforcement Detainee Evalin Ali MANDZA (Alien Registration Number (b)(6), (b)(7)(c) . MANDZA, a citizen of Gabon who was born on December 5, 1965, died on April 12, 2012, at the Aurora Medical Center South (AMCS), Aurora, Colorado. MANDZA was 46 years old when he died. At the time of his death, MANDZA was in U.S. Immigration and Customs Enforcement (ICE) custody at the Denver Contract Detention Facility (DCDF) in Aurora, Colorado. DCDF is an ICE contract facility owned and operated by The Geo Group, Inc. (GEO). Detention space at DCDF is solely dedicated to the accommodation of adult ICE male and female detainees of all security classification levels for periods in excess of 72 hours. DCDF has a detainee capacity of 1,116. The average length of stay is 26 days. Medical Care at DCDF is provided by GEO. DCDF is accredited by the American Correctional Association and the National Commission on Correctional Healthcare. The Office of Enforcement and Removal Operations (ERO), Field Office Director, Denver, Colorado (FOD Denver), is responsible for ensuring DCDF compliance with the ICE Performance Based National Detention Standards (PBNDS). An Assistant Field Office Director (AFOD) is stationed at DCDF and oversees ICE operations at the facility. (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) On April 17, 2012, Special Agent (SA) and SA , assigned to ICE, Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO), initiated a Detainee Death Review (DDR) regarding the death of Detainee MANDZA. SA (b)(6), (b)(7)(c) and SA (b)(6), (b)(7)(c) were assisted by registered nurse (RN) and subject matter expert, (b)(6), (b)(7)(c) RN (b)(6), (b)(7)(c) is employed by Creative Corrections (CC), a national management and consultant firm, contracted by ICE to provide subject matter expertise in detention management including health care. During the review, ODO interviewed staff from the DCDF and personnel assigned to the ERO office in Centennial, Colorado (ERO Centennial). Additionally, agents reviewed MANDZA's immigration, medical, and detention records. The following is a chronology of events which occurred while MANDZA was in ICE custody. On October 16, 2011, MANDZA was arrested by the Aurora Colorado Police Department for the unlawful selling of merchandise and resisting an officer. MANDZA was housed at the Aurora County Jail in Aurora, CO. On October 17, 2011, MANDZA was convicted in the City of Aurora Municipal Court, Aurora, CO, OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 3 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE for the offense of the unlawful selling of merchandise, and sentenced to 60 days in jail, 55 days suspended sentence, with three days to serve. On the same date, Immigration Enforcement (b)(6), (b)(7)(c) Agent (IEA) interviewed MANDZA at the Aurora County Jail (ACJ) in Aurora, CO, pursuant to the Criminal Alien Program. Following the interview, IEA (b)(6), (b)(7)(c) issued a Form I-247, Immigration Detainer Notice, informing ACJ that an investigation had been initiated to determine whether MANDZA is subject to immigration removal proceedings. MANDZA remained at the Aurora County Jail until his release on October 24, 2011. (b)(6), (b)(7)(c) On October 24, 2011, IEA transported MANDZA from the Aurora County Jail to ERO Centennial (Exhibit 01). At approximately 7:05 a.m., MANDZA arrived at ERO Centennial for processing. Upon arrival at ERO Centennial, IEA (b)(6), (b)(7)(c) arrested and charged MANDZA with immigration violations. At the time of the arrest, IEA(b)(6), (b)(7)(c)completed ICE Form I-213, Record of Deportable/Inadmissible Alien. The I-213 states that IEA (b)(6), (b)(7)(c)issued MANDZA an ICE Form I-862, Notice to Appear, for overstaying his admission as a nonimmigrant in violation of the Immigration and Nationality Act (INA) Section 237(a)(1)(B) (Exhibit 02). On October 24, 2011, at approximately 4:15 p.m., IEA (b)(6), (b)(7)(c) transported MANDZA from ERO Centennial to the DCDF (refer to Exhibit 01). At approximately 5:05 p.m., MANDZA arrived at the DCDF. MANDZA was processed into the facility by GEO Detention Officer (DO) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) and GEO DO (b)(6), (b)(7)(c) . During processing, MANDZA was issued facility clothing, an identification wrist band, handbooks conveying facility procedures and policies, watched an orientation video, and had his personal property inventoried and stored (Exhibit 03). At the time of admission to DCDF, MANDZA was not in possession of or taking any prescription medication (refer to Exhibit 02). At the conclusion of the initial booking procedure, an intake form was completed. At approximately 6:45 p.m., an initial medical screening was performed by GEO licensed practical (b)(6), (b)(7)(c) nurse (LPN) (Exhibit 04). During the medical intake screening performed by LPN (b)(6), (b)(7)(c) , vital signs (VS) were documented as follows: pulse (P) 81, blood pressure (BP) 101/62, respirations (R) 14, temperature (T) 97.1, all within normal limits (WNL). No chronic care issues were identified, and the form documented negative responses to all health history questions. ODO interviewed LPN (b)(6), (b)(7)(c) on May 21, 2012. LPN (b)(6), (b)(7)(c) stated she always asks more questions than listed on the form and seeks to identify possible signs or symptoms of anything abnormal. LPN (b)(6), (b)(7)(c) stated she found "nothing out of the ordinary" during her screening of MANDZA. The Nursing Incoming Screen Progress Note form documents there were no medications ordered, OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 4 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE no special treatments or follow-up referrals, and no work limitations. Additionally, no housing or bunk limitations were ordered for MANDZA (Exhibit 05). This form is designed to focus on chronic conditions requiring follow-up or medication. (b)(6), (b)(7)(c) MD, reviewed and signed the form on October 27, 2011. The Mental Health Intake Screen completed by LPN (b)(6), (b)(7)(c) documents negative responses for all items concerning mental health (Exhibit 06). The form was signed by (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) , MD, on the same date. The detainee refused syphilis testing and signed a refusal form (Exhibit 07). A chest x-ray was performed with the results documented as "Negative except for calcified granuloma (small area of inflammation of benign calcification) less than 2 cm" (Exhibit 08). Dr. (b)(6), (b)(7)(c) is no longer employed by DCDF and was not available for an interview. (b)(6), (b)(7)(c) At the completion of the intake process, GEO DO conducted a classification assessment of MANDZA to determine the appropriate classification level, as determined by previous criminal history and disciplinary issues. GEO DO (b)(6), (b)(7)(c) classified MANDZA at Level II due to his prior convictions and arrests (Exhibit 09). At the completion of the classification process, MANDZA was assigned to DCDF housing unit A2. (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) GEO DO and GEO DO were the housing unit officers during MANDZA's assignment to housing unit A2. SA (b)(6), (b)(7)(c) SA (b)(6), (b)(7)(c), and RN (b)(6), (b)(7)(c) interviewed GEO DO(b)(6), (b)(7)(c)on May 21, 2012, and DO (b)(6), (b)(7)(c) on May 23, 2012, at the DCDF. GEO DO (b)(6), (b)(7)(c) and GEO DO (b)(6), (b)(7)(c) were shown a photograph of MANDZA as well as a copy of his case file. GEO DO(b)(6), (b)(7)(c)stated he did not recall MANDZA. GEO DO (b)(6), (b)(7)(c) stated he remembered MANDZA and stated that MANDZA spoke French. GEO DO (b)(6), (b)(7)(c) stated he did not remember MANDZA complaining about any health related issues. On October 25, 2011, MANDZA submitted a sick call request stating he had a "bad movement" (Exhibit 10). On October 26, 2011, at approximately 6:00 p.m., a physical examination and health appraisal were performed by adult nurse practitioner (ANP) (b)(6), (b)(7)(c) (Exhibit 11). All history and vital signs were documented as normal. A Progress Note by Registered Nurse (RN)(b)(6), (b)(7)(c) (b)(6), (b)(7)(c) documents MANDZA was seen for sick call, because he had not had a bowel movement in three to four days (Exhibit 12). RN (b)(6), (b)(7)(c) instructed MANDZA to increase his fluid intake. MANDZA stated he understood and was given Dulcolax and Milk of Magnesia (a laxative to relieve constipation) in accordance with GEO nursing protocols (Exhibit 13). On October 31, 2011, MANDZA submitted a sick call request for "constipation movement" (Exhibit 14). MANDZA was placed on the sick call list to be seen by Dr (b)(6), (b)(7)(c) on November 3, 2011. During the ODO site visit for this review, RN (b)(6), (b)(7)(c) observed Detainee MANDZA's name was crossed off Dr. (b)(6), (b)(7)(c) sick call list with a crayon. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 5 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE SA (b)(6), (b)(7)(c) SA (b)(6), (b)(7)(c), and RN (b)(6), (b)(7)(c) interviewed Acting Health Services Administrator (HSA) RN (b)(6), (b)(7)(c) on May 21, 2012, at DCDF. Acting HSA RN (b)(6), (b)(7)(c) stated names are crossed off sick call lists with crayons to signify the medical record has been removed for the appointment. There was no corresponding Progress Note or other documentation confirming that detainee MANDZA was seen by Dr. (b)(6), (b)(7)(c) on November 3, 2011. RN (b)(6), (b)(7)(c) could not explain why the sick call appointment was missed. No other significant activity occurred regarding MANDZA until November 8, 2011. On November 8, 2011, MANDZA submitted a sick call request for razor burn (Exhibit 15). On November 9, 2011, at approximately 6:00 a.m., the medical Progress Notes document that (b)(6), (b)(7)(c) MANDZA was seen by LPN for "razor bumps" (Exhibit 16). MANDZA was given triple antibiotic cream to be applied daily for seven days (Exhibit 17). On November 10, 2011, MANDZA submitted a sick call request for constipation (Exhibit 18). On November 11, 2011, the medical record documents that the sick call request was reviewed by (b)(6), (b)(7)(c) LPN . MANDZA was provided Dulcolax and fiber was added to his diet (Exhibit 19). On November 15, 2011, MANDZA was reassigned from housing unit A2 to housing unit A3. May 21 through 23, 2012, ODO interviewed each GEO DO assigned to housing unit A3 while MANDZA (b)(6), (b)(7)(c) was there: GEO DO (b)(6), (b)(7)(c) , GEO DO (b)(6), (b)(7)(c) , GEO DO , GEO DO(b)(6), (b)(7)(c) (b)(6), (b)(7)(c) , GEO DO (b)(6), (b)(7)(c) and GEO DO (b)(6), (b)(7)(c) Each GEO DO stated MANDZA appeared to be in good health, was polite and quiet, and never exhibited any symptoms of illness. On November 17, 2011, MANDZA submitted a sick call request for a toothache (Exhibit 20). RN (b)(6), (b)(7)(c) provided MANDZA Tylenol (for pain) and scheduled him to see the dentist on November 21, 2011. MANDZA was instructed on proper dental hygiene and advised to return to the clinic if symptoms persisted or worsened (Exhibit 21). (b)(6), (b)(7)(c) On November 21, 2011, at approximately 3:45 p.m., MANDZA was seen by Dentist According to the dental health record, MANDZA complained of a lower level toothache (Exhibit 22). MANDZA was scheduled for court the following day, so MANDZA requested that his tooth extraction be rescheduled. On November 27, 2011, MANDZA submitted a sick call request for constipation and razor burn (Exhibit 23). On November 28, 2011, MANDZA was seen by RN(b)(6), (b)(7)(c)for his complaints. RN OFFICIAL USE ONLY SENSITIVE . OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 6 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE provided MANDZA Milk of Magnesia, Dulcolax, and fiber for the constipation, and triple antibiotic cream for the razor burn rash (Exhibit 24). RN(b)(6), (b)(7)(c) documented MANDZA was instructed to increase fluid consumption, not use triple antibiotic cream around his eyes, and return to the medical unit if symptoms persisted or worsened (refer to Exhibit 23). (b)(6), (b)(7)(c) On December 2, 2011, at approximately 10:30 a.m., Dr. (b)(6), (b)(7)(c) evaluated MANDZA for constipation and folliculitis (inflammation of hair follicles) (Exhibit 25). For the constipation, MANDZA was prescribed glycerin suppositories, Colace, and advised to increase his fiber intake. MANDZA was provided a triple antibiotic cream for his neck rash. On December 11, 2011, MANDZA submitted a sick call request for "Dental complaint: need to be cleaned, but not to take out" (Exhibit 26). On December 12, 2011, at approximately 6:40 a.m., MANDZA was seen by RN (b)(6), (b)(7)(c) (Exhibit 27) and was provided Ibuprofen (Exhibit 28). On December 14, 2011, MANDZA submitted a sick call request stating he fell from the top bunk and injured his foot (Exhibit 29). On December 15, 2011, Dr.(b)(6), (b)(7)(c)documented an evaluation of Detainee MANDZA. No new orders were issued (Exhibit 30). No significant activity occurred regarding MANDZA until December 20, 2011. On December 20, 2011, at approximately 1:40 p.m., Dentist (b)(6), (b)(7)(c) documented that MANDZA asked to have his teeth cleaned and complained of pain in his lower level teeth. MANDZA refused a tooth extraction and was given Ibuprofen. During the site visit for this review, ODO found no refusal form in the medical record documenting MANDZA's refusal of a tooth extraction (refer to Exhibit 22). On December 25, 2011, at approximately 11:40 a.m., a Medical Report on Injuries/Non-Injuries documents MANDZA was evaluated due to his involvement in fighting with other detainees (Exhibit 31). Tiny scratches on his chest and left wrist area were noted by LPN (b)(6), (b)(7)(c) . No other injuries were noted. The Pre-Segregation History and Physical form completed by LPN (b)(6), (b)(7)(c) documents clearance for placement in administrative segregation (Exhibit 32). The form was signed by Dr. (b)(6), (b)(7)(c) on December 27, 2011. On December 25, 2011, at approximately 11:53 a.m., MANDZA was moved to the Special Management Unit for allegedly fighting with another detainee (Exhibit 33). MANDZA was placed in administrative segregation based on an allegation of "horseplay" with another detainee while OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 7 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE awaiting the outcome of a DCDF investigation (Exhibit 34). On December 27, 2011, MANDZA was released from segregation and returned to housing unit A3 (refer to Exhibit 33). ODO (b)(6), (b)(7)(c) interviewed Lieutenant on May 23, 2012, at the DCDF. Lieutenant (b)(6), (b)(7)(c) investigated the allegations that led to MANDZA being assigned to administrative segregation. Lieutenant (b)(6), (b)(7)(c) stated that the incident on December 25, 2011, was a result of horseplay between MANDZA and another detainee. Although the incident was downgraded from fighting to horseplay, Lieutenant (b)(6), (b)(7)(c) stated MANDZA was held in segregation until the investigation was complete. On December 30, 2011, at approximately 4:25 p.m., during sick call, RN(b)(6), (b)(7)(c)documented that MANDZA complained of pain in his right big toe resulting from a soccer injury. RN(b)(6), (b)(7)(c)gave MANDZA Ibuprofen and ice packs for his right big toe (Exhibit 35). On January 3, 2012, Dr. (b)(6), (b)(7)(c) documented that MANDZA complained of a sore foot from striking it against a soccer ball. MANDZA was noted to be in no apparent distress with no swelling, tenderness or gross deformity. MANDZA was prescribed Ibuprofen and assigned to a lower bunk bed (refer to Exhibit 27). No other significant activity occurred regarding MANDZA until January 13, 2012. On January 13, 2012, MANDZA submitted a sick call request for a toothache (Exhibit 36). The request was reviewed on January 15, 2012, and an appointment was scheduled for January 16, 2012. On January 15, 2012, MANDZA submitted a sick call request for a toothache and constipation (Exhibit 37). On January 16, 2012, RN(b)(6), (b)(7)(c)documented that MANDZA was seen in medical for his constipation and dental issues. During this appointment, MANDZA was scheduled to see the dentist, Dr. (b)(6), (b)(7)(c) , later the same day, as well as Dr.(b)(6), (b)(7)(c)on January 18, 2012 (Exhibit 38). Per a Progress Note by Dr. (b)(6), (b)(7)(c) , MANDZA again refused the extraction (refer to Exhibit 22). MANDZA was given Amoxicillin, an antibiotic, and Tylenol for his dental condition. ODO did not find a refusal form for the tooth extraction in the medical record. On January 18, 2012, MANDZA was removed from housing unit A3 and taken to disciplinary segregation for allegedly refusing to obey a staff member and interfering with the population count. On January 20, 2012, MANDZA was issued a warning, released from segregation, and returned to housing unit A3 (Exhibit 39). The Pre-Segregation History and Physical completed by RN (b)(6), (b)(7)(c) documents medical clearance for housing in Administrative Segregation. "No physical confrontation just arguing" was noted. The form was signed by Dr. (b)(6), (b)(7)(c) but not dated (Exhibit OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 8 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE 40). ODO found that based on the Medical Request dated January 16, MANDZA was to be seen by Dr.(b)(6), (b)(7)(c)on January 18, 2012. There is no documentation confirming this appointment occurred. During her interview, RN(b)(6), (b)(7)(c)could not explain why Dr.(b)(6), (b)(7)(c)did not see MANDZA as scheduled. During his interview, Lieutenant (b)(6), (b)(7)(c) stated the incident on January 18, 2012, was a result of MANDZA refusing to move to a new cell unless he was allowed to consult with a Lieutenant. Lieutenant (b)(6), (b)(7)(c) stated at the time of the incident, a Lieutenant was unavailable, and MANDZA refused to move, which interfered with the population count. When Lieutenant (b)(6), (b)(7)(c) interviewed MANDZA regarding the incident on January 18, 2012, Lieutenant (b)(6), (b)(7)(c) stated MANDZA exhibited a good attitude and was cooperative. MANDZA stated he had violated DCDF rules violations, and MANDZA was issued a warning. Lieutenant (b)(6), (b)(7)(c) stated he had no further interaction with MANDZA. (b)(6), (b)(7)(c) GEO DO and GEO DO (b)(6), (b)(7)(c) were assigned to segregation on both occasions MANDZA was housed there: December 25th and January 18th, 2012. ODO interviewed GEO DO (b)(6), (b)(7)(c) and GEO DO (b)(6), (b)(7)(c) on May 23, 2012, at the DCDF. Both GEO DO (b)(6), (b)(7)(c) and GEO DO (b)(6), (b)(7)(c) described MANDZA as very quiet, polite, calm, and in what appeared to be overall good health. GEO DO (b)(6), (b)(7)(c) and GEO DO (b)(6), (b)(7)(c) stated there were no apparent health issues with MANDZA. (b)(6), (b)(7)(c) GEO DO was assigned to complete secondary classification worksheets on MANDZA each time he was sent to administrative segregation. ODO interviewed GEO DO(b)(6), (b)(7)(c) on May 22, 2012, at the DCDF. GEO DO(b)(6), (b)(7)(c)stated he had no direct contact with MANDZA. GEO DO(b)(6), (b)(7)(c)stated MANDZA was found not guilty of the allegation of fighting lodged on December 25, 2011. MANDZA was released once the investigation was completed. GEO DO (b)(6), (b)(7)(c)stated MANDZA was found guilty of the allegations of refusing to obey a staff member and of interfering with the population count lodged on January 18, 2012. Neither incident had any effect on MANDZA's classification level or housing assignment (Exhibit 41). On January 27, 2012, at approximately 5:48 p.m., a Progress Note by ANP(b)(6), (b)(7)(c)documents MANDZA complained of constipation, but declined the Colace and the fiber recommended by ANP (b)(6), (b)(7)(c)(Exhibit 42). Glycerin suppositories were renewed for three days, and MANDZA was counseled on taking the prescribed treatment for constipation. ODO found there were no refusal forms for Colace and fiber contained in the record. ANP(b)(6), (b)(7)(c)stated it is not a customary practice to have detainees sign refusal forms for over-the-counter medications. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 9 of 21 1. CASE NUMBER 201207288 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 February 9, 2012, a Progress Note by RN(b)(6), (b)(7)(c)documents MANDZA complained of constipation and had not had a bowel movement since February 3, 2012 (refer to Exhibit 42). According to the Progress Note, MANDZA's bowel sounds were decreased and his discomfort was increased. MANDZA was provided Dulcolax and Milk of Magnesia per GEO nursing protocol. On February 14, 2012, MANDZA submitted a sick call request for a "problem with my teeth" (Exhibit 43). A note (illegible initials) documents MANDZA was scheduled to see the dentist that (b)(6), (b)(7)(c) day. Doctor of Dental Medicine (DMD extracted tooth number 18. MANDZA signed a Consent to Dental Procedures form (Exhibit 44). No other significant activity occurred regarding MANDZA until March 1, 2012. On March 1, 2012, MANDZA submitted a sick call request complaining of burning eyes and constipation (Exhibit 45). On March 3, 2011, MANDZA was seen by RN(b)(6), (b)(7)(c)and was provided Dulcolax, Milk of Magnesia, and artificial tears (Exhibit 46). MANDZA was instructed to return to the medical unit if symptoms persisted or worsened. MANDZA was placed on the physician sick call list for March 5, 2012. On March 5, 2012, Physician Assistant (PA) (b)(6), (b)(7)(c) documented the detainee presented with complaints of constipation in the following note as translated by RN (b)(6), (b)(7)(c) "no dumping (when food passes too rapidly from the stomach into the upper intestine), H2O, on meds." Observations: "Lungs clear, heart-no [illegible], abdomen soft, visceromegaly [abnormal enlargement of the soft internal organs];" Assessment: "Constipation, no water;" Plan: "Increase fiber, increase water, increase exercise" (Exhibit 47). PA(b)(6), (b)(7)(c)was not available for interview. On March 10, 2012, MANDZA was reassigned from housing unit A3 to housing unit A4. GEO DO (b)(6), (b)(7)(c) was assigned as a housing unit officer in housing unit A4 while MANDZA was housed there. ODO interviewed GEO DO(b)(6), (b)(7)(c)on May 22, 2012, at the DCDF. GEO DO(b)(6), (b)(7)(c)stated he saw MANDZA every day and recalled that MANDZA spent almost every day in the law library. GEO DO(b)(6), (b)(7)(c)stated that MANDZA appeared in overall good health, had no known medical problems, was very happy and respectful, and was not considered a problem detainee. GEO DO (b)(6), (b)(7)(c)stated he saw MANDZA the day before he died, and MANDZA showed no signs of pain or distress. GEO DO(b)(6), (b)(7)(c)was surprised to hear that MANDZA had died. No other significant activity occurred regarding MANDZA until March 21, 2012. On March 21, 2012, MANDZA submitted a sick call request for constipation and razor burn (Exhibit 48). LPN(b)(6), (b)(7)(c)documents MANDZA was seen in the medical unit, scheduled for a medical review, and provided Milk of Magnesia and Dulcolax. Dr. (b)(6), (b)(7)(c) completed a Progress OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 10 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE Note documenting MANDZA's history of constipation with stress; Colace was ordered (Exhibit 49). On March 25, 2012, at approximately 9:20 a.m., Dr. (b)(6), (b)(7)(c) completed a Progress Note documenting that the medications were working well, and that MANDZA was not experiencing nausea, vomiting, or diarrhea. Additionally, MANDZA had no complaints, his vital signs were stable, and his medications were to be continued (Exhibit 50). On March 31, 2012, MANDZA submitted a sick call request for constipation (Exhibit 51). On April 1, 2012, LPN (b)(6), (b)(7)(c) documented in the Health Services Nursing Assessment Protocols that MANDZA was seen in the medical unit, where MANDZA was provided Dulcolax and Milk of Magnesia (Exhibit 52). No other significant activity occurred regarding MANDZA until April 12, 2012. On April 12, 2012, GEO DO (b)(6), (b)(7)(c) was assigned as the housing unit officer for housing unit A4. ODO interviewed GEO DO (b)(6), (b)(7)(c) on May 22, 2012, at the DCDF. GEO DO (b)(6), (b)(7)(c) stated he worked in housing unit A4 from April 11, 2012, at 7:00 p.m. to April 12, 2012, at 7:00 a.m. GEO DO (b)(6), (b)(7)(c) stated he observed MANDZA at the beginning of his shift and during his rounds. GEO DO (b)(6), (b)(7)(c) stated he had never heard MANDZA complain about any medical conditions, and MANDZA appeared to be in good health. GEO DO (b)(6), (b)(7)(c) stated MANDZA appeared to be fine and expressed excitement regarding his next court date. On April 12, 2012, at approximately 5:24 a.m., GEO DO (b)(6), (b)(7)(c) was conversing with Lieutenant (b)(6), (b)(7)(c) when a detainee called GEO DO (b)(6), (b)(7)(c) over to MANDZA's cell. GEO DO (b)(6), (b)(7)(c) stated he observed MANDZA lying in bed, holding his chest, rolling back and forth in obvious pain. At that time, GEO DO (b)(6), (b)(7)(c) stated he directed Lieutenant (b)(6), (b)(7)(c) to call a code blue (medical emergency). According to DCDF Logbooks, on April 12, 2012, at approximately 5:25 a.m., a code blue was initiated in housing unit A4 (Exhibit 53). GEO DO (b)(6), (b)(7)(c) stated nursing staff arrived within 3 minutes. GEO DO (b)(6), (b)(7)(c) completed a GEO General Incident Report documenting this event (Exhibit 54). ODO interviewed Lieutenant (b)(6), (b)(7)(c) on May 22, 2012, at the DCDF. Lieutenant (b)(6), (b)(7)(c) stated that on April 12, 2012, at approximately 5:24 a.m., he was conducting rounds and speaking (b)(6), (b)(7)(c) with GEO DO in housing unit A4, when he heard a detainee call out for GEO DO (b)(6), (b)(7)(c) . Lieutenant (b)(6), (b)(7)(c) stated GEO DO (b)(6), (b)(7)(c) entered MANDZA's cell and then instructed him to call a code blue. Lieutenant (b)(6), (b)(7)(c) activated the code blue, began organizing first responders, and ordered side doors to be manned and held open for the medical staff. Lieutenant (b)(6), (b)(7)(c) observed MANDZA holding his hand over his chest and MANDZA appeared OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE Page 11 of 21 DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE to be in pain. Lieutenant (b)(6), (b)(7)(c) stated nursing staff arrived within four minutes and began their assessment of MANDZA. Lieutenant (b)(6), (b)(7)(c) completed a GEO Serious Incident Report (Exhibit 55) and a GEO Supervisor Report (Exhibit 56) documenting this event. The nursing staff determined MANDZA had to be moved to the medical unit for further evaluation. Lieutenant (b)(6), (b)(7)(c) stated MANDZA's pain appeared constant, but MANDZA stopped moaning once he arrived at the medical unit. At approximately 5:28 a.m., GEO medical staff, RN at housing unit A4 in response to the code blue. (b)(6), (b)(7)(c) , and LPN (b)(6), (b)(7)(c) arrived (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) ODO interviewed RN on May 22, 2012, at the DCDF. RN stated she did not recall having any previous contact with MANDZA prior to her response to the code blue on April 12, 2012. According to RN(b)(6), (b)(7)(c)on April 12, 2012, at approximately 5:24 a.m., she was alerted to a code (b)(6), (b)(7)(c) blue in housing unit A4. RN and LPN (b)(6), (b)(7)(c) responded. Upon arrival in housing unit A4, (b)(6), (b)(7)(c) RN found MANDZA in his bed, touching his left side, complaining of chest pain. RN(b)(6), (b)(7)(c) observed MANDZA was calm, alert, and verbal. MANDZA's skin was warm and dry, his color was normal, and he was not short of breath. MANDZA rated his chest pain on a scale of one to ten as an eight to nine. (Agent's note: a pain scale is a way for people to measure their pain so that health professionals can help plan how best to control it. Most pain scales use numbers from zero to ten; zero means no pain, and ten means the worst pain the person has ever known or felt. [www.health.com]) MANDZA's blood pressure was mildly elevated with remaining vital signs within normal limits. MANDZA also stated chest pain worsened upon inspiration (increase pain (b)(6), (b)(7)(c) with breathing) (Exhibit 57). RN recommended the patient be transferred to the DCDF trauma room for further evaluation. RN completed a GEO General Incident Report documenting this (b)(6), (b)(7)(c) event (Exhibit 58). ODO interviewed LPN (b)(6), (b)(7)(c) on May 22, 2012, at DCDF. LPN(b)(6), (b)(7)(c)stated she had interacted with MANDZA during sick calls when he complained of constipation and razor burn and when he came to the nurses' cart to receive fiber pills. LPN(b)(6), (b)(7)(c)recalled MANDZA was very polite and never exhibited signs or symptoms of a serious medical condition. LPN(b)(6), (b)(7)(c)stated that on April (b)(6), (b)(7)(c) 12, 2012, she and RN responded to a code blue in housing unit A4. Upon arrival, they found MANDZA lying in bed holding his chest. MANDZA was responsive, alert, and described his pain as an eight on a scale of one to ten. LPN(b)(6), (b)(7)(c)completed a GEO General Incident Report documenting this event (Exhibit 59). On April 12, 2012, at approximately 5:28 a.m., MANDZA was transferred to the DCDF trauma room. At this point, no medications had been administered to the patient in an attempt to relieve OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 12 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE his chest discomfort. MANDZA was taken to the trauma room where he was placed on oxygen, his vital signs were obtained, and an electrocardiogram (EKG) was performed. In her attempt to (b)(6), (b)(7)(c) diagnose MANDZA, RN used two different EKG machines. RN(b)(6), (b)(7)(c) was unable to get a reading with the first EKG due to her unfamiliarity with the machine, but was able to get a reading (b)(6), (b)(7)(c) utilizing the second EKG machine. When asked if she could interpret the EKG results, RN stated she was not trained on the use of an EKG or in the interpretation of EKG test results. RN (b)(6), (b)(7)(c) stated she relied on "gut instinct" to send MANDZA to the hospital. A Progress Note (b)(6), (b)(7)(c) completed by RN indicated she contacted Dr. (b)(6), (b)(7)(c) and received the verbal order to transport him to the hospital (refer to Exhibit 57). During her interview, LPN(b)(6), (b)(7)(c)stated MANDZA was moved to the trauma room and placed on (b)(6), (b)(7)(c) LPN(b)(6), (b)(7)(c) made the required oxygen. LPN(b)(6), (b)(7)(c) left MANDZA in the care of RN notifications by phone and began the required paperwork. ODO asked LPN(b)(6), (b)(7)(c) about the use of the EKG machines; LPN(b)(6), (b)(7)(c) stated she had not received any formal training on their use or interpreting the results. LPN(b)(6), (b)(7)(c)stated she called Dr. (b)(6), (b)(7)(c) the Acting HSA (b)(6), (b)(7)(c) , ICE ERO AFOD(b)(6), (b)(7)(c), Lieutenant (b)(6), (b)(7)(c) and the AMCS. ODO interviewed Dr. (b)(6), (b)(7)(c) on May 23, 2012, at the DCDF. Dr. (b)(6), (b)(7)(c) stated that on April 12, 2012, he was contacted by the DCDF nursing staff about MANDZA, who was suffering from chest pains. Dr. (b)(6), (b)(7)(c) stated he never had any contact with MANDZA. ODO provided the EKG (b)(6), (b)(7)(c) results of the test performed by RN to Dr. (b)(6), (b)(7)(c) and asked for his interpretation. Dr. (b)(6), (b)(7)(c) stated the EKG results were not complete and an interpretation could not be made. When asked about the EKG tests performed at the DCDF, Dr. (b)(6), (b)(7)(c) stated it was his opinion that performing the EKG test on MANDZA at DCDF was a waste of time, and the patient needed to be transported immediately to the hospital for further evaluation. Dr. (b)(6), (b)(7)(c) stated that on April 12, 2012, at approximately 5:50 a.m., he authorized the transportation of MANDZA to an (b)(6), (b)(7)(c) off-site medical facility for further evaluation and instructed RN to call 911. At approximately 6:20 a.m., Lieutenant (b)(6), (b)(7)(c) called the nursing station to check on MANDZA. During this call, he was instructed by LPN (b)(6), (b)(7)(c)to call 911. During his interview with ODO, Lieutenant (b)(6), (b)(7)(c) stated he immediately called 911 for Emergency Medical Services (EMS). Lieutenant (b)(6), (b)(7)(c) expressed concern over the time it took for 911 to be called (refer to Exhibits 55 & 56). During the ODO interview of Dr. (b)(6), (b)(7)(c) , Dr. (b)(6), (b)(7)(c) stated he was unaware of any delay that resulted in EMS not being called until approximately 6:21 a.m. Dr. (b)(6), (b)(7)(c) stated EMS should have been contacted immediately, and any GEO protocols that were followed resulting in this delay need to be modified. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 13 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE ODO interviewed LPN(b)(6), (b)(7)(c)on May 22, 2012. LPN(b)(6), (b)(7)(c)was questioned about the delay in calling EMS. LPN(b)(6), (b)(7)(c)stated it was her understanding that MANDZA would be transported by (b)(6), (b)(7)(c) GEO personnel in a GEO van. Sometime later, she was told by RN that MANDZA needed to (b)(6), (b)(7)(c) go to the AMCS by ambulance. LPN stated she did not call 911, and she did not instruct the GEO Control Officer to call 911. LPN(b)(6), (b)(7)(c)stated while she continued processing the necessary paperwork to have MANDZA transferred to an off-site medical facility, she received a call from Lieutenant (b)(6), (b)(7)(c) . While speaking to Lieutenant (b)(6), (b)(7)(c) , LPN(b)(6), (b)(7)(c)asked him to call 911. When asked about the delay in calling 911, LPN(b)(6), (b)(7)(c)stated she needed to get the paperwork concerning MANDZA's medical condition completed before making the call (refer to Exhibit 59). At approximately 6:26 a.m., Rural/Metro Ambulance personnel arrived at the DCDF and provided medical care to MANDZA. According to EMS records, MANDZA complained of chest pain from his upper abdomen up to his throat (Exhibit 60). EMS treated MANDZA in the DCDF trauma room, and MANDZA denied any previous trauma or illness. MANDZA stated he had eaten soup with hot peppers for dinner on April 11, 2012. EMS noted in their report that the symptoms were indicative of indigestion. At approximately 6:43 a.m., EMS personnel transported MANDZA from the DCDF to the AMCS Emergency Room (ER). During the transport, MANDZA became uncooperative, would not answer questions, and would not allow the EMS crew to take his vitals. The EMS crew administered aspirin to MANDZA when his pain appeared to intensify, but MANDZA refused to chew the aspirin as instructed. MANDZA vomited, and the aspirin pills were visible in the vomit (refer to Exhibit 60). (b)(6), (b)(7)(c) GEO DO accompanied MANDZA in the ambulance while GEO DO (b)(6), (b)(7)(c) followed in another vehicle. (b)(6), (b)(7)(c) ODO interviewed GEO DO on May 21, 2012, at the DCDF. GEO DO (b)(6), (b)(7)(c) stated she had no previous contact with MANDZA prior to April 12, 2012. On April 12, 2012, GEO DO (b)(6), (b)(7)(c) was assigned transportation duty, and was alerted to a medical emergency requiring EMS. GEO DO (b)(6), (b)(7)(c) went to the medical unit where she saw MANDZA, who appeared to be "okay." GEO DO (b)(6), (b)(7)(c) stated while riding in the ambulance with MANDZA, his condition changed, and MANDZA appeared to be in a lot of pain, clutched his chest, and would not remain still. GEO DO (b)(6), (b)(7)(c) stated when MANDZA's condition worsened, the EMS crew administered aspirin. GEO DO (b)(6), (b)(7)(c) completed a GEO General Incident Report documenting this event (Exhibit 61). ODO interviewed GEO DO (b)(6), (b)(7)(c) on May 23, 2012, at the DCDF. GEO DO (b)(6), (b)(7)(c) who was previously listed as a housing unit officer in housing unit A2, was later transferred to transportation OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 14 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE duty. According to GEO DO (b)(6), (b)(7)(c) on April 12, 2012, while assigned to transportation duty, he responded to a code blue medical emergency requiring transportation to the AMCS. GEO DO (b)(6), (b)(7)(c) stated he followed the ambulance to the AMCS, and his partner, GEO DO (b)(6), (b)(7)(c), rode in the back of the ambulance with MANDZA. GEO DO (b)(6), (b)(7)(c) completed a GEO General Incident Report documenting this event (Exhibit 62). On April 12, 2012, at approximately 6:58 a.m., MANDZA arrived at the AMCS ER and was received by RN (b)(6), (b)(7)(c) (refer to Exhibit 60). MANDZA was examined initially by AMCS physician (b)(6), (b)(7)(c) During an ODO interview conducted on May 21, 2012, GEO DO (b)(6), (b)(7)(c) stated MANDZA had difficulty speaking to the treating physician upon arrival at the hospital, but was able to point to his chest and say he was in pain. During an ODO interview conducted on May 23, 2012, DO (b)(6), (b)(7)(c) stated, while in the ER, MANDZA was administered baby aspirin and told by the treating physician that he might be having a heart attack. MANDZA either could not, or would not, cooperate and answer questions by medical staff. According to AMCS medical records, at approximately 7:10 a.m., an electrocardiogram (EKG) was (b)(6), (b)(7)(c) performed on MANDZA in the ER (Exhibit 63). At approximately 7:11 a.m., Dr. received the results of the EKG and asked MANDZA questions. Dr.(b)(6), (b)(7)(c) documented that MANDZA did not answer his questions for several minutes. (b)(6), (b)(7)(c) On April 12, 2012, at approximately 7:17 a.m., Dr. believed MANDZA was having a heart (b)(6), (b)(7)(c) attack and called a cardiac alert (refer to Exhibit 63). Dr. told MANDZA he needed his cooperation. MANDZA stated that the onset of his chest pains occurred at approximately 4:00 a.m. MANDZA stated he did not have any medical history or family history of heart disease or any contributing factor to heart disease, had not had any previous symptoms of a heart attack, and was not taking any medications. On April 12, 2012, at approximately 7:28 a.m., MANDZA was admitted to the Cardiac Catheter Laboratory (refer to Exhibit 63). During the catheterization procedure, MANDZA went into cardiac arrest, at which time cardio-pulmonary resuscitation (CPR) was performed. All attempts to revive (b)(6), (b)(7)(c) MANDZA were unsuccessful, and Dr. pronounced MANDZA dead at 8:38 a.m. (refer to (b)(6), (b)(7)(c)cited the cause of death as anterior myocardial infarction (MI), and severe Exhibit 63). Dr. left main coronary artery stenosis. A State of Colorado Certificate of Death was generated regarding MANDZA. According to the Certificate of Death, MANDZA's immediate cause of death is listed as anterior MI, and severe left OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 15 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE main coronary artery stenosis (Exhibit 64). Due to MANDZA's death occurring while under the (b)(6), (b)(7)(c) care of AMCS medical staff, Arapahoe County Coroner did not perform an autopsy. MANDZA's body was not claimed by next of kin, and was turned over to the State of Colorado for a pauper's burial. After MANDZA's death, ERO personnel made appropriate notification to the ICE ERO Assistant Director for Field Operations, the Joint Intake Center, and the Gabon Consulate. According to the ERO Notification and Reporting of Detainee Deaths Individual Incident Checklist, the next of kin notification was made to MANDZA's brother by Supervisory Detention and Deportation Officer (Exhibit 65). (b)(6), (b)(7)(c) ODO reviewed MANDZA's detention file and HCDF documentation to identify any grievances filed by MANDZA. After a review of MANDZA's detention file and DCDF documentation, and consultation with GEO Grievance Coordinator, it was determined MANDZA did not file any grievances or complaints about medical services during his stay at DCDF. MEDICAL COMPLIANCE REVIEW ICE OPR ODO contractor, Creative Corrections (CC), a national management and consulting firm, contracted by ICE to provide subject matter expertise in detention management including health care, conducted a Medical Compliance Review of the medical care provided to MANDZA while in ICE custody. The Medical Compliance Review consists of a timeline of medical encounters documented in MANDZA's medical record and findings with respect to compliance with ICE Performance Based National Detention Standards (PBNDS). The review was performed by RN (b)(6), (b)(7)(c) , a CC Health Care Service subject matter expert. RN (b)(6), (b)(7)(c) found the medical care provided by DCDF was deficient in the following areas of the ICE PBNDS: MANDZA's healthcare needs were not met in a timely and efficient manner, MANDZA required health care beyond the facility resources, but was not transferred to an appropriate medical facility in a timely manner, and DCDF medical personnel were not trained in the use and maintenance of available equipment. The CC report is attached to this document (Exhibit 66). Immigration Health Services Corps (IHSC) reviewed the medical records regarding MANDZA to determine the appropriateness of the medical care he received while in ICE custody. IHSC provided their findings in an IHSC Medical Record Review/Investigation (Exhibit 67). The report cites the cause of MANDZA's death as anterior MI, and severe left main coronary artery stenosis. IHSC determined that MANDZA did not have access to appropriate medical care while detained in the DCDF. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 16 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE MORTALITY REVIEW CC conducted a Mortality Review as part of the ODO investigation into the death of MANDZA. (b)(6), (b)(7)(c) M.D., CC Chief Medical Officer, conducted the Mortality Review and prepared the report detailing the findings and conclusion. The review is based on available medical and hospital records, and information obtained during on-site interviews. Dr.(b)(6), (b)(7)(c)stated in his report that DCDF medical staff were unfamiliar with the institution's Chest Pain Protocol, appropriate cardiac medication was not administered, and the time it took to transport the patient to a higher level care facility, all may have been contributing factors to the death of the patient. The CC report is attached to this report (Exhibit 68). IMMIGRATION AND DETENTION HISTORY Detainee Evalin Ali MANDZA, a citizen and national of Gabon, was admitted to the United States as a visitor under a B-2 nonimmigrant visa at Newark, NJ, on October 24, 1996. MANDZA was given a period of admission until November 7, 1996. On June 12, 1997, MANDZA filed an I-485 Application to Adjust Status to Lawful Permanent Resident, based on his marriage to a U.S. citizen spouse. On May 4, 1998, in Hartford, CT, MANDZA's I-485 was denied for lack of prosecution. (Agent's note: MANDZA failed to respond to a service request for evidence or documentation, which resulted in his application being denied for "lack of prosecution.") On May 21, 2001, MANDZA filed another I-485 Application to Adjust Status to Lawful Permanent Resident, based on his marriage to a U.S. citizen spouse. On August 29, 2002, the I-130 Immigrant Visa Petition filed by MANDZA to support his I-485 application was denied for lack of prosecution. MANDZA's I-485 was denied due to the lack of an immediately available immigrant visa. On October 17, 2011, ERO Centennial encountered and interviewed MANDZA while he was in custody at the Aurora County Jail in Aurora, CO, pursuant to the ICE Criminal Alien Program (CAP). ICE provided a Form I-247, Immigration Detainer-Notice of Action Form, to the Aurora County Jail advising them an investigation is ongoing to determine whether MANDZA is subject to removal from the United States. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 17 of 21 1. CASE NUMBER 201207288 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 24, 2011, MANDZA was taken into ICE custody and served a Form I-862, Notice to Appear (NTA), for overstaying his admission as a nonimmigrant in violation of the Immigration and Nationality Act (INA), Section 237(a)(1)(B). MANDZA appeared for immigration removal proceedings before an Immigration Judge on November 22, 2011, December 7, 2011, December 28, 2011, and January 11, 2012. At the time of his death, MANDZA had an immigration removal hearing scheduled for April 12, 2012. On April 12, 2012, Immigration Judge J. P. Vandello terminated MANDZA's removal proceedings. CRIMINAL HISTORY MANDZA was assigned (b)(7)e York SID# . (b)(7)e , State of Colorado SID# (b)(7)e , and State of New The following criminal history information on MANDZA was recovered from the National Crime Information Center, Superior Court of the State of New York, County of New York, Criminal Court of the City of New York, County of New York, City of Aurora Municipal Court, and his Alien File. On November 28, 2007, MANDZA was convicted in Superior Court of the State of New York, County of New York, for the offense of possession of a forged instrument, in violation of the New York Penal Law 170.20, for which he was sentenced to 90 days in jail. The case number is 06240-2006. On April 4, 2008, MANDZA was convicted in the Richmond County Criminal Court, NY, for the offense of patronizing a prostitute, in violation of the New York Penal Law 230.04, for which he was sentenced to time served. The case number is 2008RI003247. On October 17, 2011, MANDZA was convicted in City of Aurora Municipal Court, Aurora, CO, for the offense of selling of merchandise, for which he was sentenced to 60 days in jail, 55 days suspended sentence, with three days to serve. The case number is J146740. INVESTIGATIVE FINDINGS Detainee MANDZA came to ICE custody on October 24, 2011, and was provided an initial medical screening and physical examination in accordance with the ICE PBNDS. During MANDZA's initial medical screening, no medical conditions were identified, and MANDZA was housed in general OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 18 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE population. On April 12, 2012, MANDZA was found in his cell complaining of chest pains. This review determined that DCDF failed to provide MANDZA access to emergent, urgent, or non-emergent medical care. As a result, his health care needs were not met in a timely and efficient manner in accordance with the ICE PBNDS. ICE PBNDS Medical Care, section (II)(7), requires that a detainee who needs health care beyond facility resources will be transferred in a timely manner to an appropriate facility where care is available. On April 12, 2012, a code blue emergency was activated at DCDF at approximately 5:24 a.m., and the facility contacted 911 at approximately 6:20 a.m. An approximate total of 56 minutes elapsed between activation of the code blue emergency and the call to 911. Additionally, at approximately 5:50 a.m., Dr. (b)(6), (b)(7)(c) ordered that MANDZA be transferred to the emergency (b)(6), (b)(7)(c) room and that RN call 911. When 911 was contacted by Lieutenant (b)(6), (b)(7)(c) at approximately 6:20 a.m., approximately 30 minutes had elapsed after Dr. (b)(6), (b)(7)(c) order. As a result of the lapse in time between activation of the code blue, Dr. (b)(6), (b)(7)(c) order to contact 911, and the call to 911, CC concludes that on April 12, 2012, DCDF failed to comply with the ICE PBNDS Medical Care, section (II)(7). ICE PBNDS Medical Care, section (V)(O), requires that medical and safety equipment is available and maintained, and that staff is trained in proper use of the equipment. Because DCDF did not document whether EKG machines were checked daily to determine if they were in working order (b)(6), (b)(7)(c)nor LPN(b)(6), (b)(7)(c)had documented formal or for memory capacity, and because neither RN training on use of the EKG at DCDF medical clinic or in recognizing lethal rhythms, CC concluded that the facility was not in compliance with the ICE PBNDS Medical Care, section (V)(O) . ICE PBNDS Medical Care, section (II)(2), requires that healthcare needs be met in a timely and efficient manner. Because there was no documentation that Dr. (b)(6), (b)(7)(c) evaluated MANDZA for his complaint of constipation on November 3, 2011, and because MANDZA was not seen again by a physician until December 2, 2011, CC concludes that on November 3, 2011, DCDF was not in compliance with ICE PBNDS Medical Care, section (II)(2). AREAS OF CONCERN ODO found the nursing staff was unfamiliar with established GEO Nursing Protocol and polices. Nursing staff also lacked proper training on the use and maintenance of supplied medical equipment. (b)(6), (b)(7)(c) On April 12, 2012, in response to the code blue, RN did not use the assessment criteria in the OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 19 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE GEO nursing protocol for chest pain. Though she documented "color adequate," she did not note whether MANDZA was pale or cyanotic (bluish discoloration of the skin indicating lack of oxygen). (b)(6), (b)(7)(c) In addition, RN did not address the presence of diaphoresis (perspiring) or the quality of MANDZA's respirations, i.e., whether they were shallow or labored. Although she noted the intensity of the pain and that it worsened with inspiration, she failed to inquire as to the duration of the pain. The only vital sign taken was a pulse oximetry reading. As noted, RN(b)(6), (b)(7)(c) recorded the encounter in a Progress Note, only. There was no completed Chest Pain Protocol form in the medical record. (b)(6), (b)(7)(c) On April 12, 2012, at approximately 5:28 a.m., RN obtained MANDZA's vital signs, which appeared normal. MANDZA's vital signs were not documented again until 6:20 a.m. GEO nursing protocol for chest pain requires that vital signs be taken every five minutes. The GEO nursing protocol for chest pain requires a 12-lead EKG. During site visit, ODO learned DCDF has two 12-lead EKG machines made by different manufacturers: a Welch Allen EKG machine and a Schiller AT-102. RN(b)(6), (b)(7)(c) chose the Schiller AT-102 and proceeded to attempt a three-lead rather than 12-lead EKG. A three-lead EKG monitors only two areas of the heart; a 12-lead EKG provides detailed monitoring of all three areas of the heart. During her interview, RN (b)(6), (b)(7)(c) stated she chose to perform a three-lead EKG, because she had not performed a 12-lead (b)(6), (b)(7)(c) EKG "in years." RN further stated she had no formal training in the use of either machine. (b)(6), (b)(7)(c) When RN connected MANDZA to the Schiller AT-102 EKG machine, she realized the memory was full and requested assistance with the machine from LPN(b)(6), (b)(7)(c) When LPN(b)(6), (b)(7)(c)was (b)(6), (b)(7)(c) unsuccessful in erasing the memory, RN detached the Schiller AT-102 and used the Welch (b)(6), (b)(7)(c) Allyn machine instead. RN stated she was unable to interpret the EKG results and relied on her "gut instinct" to ultimately send the detainee to the hospital. (b)(6), (b)(7)(c) During interviews, both RN and LPN(b)(6), (b)(7)(c)stated they had not received formal training in reading an EKG. They stated that in the past, results from the Schiller AT-102 machine were faxed to the on-call physician or a cardiology practice for interpretation; however, faxing results from the Welch Allyn machine is not possible because the machine is not programmed the same way as the Schiller AT-102. When asked about maintenance of the EKG machines, RN(b)(6), (b)(7)(c) stated she had previously reported the Schiller AT-102 memory issue to Acting HSA (b)(6), (b)(7)(c) According to LPN(b)(6), (b)(7)(c), the EKG machines are checked daily for operability, though the memory is not always checked. Acting HSA (b)(6), (b)(7)(c) was able to produce documentation of checks for the other emergency equipment in the clinic, including oxygen tank, oxygen mask and tubing, Ambu-Bag, pulse oximeter, and automated external defibrillator; however, there was no record documenting a check of either EKG machine. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 20 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION Exhibit List HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 01- Holding Cell and Processing Log 02- Form I-213 03- Property Issuance Form 04- Medical Screening Form 05- Nursing Incoming Screen Progress Note 06- Mental Health Evaluation 07- Medical Release Form 08- Chest X-Ray Results 09- Classification Worksheet 10- Medical Request dated October 25, 2011 11- Medical History and Physical Assessment Form 12- Progress Note dated October 26, 2011 13- GEO Nursing Protocol dated October 26, 2011 14- Medical Request dated October 31, 2011 15- Medical Request dated November 8, 2011 16- Progress Note dated November 9, 2011 17- GEO Nursing Protocol dated November 9, 2011 18- Medical Request dated November 10, 2011 19- GEO Nursing Protocol dated November 11, 2011 20- Medical Request dated November 17, 2011 21- GEO Nursing Protocol dated November 17, 2011 22- Dental Progress Note dated November 21, 2011, December 20, 2011, and January 16, 2012 23- Medical Request dated November 27, 2011 24- GEO Nursing Protocol dated November 28, 2011 25- Progress Note dated December 2, 2011 26- Medical Request dated December 11, 2011 27- Progress Note dated December 12, 2011 28- GEO Nursing Protocol dated December 12, 2011 29- Medical Request dated December 14, 2011 30- GEO Nursing Protocol dated December 15, 2011 31- Medical Report on Injuries/Non-Injuries dated December 25, 2011 32- Pre-Segregation History and Physical Form dated December 27, 2011 33- Special Management Unit Housing Record dated December 25-27, 2011 34- Administrative Segregation Order dated December 25, 2011 35- GEO Nursing Protocol dated December 30, 2011 36- Medical Request dated January 13, 2012 37- Medical Request dated January 15, 2012 38- GEO Nursing Protocol dated January 16, 2012 OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 21 of 21 1. CASE NUMBER 201207288 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION Exhibit List HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 39- Disciplinary Segregation Documents dated January 18, 2012 40- Pre-Segregation History and Physical Form undated 41- Post Segregation Re-Classification Worksheets 42- Progress Note dated January 27, 2012 43- Medical Request dated February 14, 2012 44- Consent to Dental Procedures Form dated February 14, 2012 45- Medical Request dated March 1, 2012 46- GEO Nursing Protocol dated March 3, 2012 47- Progress Note dated March 5, 2012 48- Medical Request dated March 21, 2012 49- Progress Note dated March 21, 2012 50- Progress Note dated March 25, 2012 51- Medical Request dated March 31, 2012 52- GEO Nursing Protocol dated April 1, 2012 53- DCDF Log Books 54- GEO Incident Report from GEO DO (b)(6), (b)(7)(c) 55- GEO Serious Incident Report from Lieutenant (b)(6), (b)(7)(c) 56- GEO Supervisor's Report from Lieutenant (b)(6), (b)(7)(c) 57- Progress Noted dated April 12, 2012 58- GEO Incident Report from RN(b)(6), (b)(7)(c) 59- GEO Incident Report from LPN (b)(6), (b)(7)(c) 60- Rural/Metro EMS records 61- GEO Incident Report from GEO DO (b)(6), (b)(7)(c) 62- GEO Incident Report from GEO DO 63- Aurora Medical Center South Medical Records 64- State of Colorado Certificate of Death 65- ERO Notification and Reporting of Detainee Deaths Individual Incident Checklist 66- Creative Corrections Medical Compliance Review 67- IHSC Medical Record Review Report 68- Creative Corrections Mortality Review OFFICIAL USE ONLY SENSITIVE (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(7)e (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(7)e (b)(6), (b)(7)(c) (b)(7)e (b)(7)e (b)(7)e (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) (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) i US. Department of Homeland Security Continuation Page for Form 1213 Alicn?s Name ilc Number Date MANDZA. Evalin 10/24/2011 SUBJECT CLAIMS 3 use CHILDREN RECORDS CHECKED Record of Deportable/Excludable Alien: Subject MANDZA was encountered at the Aurora County Jail in Aurora. Colorado on October 17, 2011 during routine CAP Operations after being arrested and charged with resisting officer. Disposition of this case is pending. was interviewed by land a detainer was placed. On October 17. 2011 MANDZA was transported from Aurora County Jail to Denver Field Office for processing. MANDZA stated that he is a citizen and national of Gabon by virtue of birth. MANDZA stated that his parents are citizens and nationals of Gabon. MANDZA is not in possession of valid immigration documents allowing him to be or remain in the United States legally. ENTRY DATA MANDZA stated that he entered the United States at or near Newark. New Jersey. on or about October 24. 1996. with inspection by U.S. Immigration Officers. MANDZA stated this is his first and only entry into the United States. Subject stated he-is a native and citizen of Gabon born on 12/05/1965 in Gabon. to Gabon citizen parents. At no time did the subject make any claim to derivative US citizenship IMMIGRATION HISTORY database checks indicate prior immigration history for MANDZA. MANDZA entered the United States on/or about October 24.1996 as a 32 visitor and permitted to remain in the United States until November 7. 1996 . ICE has no record of MANZA ever departing the United States on or before the expiration of his admission. CRIMINAL HISTORY Criminal history checks for MANDZA were positive. CHARGES AS FOLLOWS: 11/15/2006 . 1) FORGERY 2ND OFFICIAL DOCUMENT CLASS FELONY 2) UNLAWFUL POSS PERSONAL ID - 3RD CLASS A MISDEMEANOR 3) IDENTITY THEFT 3 OBTAIN GOODS CLASS A MISDEMEANOR 4) GRAND CREDIT CARD CLASS FELONY 5) GRAND SERV CLASS FELONY 04/02/2008 1) PATRONIZE A PROSTITUTE- 3RD CLASS A MISDEMEANOR CONVICTED UPON PLEA OF GUILTY SENT TO TIME SERVED COURT - POLICE DEPARTMENT NEW YORK FORGED INSTRUMENT 3RD ON NEXT PAGE) Signature Title IMMIGRATION ENFORCENENT AGENT Pages Fonn 1-83] Continuation Page (Rev. Continuation Page for Form 1213 US. Department of Homeland Security Date 10/24/2011 Alien's Name MANDZA Eval in SENTENCE - CONVICTED UPON PLEA OF GUILTY SENT 90 DAYS CHARGES Section 237(a) (B) of the Immigration and Nationality Act (Act), as amended, in that atter admission as a under Section 101(a) (15) of the Act, you have remained in the United States for a time longer than permitted, in violation of this Act or any other law of the United States. DISPOSITION HANDZA was advised of his right to speak to a consulate officer from Gabon. HANDZA states he has fear of persecution or torture it removed to Gabon. HANDZA has no imigration petitions or applications pending at this time. MANDZA was offered a Stipulated Removal and he refused a Stipulated Removal. MANDZA requested to see an immigration judge. MANDZA was issued a Notice to Appear. HEALTH. FAMILY WELFARE, AND FUNDS MANDZA stated he was in good health and taking no medications, and appeared to be in good health. mom states he has three children which lives in New York with thier mother. MANDZA has's33.00 in 0.8. funds in his possession. Check #3249 MANDZA was provided a copy of the Detainee Handbook. Signature Title IMIGRATION ENFORCEMENT AGENT of Pages Form 1-83] Continuation Page (Rev. 08/0110?) EMEI DISI EQRM DOB: 12151965 Nation: GABON Arrival Date: 10(2412011 17:05 Detainee Name: Date: IWish to providee enc contact/roert dissition information: . No Name/Nombre: Street Address/Direccion: City/Ciudad: do: 4. Zip Code/Codie Postal: c9 .. ZQD ?Kb 6 (We) (WW3) Country/Pals: Detainee Signature/Finna del Detenido: By my signature. I authorize the facility to se?dr my personal property to the above designated person in the event of an emergency. 1 Con mi ?rma. yo autorizo esta facilidad que mande mis penenencias personales a la direccion de ariba en caso de una enmergencia. CLOTHING. BEDDING, LINEN. HYGIENE ISSUE RECEIPT ShirtsL L.S. Sh Toothpaste Comb 1 Pants 2 . T-Shirts 2 Toothbrush Soap Shoes_1_p_ai_r Blankets Pillowcase_1_ Towel_1_ Socks 3 pair Sheets 2 Radio 1 Lotion Headset Jum it 2 Shorts 1 Undergarments 3 Shower 1 pair (Lev 3 only) Shoes Brig. (F ale only) Discrepancies Ll E) (Q2 CROSS OUT ITEMS NOT RECEIVED WASH STREET CLOTHES LAVAR LA ROPA DE LA YES .I I verify I have received copy number of the detainee handbook and have been shown the orientation tape in Intake. I understand that I need to return the andbook to staff upon my release from the facility. Yo veri?co que recibi la c0pia numero 3 del Manual de Detenidos, que el video de orientacion fue presentado durante mi proceso inicial. Yo entiendo que necesito regresar este manual a los empleados cuando salga de la facilidad. Of?cer Signature: Detainee Signature: W17 SIGNED FORM INDICATES ACTIVATED DETENTION FILE Gee .. (WW :eiving Screening The GEO Group. Inc. MANDZA, EVALIN DOB: 12l5/1965 Natlon- GABO - . Inmate} Arrival Date. 10/24/2011 17:05 Sex: Date ofBirth: um . 7 MI Inmate Number: Date: [0 AR I II Time: PM I g, sigaAM Previous Commitment? B?Yes No Where? c, GI, Interviewed by: "iIify?Name VISUAL OBSERVATION: (Explain any ?Yes? um, ?Remy?? Resp Twill? ls inmate unconscious or have obvious pain, bleeding, injuries, illness, or other suggesting need Yes for emergency medical referral? 2 2. Is inmate carrying any prescribed medication? If yes, what? Yes IjNo 3. is there obvious fever or other evidence of infection? Yes EN0 4. Is there evidence of infestations, rashes, needle marks, bruises, lesions, jaundice or trauma markings? Yes ng0 5. Does inmate appear to be under the in?uence of, or withdrawing ?-om drugs, alcohol or an unknown substance? Yes ErNo 6. Does inmate exhibit any signs of abnormal behavior, tremors, sweating, persistent cough or lethargy? Yes No 7. Does inmate's behavior or physical appearance suggest the risk of suicide or assnult on sta?? or other inmates? Yes EPdo 8. Is inmate?s mobility restricted in any way or has any body deformities? Yes No Does inmate have Physical Aids: Glasses Hearing Aid Cane Clutches Dentures Other 9. Is inmate experiencing visual or auditory hallucinations? Ifyes, Explain Yes Dido Inmate Questionnaire: (Explain any ?Yes? answers under ?Renter-ks?) 10. Presently taking medication under a doctor's order? What? HOW often? Yes i 11. Ever had: diabetes, seizures, asthma, ulcers, high blood pressure, heart condition, or a disorder? CI Yes IZNO 12. Arcyou onaspecial diet prescribed byaphysician? Yes 13. hospitalized or treated by a or a physician within the past year? Yes [3140. Why? Where? 14. History of or current communicable illnesses: venereal disease, TB infections, "hepatitis, HIV or suggestive of such illness? lethargy, cough, spitting up blood, wealmess, weight loss. loss of appetite, fever. Yes No of appetite. fever. IS. Allergic to anything (drugs, foadpld?nts, etc)? Yes 16. Ever been treated for a. mental disorda' or attempted suicide? When? Where? Yes l7. Painted recently or had a recent head-injm'y? Yes wNo l8. Visualize the mouth, teeth and gums. Are there any dental problems noted? Yes If yes, please commenti . 19. Are there any edical or mental problems you have not told me about? - Yes Mo 20. Use alcoho What kind? How often? When was the last time? How much? I . 21. Use dru kind? How o?en? When was the last time? How much? . 22. Ever had problem following withdrawal of alcohol or drug use? What kind of problem? Convulsions? 23. Females: Current gynecological problems? 24. Language: (circle one) 25. Placement recommendation: (circle one) Remarks: Other emergency treatment next sick call - or on birth control pills? Recently delivered/aborted? isolation i acknowledge that I have answered all questions truthfully and have been told and shown in writing how to obtain medical, dental services. I consent to reasonable and customary medical, dental and treatment offered in this facility. native received educational information regarding personal and dental hygiene. . - V) inmate?s Sianatu Date 1671791 i . . 4? mane-autumna our ee? The GEO Group. Inc. 1- onmina Screen Progress Notes Inmate Name: MANDZA, EVAUN AGE: Inmate Number: 20?32:31511965 Nation: GABON SEX: l'l' va at . UNIT: 10/24/2011 17.05 Date ofBirth: Date 'h?me AllergiesDATECDMPIEED . .1NPROGRESS: Wm- RBULTS: A .: 55,5, Tomcamc mm? MEDICAETKON ORDERS . . Where? Geo HEALTH EVALUATION MANDZA, EVALIN The GEO Group, Inc. DOB: 12I5I1965 Nation: GABON Arrival Date: 10l24l2011 17:05 Inmate Number: . -DateofBirth: 1. Have you ever been hospitalized for an emotional or nervous problem? Yes W, what hospital? - When? A . 2. Have you ever receivedco ling or outpatient mental health treatment for the above? Yes If yes, when? . Where? 3. Are you taking any medication for a nervous condition? Yes Wm of medication/dosage How often? Who prescribed it? How log have you been itthe follow Liquor? How much? How often? - Howlong? ?f I, Have you everbeen treated for alcohol Yes 0 If yes, how many times? Whendid custart thesedru If yes, how many times? months? When? Where? How 10 6. Haveyou overused illegaldrugs? I [Yam 7. Have you ever been treated'for drug abuse? memo?I 4 "gi ?When? Where? How [on 8. 'Haveyou everattempted suicide?l IYesl Ra It??yes, howmanytimes? - Where? . HOSpitalized? . Where? Ifyes, how many times? When? 9. Have you ever thought about suicide? Elme Ifyes,'whenwas the lasttime? I I I Do you think of it o?en? Sometimes? Seldom? 9a: Have you ever hurt yom'selfwithout wanting to die? El Yes?lj??o If yes, when was the last timo? Do you thinkofit-otten? .- Sometimes? Seldom? - Have you ever been-suspended-?om sclibolhl] Yes ?e If yes, how many times? . you 0f Yes how many if 1 :12. Have youeve'rfhad aseime? El'Yele?NtT Ifyes,when? -. Have you everhadaheadmjury? El Y?s Ifyes, when? is: . Blade did you-complete in A 7 . ~515- ?We1'? ?nyspeci? education classes? Yes Bahia Ifyes, What class "335 2 16.-.Are youable? towed and write mew . - - Have-youeverbeenconvicted-ofa vio ent crime? Yes When? ere? .What-ctime? Whatwasyoursentence? :18. Have you ever-heme? victimiot?a. violent crime or. semralabuse7-UYesELNe- Ifyes, When? "Do people con?de: you a Violentoetson? Yes Wyesmhy? . you have ahistory. ofsexual ?Have youeveribeeneonvicted of aggression or sexual assault? Yes . If yes, When? a sexual o??ense? Yes If yes, When? Where How do you feel about your incarceration? fathom-1m, 7m - lion'siekca? Regulation I . aye?x 5 Date PIS-158 A Release of Responsibility for Medical Services The GEO Group. me. ALIN DOB 2, Inmate Number: 4 1 511965 Nation: GABON A - . . . AM mval Date 10/2412011 17.05 Date. (0 ,1 Time, /g I PM This is to certify that l, under thecare of the Inmate Name Facility Name and under medical supervision of an attending physician employed by The GEO Group, Inc., am REFUSING to accept the following treatment plan: 1. Admission to institutional in?rmary Stay in institutional in?rmary 3.. iMedical/Surgicai interventions (Specify) . 4; .?Medica?pn (Specify) Syphilis s. Physician?s (Specify) Services in a Hospital Emergency Room - Diagnostic Testing 8. Services as anziin?patient in a hospital 9. History and Physical including labtests if in appropriate plan, whiciis bein? refused incl din ris 1 . . .dndlagnose?d?Dusehlsea FWCESS - Condition .ncknowledge that I have been informed of the risk involved in re?lsing the above treatment Plan, alld hereby..r?lea3?m?h? - attending physician and GEO ?-om ALL for adverse effects resulting from such re?rsal. a t' L/j Q/abr/px Rev 01103" n-n-.-umcuDIANAssociates Teleradiology UNIVERSITY OF MARYLAND RADIOLOGY CHEST X-RAY TB SCREENING REPORT Phone: 410-328-3471 Fax: 410-328-0641 DIANAssociates INC. Severua Park, MD 2 I46 410644-7846 Fax: ?0644-5203 SITE: NAME: MANDZA, ALIEN DATE OF X-RAY: 10/24/201 1 DATE OF BIRTH: 12/05/1965 STUDY TYPE: FINDINGS: Negative except for calci?ed granuloma (ta) 2cm. SIGNED BY RADIOLOGIST: SIGNED AT: 20] 1/10/24 22: 19:56 EDT - . .mu-u. vw-?v M-u DETAINEE CLASS: . CATION SYSTEM PRINIARY . JSSMENT FORM Name- Date of Birth: - Country of Citizenship: Ea ?g :1 . . .- 51': .. .Date of request: ?6 I 2:3 WI) - (Please check one) (For ?vormarque uno)si?a0ueja med?iga 11. I Ge 1116650 Group. ll . Medic'a?lRequestl. . Solicated De Asistencia Medica DentalComplai: '2 Oueja Dental Fecha de S'oticitud Psintl: Eda/:1} 1 M13 {7421; L?tra-Molde lrunates Name! e3. 20! um Re?lling location! 30b [3331mch Duty Houlsl- Norrhedelneso de?ade mm SiiodeYivh'tda . . . Brie?y state the reason for your request; you will receive a response to your request. Please??llow several days for your 'request to be sulymiuei'answeze?? and returned. A copy of your request will be ?led in you rds. Exp?Que brevemente la razon de su solieimcl. Permita varios dias para que s?usolicitud sea?p?'ooesada. Una?oop'ia de sn solicitud sm-mphivada en sus records. Prisionerbs de-habla hispana pueden solieitar dicha assisteneia en espanol. (27,3, c3 mo tie ey?? PROBLEWQUEJA: del Pre?so . 3' .g DO WRITE BELOWTBIS-IJNEINO .ESCRIBA .0 DE ESTA . bate (sappgate) i I?Iato Reviewed?!" W?tinge'sponse (seefbelow) Bse?m Medical as" ACTION name .. . . . . I Placed on sick call list. Date of-Appointment: I A I B'Plaeed on Date of?p?yimment: ?l?he GEO Group. Inc. Medical-History and Physical Assessment Site: Mental Health Assessment O?aua?on General Health Assessmen Sex: I Problems General- manninch pain. mom - quMIesmns. Woodie Head - nomcepha?c. hair, scalp Eyes - simian. pupils semen. Nose - sinuses "Throat-teeth. abuse . abuse hx - mobility. veins m?dS. - con?g. ausdresp, masses . .Comnguuicablel . Heart-misc Jewel hernia - tenderness, bladder tenduncss. Back -ROM. Extt?en'mies - edema, cyanosis. ROM. Genital:- 1 deferred EVALIN DOB: 12/511965 Natio . . n: GABON Amval Date. 10I24IZO1 1 1 7:05 (W6), ..- no?: ee? Progress Notes sea Group. Inc. MANDZA, EVALIN Site: Auroral ICE Processing Center nos: 1215:1955 Nation: GABON Arrival Date: 10!24(2011 17:05 "Detainee Name: DATE TIME PROGRESS NOTE ORDERS VW340/?Mfwd? 2a Wile boa19/26 mp: MM ?5?1311:- . .. 3o . .. 32?! . I I 1.1.- .. . Ra? er:? .- Amh' . Dianne? - .. 4-. . w?mi?mloa: a aw .- pietuyha?it?Bat-m - mm - ms?: . . . wwi- - ?0159?92'5erme 1 . A. MANDZA. EVALIN DOB: 121511985 Nation: GABON Arrival Date: 10!241201 1 17:05 (bxmc) 5 tom. Medical Request Soiicated De Asistencia Medica mam-?WW Date of request: I (Please checkone) Medical Complaint Dental Complain Fecha de Soiicitud Por favor marque uno) medicg Dental 6 Print Elk?! 0 04232293; per?20 Mata; 1 Letra Moide inmates Name] . Number Housing Lotion Job Assignment Duty Hour Nornbre del Preso Numero Sitio de Vivienda Asignaoion de Trabajo Hares de ?l Briefly state the reason for your requestfyou will receive a response. to your request. Please allow several days your request to be submitted, answered, and returned, A copy of your request will be ?led in your records. Emiique-brevemente :5 razon de su Permits varies dies para que en ooiodtud rea procesada. Una col . susoiicitud sear archivada en sus records. Prisioneros tie habia hispane pueden solicitor dicha assistenoia ones I QUEJA: . CO (Istqu?ED) Hbue??leid?. word? Mr inmate's Signature Firme del Preso WOO NOT BELOW THIS N0 ESCRIBA DEBAJO DE ESTA . i . i A DateReceived: . (Stamp Date} Date Reviewed: A . Written Response {see belowi? Seen in Medical ?mien: Pi?ceri on Sick Call List Date of Appointtnent: 3 :l Placed on Dental List . Date of Appointment: 4 1 Other (Miami .7 (W6), I Medical Request Soiicated De Asistencia Medica Dateofrequest: (7g ll Fecha cle Soiicltud (Please check one) Por favor marque uno) Oueja medlca Mr Number Housing Location Job Assignment 5 print f; .EUQU '1 dz? Lets-a Moide inmates Name Nombre del Preso see The ?au?mm, m: - Medical Complaint Dental Complain Ouela Dental Numero Sitio de Viviencla Aslgnaoion de Trabajo Hares de Brie?y state the reason for your reqcrestfyou will receive a response to your request. Please allow several day your request to be submitted, answered, and returned. A coml of your request will be flled in your records. Emllquebrevemente la razon de su aoiidtud. Permlta varies dies para que su solocitud tea prooesade. Una co susoiidtud sear archivada en sus reoo-ds. Prisioneros de habla?hispana puetien solicitar dicha enes PROBLEM QUEJA: - natal ?(Lung E?s} all .4 inmate's Signature Finna del Preso . Date:Recelved: 'Nor WRETE BELOW nus urge no ESCRIBA DEBAJO DE ESTA mam - . . (Stamp Date) - a . I . Date Reviewedzjz/ ?b . Written Response {see below/? Seen in Medical 'tlcnoumkeu:fl 7JM6 . I Placer} on.Sick Call List Date of Appointment: Placed on Dental List Date ofeppointment: I 3 other (Explain) .. - Zee? Progress Nift?s The GEO Group. Inc. ,1 . Site; Aural-g MANDZA, EVALIN DOB: 12I511965 Nation: GABON Arrival Date: 10l24l2011 17:05 Detainee Name: DOB DATE (TIME PROGRESS NOTE - ORDERS . Q1) Zea/25w ?uf@ Owe It?: i. . . - NURSINGASSESSMENTPROTOCOIS 'l'thEOMlnc. - CONTACT CHIEF COMPLAINT: ?72 AILEIGIES: .Courseandometof Didit to orchanicals: a Yes Pain Scale 1-10: 015 .n fave:- 0 Asthma a Eczema comb-l r= ?q me lsizeof mama: Color! I of rash/lesions: - Dwaibe a aPmtules ?u Vesicles of?mfe?ta?'ecteiu Yes ?raPurulcnt u~Rodnes? a Edema - (-9 mdmcuvith Eknown: andwatal well: ,_ofan Car 'aeamm 3 ?u . Ztabs bidet: EVALIN . DOB: 12I511965 a - . a on. GABON .. Arrival Date. 1012412011 17:05 (W6), 4? wkka Medical Request Soiicated De Asistencia Medica mama?va Date of request: (Please check one) Medical Complaint Dental Complaint Fecha de Soiicitud Por favor ma - ue uno) Ouela medics Dental Lets-a - Moide inmates Name I . Number Housing Location Job Assignment Duty Hours Nombre del Preso Numero Sltio de Vivienda Asignacion de Trabajo Horas de 7: Briefly state the reason for your requestfyou will receive a response to your request. Please allow several days VOW request to be Submitted, answered, and returned. A coml of your request will be ?led In your records. Explique'brevemente la razon de su soiicitud. Permits varios dies para que su soiocitud sea prooesada. Una copl susoiidtud sear archival-la en sus records. Prisioneros tie habia hispana pueden solicitor dicha assistencla enesp PROBLEM UEJA: 0 -- IQ ?fth-if 5'2 344;: inmate?s Signature Firma del Preso . Nor WRITE BELOW 'n-ns until no ESCRIBA DEBAJO DE ESTA unam? DatefReceived: - (Stamp Date), Date Reviewed; . Written Response {see belo?Seen in Medical small! TAKEN: 9 Placeci on Sick Call List Date of Appointment: . I 3 Places! on Dental List :1 Other (Explain) I . m.me The? Am stand: (W6), MANDZA, EVALIN DOB: 12/511965 Natlon: Arrival Date: 10/2412011 17:"R&Em?m 3.0mmh: ?ea-hum; :?mwwh??mmw?u VI Junta 'mms: D. :1Fm??v mwo ?xr pa. GABON . 14m Amt: .malbwda-mamon.? Dada..?f 3 ?any'Moxe .E ?m?m?kbmy??yum?@14?,[?wmimqmor A . ?agFarah #un . Ifstat?sl' "lilaodiis'm?do WW '0 8.mime:- . - 4:121..-. . n. ?will1&c-.1:91 I. Ly . ?1933'Ivl . O. I 1.. 341M137 I a. a a" (6), (WW) .1766Wka - Medical Request Solicated De Asistencia Medica Date of request: NOV 7 (Please check one) Medical Complaint Dental Complaint Fecha de Solicitud Por favor marque uno) Oueja medica ueja Dental I i Print are}! an aim We? 42. Letra Molde Inmates Name Numbfer Housing Location Job Assignment Duty Hours Nombre del Preso Numero Sitio de Vivienda Asignacion de Trabajo Horas de Trabajo Briefly state the reason for your request; you will receive a response to your request. Please allow several days for your request to be submitted, answered, and returned. A copy of your request will be ?led in your records. (. Explique brevemente la razon de su solicitud. Permita varies dias para que su solocitud sea procesada. Una copia de su solicitud sear archivada en sus reocrds. Prisioneros? de habla hispana pueden solicitar dicha assistencia enespanol. Dammit; afgn??o?o SM. Inmate?s Signature/ Firma del Preso NOT WRITE BELOW THIS NO ESCRIBA DEBAJO DE ESTA Date Received: I (Stamp) Date) Date Reviewed: ?l E) Written Response (see below) E) Seen in Medical TAKEN: Fen \lan 171' moi (11/1 cl and 90 diary-HST ?'1th OD "Mama? om huimgim. Emmi/1h) mam/a1 i? sumpth ii, . Placed on Sick Call List Date of Appointment: I [Eflaced on Dental List Date of Appointment: o7 Other (Explain) '3 i A v.0 - (W6), ANDZA. EVALIN 12/5/1955 Nation: \rrival Date: GABON 10/24/2011 17:05 (W6), . Isms W%smw (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) '4 may; . ee? The GEO Group. Inc. EVAHN 008:121511965 Nation: GABON . :?-ArrlvalDatn: .. 7 17:05 . HEALTH SERVICES DENTAL HEALTH RECORD . $01332qu EmmAndN Munch ?faunas-nmhm - msusma 5330mm (complete a: ma) . Cyan-- agr?gamood?m S-?ilw. DATE- DATE DATE DATE - ins-124Medical Request Solicated De Asistencia Medica Date of request: (Please check one) Medical Complaint Dental Complaint Fecha de Solicitud Por favor marque uno) Oueja medics Oueja Dental . 7 Print 31mm Moodza Asa-09 Letra Molde inmates Name Number Housing Location Job Assignment Duty Hours Nombre del Preso Numero Sitio de Vivienda Asignacion de Trabajo Horas de Trabajo Briefly state the reason for your request; you will receive a reSponse to your request. Please allow several days for your request to be submitted, answered, and returned. A copy of your request will be ?led in your records. Exp?lique brevemente la razon de su solicitud. Permita varios dias para que su solocitud sea procesada. Una copia de su solicitud sear archivada en sus reocrds. Prisioneros de habla hispana pueden solicitar dicha assistencia enespanol. PROBLEM QUEJA: EM, 6/ Q, VU mag Ma} Wall 0 Hon Inmate's Signature Firma del Preso NOT WRITE BELOW THIS LINE NO ESCRIBA DEBAJO DE ESTA Date Received: (Stamp Date) E) Written Response (see below) Seen in Medical Gwen l/l/lOl/Vl and Ducal/11x Xi. Q?bgz 5' ll; Xi?da?ls also aux/en 7740 pay razor [mum mm 1721 Fm- Alwnl?da. {01? 0F do 1740 mm rel-urn mazKa? i! st/mpfam persis?/wonwn- Date Reviewed: l\ 2 (l Placed on Sick Call List Date of Appointment: Placed on Dental List - of Appointment: C) Other (Explain) i . . i - 2A. EVALIN DOB: 12/5/1965 Nation: GABON Arrival Date: 10/24/2011 17:05 (W6), -. - NURSINGASSESSMENTPROTOCOLS the-Gli - oonmcr comm: . mam: .Comseandonsetof Wha'ediditstartz 0 a; No Pain Scalel-IO: . of: .u ?wcr As?zma 1: Emma a P=1o Ran qu-M 49/..Oz foldsof behindthe and 0010:] of rash/lesions: Descn'bo a a Pustules 'a Vesicles a excoriation lesions uHivgs . . 'OfSkima Yo's - a Yes the the Amhe'soleofhfebta?eote?u Yes ?of 5.1mm a Edema water! well: 25 . .ofan 1%bid x3 :1 Yes; . tabs bid; 3' f6: bidet: 5 MANDZA, EVALIN DOB: 1215:1965 Nation: GABON Arrival Date: 101242011 17:05 713..?Ge? Progresanms .1 my GEO Group, inc. . Site: Auroral ICE Proces'sing Center 7 21308: 121511965 Nation: GABON "-ArrlvalDate: 1 1012412011 17:05 _2 1 Juan . 1 . . .tl? DATE TIME PROGRESS NOTE ORDERS "19/2/11 . .1050 ?s?i . a, ?3,111.. (- 45w Auk - 5.1mm?, PI: . I . . 175.5/10/11; . a) :0 ks . ~11. 141,5) 02;? . 11015 01 4043 . . 'he Age/L: (zit/0.911! . - L?l? icy/1342;? 1? .. JJ, I h?b/L E/oxy?g 3111 I 1L1 aim/1:31am . .l?o -- - - awe/w Medical Request Solicated De Asistencia Medica Date of request: I Z. I I (Please check one) Medical Complai Dental Complaint Fecha de Solicitud rque uno) Oueja medica Ouejag Dental mil?0i (l Print 2 r) (W6), (mam) G) Letra - Molde Inmates Name I Number Housing Location Job Assignment (Duty Hours Nombre del Preso Numero Sitio de Vivienda Asignacion de Trabajo Horas de Trabajo Brie?y state the reason for your request; you_wi l receive a response to your request. Please allow several days for your request to be submitted, answered, and returned. A copy of your request will be ?led in your records. Explique brevemente la razon de su solicitud. Permita varios dias para que su solocitud sea procesada. Una copia de su solicitud sear archivada en sus reocrds. Prisioneros de habla hispana pueden solicitar dicha assist?ncia enespanol. 15a,er complaint I (L3 beefeanael?m? ?l-b Jakee - I: .. A__n_n xi. are/r}? Hanka Inmate's Signature] Firma del Preso NOT BELOW THIS N0 ESCRIBA DEBAJO DE ESTA Date Received: (Stamp Date) ACTION TAKEN: )7 Date Reviewed: '3 Written ReSponse (see belowl?g Seen in Medical '1 l, Placed on Sick Call List Date of Appointment: I. EPlaced on Dental List I Date of Appointment: (.2. I Other (Explain) (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) Geo The GEO Group. Inc. NAME ?nally ms; menses-maiden: NUMBEI Meal'nater HEALTH SERVICES NURSING ASSESSMENT PROTOCOLS DENTAL - TOOTHACHE PROTOCOL 8.) CW COMPLAINT: Time onset: Pain Any trauma or . >14 chewins. Alleviating factors: Current Review dental record recent extraction, etc): 0.) or Inimy to the tooth: Is tooth positive to White Eat-ache or sore positive): 726 A.) P.) dentist or secondary for speci?c orders or pain, positive to pmussion, or temp 100.4: If none the choice Ibuprofen 200 mg, two 3 . or Tylenol 325 mg, 2 tid pm pain it 3 or seen for next dental call: are present: Nurse may E.) Instruct regarding proper at an angle against the your with your tongue. Repeat on teeth and out. Scrub the all chewing surfaces and then Rinse 3 Instructed to return to medical if persist/worsen: hygiene: brush and ?oss properly each and forth gently but at least a dozen times, of your ?ont the your everyuse Brushforatotal ?10124120113395 22 .r . "no. . . . . Medical Request I Solicated De Asistencia Medica Medical Complaint Dental'Complaint Oueja medica Ouejal Dental Date of request: l7, i (I I (Please check one) Fecha de Sol icitud (.Por favor marque uno) Print 1 MahJZ?l Letra Molde l. (W6), ~206 Number Housing Location Job Assignment tDuty Hours Numero Sitio de Vivienda Asignacion de Trabajo Horas de Trabajo Inmates Name Nombre del Preso . Brie?y state the reason for your request; you will receive a response to your request. Please allow several days for your request to be submitted, answered, and returned. A copy of your request will be ?led in your records. i . (. Explique brevemente la razon de su solicitud. Permita varios dias para que su solocitud sea procesada. Una copia de su solicitud sear archivada en sus reocrcis. Prisioneros de habla hispana pueden solicitar dicha assistencia enespanol. PROBLEM QUEJA: i Fir? Worn the. 14p (seal? imaer gal an Inmate?s Signature Firma del Preso NOT WRITE BELOW THIS NO ESCRIBA DEBAJO DE ESTA i. Date Received: ?1 Date Reviewed: (Stamp Date) Written Resonse see below)Cg?S?en in Medical (W6), (ye Wn Sick Call List Placed on Dental List Date of Appointment: l?L?l ?5 I Date of Appointment: . *mv?b- it? --Q (W6), Baby (Explain) 1W .gezenzs.? La?w A 3 HEALTH SERVICES . ASSESSMENT PROTOCOLS nomenclature. TRAUIIMA PROTOCOL . S.) CHIEF COMPLAINT: onset: 0700 at onset: Pain location: 1 Character: stabbing Pain of previous injury to same site: yes/no When: Most sitting to yes/no so, (if 5 skin broken. notify physician for-order for booster). 03" [weak g" . [uneven [labored normal Range re?ll to Peripheral pulses to appearance: P.) 24 hours (on 45, 15) yes/no; warm compress we 1: . i . wrap applied only): I noti?ed: yes/no time: Orders sick issued: type/eXp. . transfer to ER. cOndition: stable guarded E.) to resume . stay 3: 48 yes/no on use of ice Compresses: instructed to ream: to if persist/worsen: Inmate {um ?mdjzor, can (W6), 4s i on ?Injgries/NonQImlries I 008:12511965 Nation: GABON Date ofBir? 'Arriyamate: 1012412011 17:05 ?nateNmnben Dataofincident: gg?JS?v-It Time: 1130 DPM Place: '?meofnoti?cation: ?r . mermaide Use ofFa-?e 0am: Middle Name: km Nc? mom?? ?Timi mWon th?-diagramysition or place pfidjmy, if any: 7 .3102 K. ,0 2M 1w- - (W6), (W6), EVALIN Nation: GABON Arrival Date: 10I24I2011 17:05 INMATENAME B: 123119 nauqn: - . .. . 33.; tzA, ??gmgah?n'zms??and Physical mews: 1am CHRONIC CLINICS: WEIGHT: [2"59?m: RESP: 3 CIRCLE APPROPRIATE RESPONSE aw - no PRESENTLY 0N MEDS: I me 660 Grqup. GENERAL APPEARANCE ?Ctm Neat Dirty Dishede ism Lam?ons Contusions Bna'ses - NEUROMGICAL I. Headache/Dizziness 2. Speech 3. Pupils 4. Gait Orientation I a Coherenoeof'l?hought Process Special Management Unit Housing Record NameoiDetainee: on. wt in A: . Time Received ii5? Time Reieesed Vioiati'on or Reason: 70? EQHTIND, Admittance Authorized by; LT . [Date Released? Pertinent information; Administrative Segregation Protective Custodyl?Speoaal Management Disciplinary Segregation l~fiedica30oservation a . J: . i Housing Comments- Use Reverse sioe If Date Shift Sh RC: Medicai' Of?cer reouired 2nd :?rat I Pertinent information - Epileotic. Diabetic, Suicidal. Assaultitfe. etc. (Breakfast) (Lunch) (Dinner) Shower?indicate Yes No Refused (P: Rec (Recreation) - log in actuat time, 0900/1000 3 Medical staff will sign the segregation lOg and the housing unitirecord each time a detainee is seen. A: a minimum. the uni: record must be signed attest once each day by a medical staff member. Comments: Conduct Attitide, etc. Additional comments on reverse side must include date, siganture? and titteHousmg Unit Ofncer Signature: AsSigned ofncer must Sign all record sheets eacn shi?. (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) . HEALTH SERVICES NURSING ASSESSMENT morocow me GED Gang, Inc. . -. m: SKELETALWPROTOCOL . (WW sacrum: [cm 1?04 Mm? Liz/ad? . - Timeofonset: ?906 Dlauma .- Painlocation: (Q 10mm . - Radiation: 930% J. f. _e\oae: mmorm" swam pam- . 3 . A . cl?ch . Mtorintamiaenc . Wormw- Cg,? o/aumn an.? scum Medications: . - . . trugER ?Numbnessor?ng?ng: 14,0 - - /39/m 1?1 1* 570.2: (45 vmway Lmsso?nds: diam Methodot?anivaltamedicah ,mimg- - Heausounds: - . Falshrina- @Sidn- . L, - 'Abmsions?bleeding: j" 4g . - . Braking-Noni. rid-ed - Swelling y- - a104? 0F main with Elgagm . . 4; -. . . . - ?sun?rmtaw: amncas - 1 P?iphetafpulses divaltoitM' l\ P: PJR?n?lmeegxt-unitymumoold - - - 1 ., IfW?rqtinvolved: issuatzmc'hesHm? a?mt two tablets 6139.0. 1: 3 days: . 'or igu- 200 Em Whid-poxS days: - ?1711910?5 Padang! Win12;- of- . 3; 'apply magma areamrioe daib'. ,b?seva'epabg comm Maia, or} notgjm'lywcian/br. spec??: orders: E.) Instructed pm; to avmd hwy liking, strenuous nun! pmblem resolved, to machqu gradually, and return to medlcal ifppoblcm Mists 91" 23 4 I Instructed to keep ?umtyelevated and'useoold/mtm compresses dorm. \f 05 Inshuctedtoavoul contact vadi ?3 on bene?ts of regular excm'se, slowly progmss'ing to 20 marines Q1) weekly q??er . ea:- ALIN (bxe), DOB: 121511955 Nation: GABON . . Arrival Date: 10042011 17:05 I Medical Request! Group, Inc. - . Solicated De Asistencia Med'ica' (We) Date ofrequest: 0 2: 12, (Please check one Medical Camp amt Dental Complaint de oHcitud I Cu '3 medica ?a Dental E??l??-Hll . e} OJ Print/z Letm-Molde Inmates Name! Number/ Housing Location! Job Assignment! Duty Hours/ Nodhedell?reso . Nmnao S?odeViviemh - Harasde'llabl?o Brie?y state the reason for your rogues: you willmeive a to you; request. Please allow several days for your . requesttobe submittemahswered, and returned. A cepy of your request will be ?led in records. . 'Explique brevemente la razon de su solicitud. Permits varios dias para que su solicitud sea prooesada. Una oopia de su solicitud sera 'mbliivada en sus Prisioneros do ha'bla pueden solicitar dioha assistencia en eSpahol. PROBLEWQUEJA: Preso DO NOT uEmw'nm yum/ism Escmm DEBAJO DE gm Recelv?o? (stamp Date) . . . {pate harmed? 5 I Written Response (see helm In Medical? ..kemON'rmm - - . rile A n- .. TPlac'edoi Qihk?mu'?st' Dst?e EDI-Appointmentmeet! list - - hare orAppotnunem I I Merriam); - - A (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) HEALTH SERVICES GEO GINO. Inc- NURSING ASSESSMENT PROTOCOLS a, . ABDOMINAL PROTOCOL S.) CHIEF . ALLERGIES: History disease/ recent surgeries! recent Time/Activity at onset: After eating, does increase decrease Pain location: Duration: . or Current . factors: Cramping stabbing Flaws: I 3 Scale 1-10: Last BM: Consistency: a Amt: I Blood (ifyes, red black/ or maroon, and amt): or Degree: Urinary ?'equency: Low 7 7 Dietary habits: Fat O.) . Bowel Sounds: in all 4 quadrants: Rebound tenderness: states blood in stool, do Pain location: More standing Able to sit ?ushed cyanotic mild severe n/a Bladder orthostatic . distress severe distress Obvious anxiety: A.) A . P.) The Nurse may Patient the choice of Antacid, Magnesium, Bmetrol, to vaorniting .or clear diet 24 lay-in unless otherwise or severe in otherwise ordered: 0 . nausea or vomiting com?patlan, . mutate: or pt appear mat E.) to avoid eat small meals, chew and 6-8 glasses water Instructed not to lie down at 2 after eating: Caution to quit a ., Instructed on stress measures, high diet, adequate exercise: Rem gs . -. instructions: :5 i . . MANDZA. EVALIN I NUMBEI nos: 12I5l1865 Nation: GABON Arrival Date: 1012412011 17:05 .1: 1 :25) ?as, "'I'zsmo SIGNATURE INVESTIGATION REPORT Detainee Name: ?20m dza- ?rm?[in . #51" Date Time of Incident: lg 696916) Place of Incident: 3 an 1' 7L Housing As'signment: 43-. Date of Investigation: adv/5%- 4,3 Code(s): 32:2- 3 f?cer: advised that he/she has the right to remain silent at stages of the disciplinary process, but, I I 7 that silence may be used to draw an adverse inference against him/her at any stage of the disciplinary process. However, silence alone may not be used to support a ?nding that he/she committed a prohibited act: Detainee Statement and Attitude during the Interview: Dc?riauvt 61? I?YWaqmolza? (2:126:31 I 1?79? nice! .zvi'll-lt 1 Cl" lair-?r I rung/'ch Cut {p I Lam am?th?pf +0 kmoed Opt/3 4 niceJXQ LURE dezfl?g t/lfa} Other Facts About the Incident witness statements, disposition of evidence, etc.): A Slain/.7) can (Tia-n Lo/za? ?v'?lzh aid/11': ?at/Ht; ccxr?tL?SS Ar gnawed Lentil-A J41 [jet/diam? Investigator?s Comments and Gig.?? gm? tie-L4 3/91 1.252 ital/-1 654? AC5 anew-q diff-7771331614 510 L160 5 ?tzt 441 cu r5 Date and Time Investigation Began: j- Date and Time Investigation Ended: 4-, 1 Z, 5 Reviewed for Accuracy by Supervisor I . Avv??~u?t?lh?luh? nw-h-vo?umc- an." M. . INSTITUTION DISCIPLINARY PANEL REPORT Detainee Name: Eng}; .4. A-Number: I 1 Date of Incident: t/t g/Ze r1, Code(s): 3 a ?7 '5 Sq Notice of Charge(s): A. Advance written notice of charge(s) (copy of Incident Report) was given to the detainee . at (Dale) (Time) B. The IDP hearing was held on at (Date) C. The detainee was advised of his/her rights before this IDP by (OlTIcer) on and a c0py of the advisement of rvorm is attached. (Date) 1 II. Staff Representative: A. Detainee waived his/her rights to staff Vent ve: B. Detainee reQuested staff representative (1 appeared. . (Sta Representative] C. Requested staff representative dec he or could not appear but detainee was advised of option to postpone hearing to obtain an alte tive staff representative with the following result Presentation of Evidence: A. Detainee has been . vised of his/her right to present a statement or to remain silent, to present documents, in ding written statements of unavailable witnesses, and for relevant and material witnesses a appear on his/her behalf. B. Suminm'y of detainee?s statement: C. Witnesses: 1. The following persons were called as witnesses at this hearing and appeared: A summary of testimony of each witness is attached. The following persons requested were not called for the reason(s) given: Wk.) 4. Unavailable witnesses were requested to submit written statements and those statements received were considered (statements attached). Documentary Evidence: In addition to the incident report and investigation, the panel considered the following documents: 6. Con?dential information was considered by the?IDP and was not provided to the detainee on Date) IV . Findings: a. The Act was Committed as Charged b. The Following Act was Committed: c. No Prohibited Act was Committed V. 6 Speci?c Evidence Relied on to Support Findings VI. Sanctions or Action Taken: Offense Severity: Hearing Board Chaim/(arson Date Heayrd Member Date Healing Board Member I Date Review and Concur: A. Concur with ?ndings: B. Proceedings terminated: C. Discipline Imposed: Findings Administrator?s Signature: Date/Time: Cop)I delivered to detainee by: . on 7 (Signature and Title) (Dale) (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) NOTICE OF INSTITUTION DISCIPLINARY PANEL HEARING AVISO DE LA AUDIENCIA DISCIPLINARIA DEL PANEL DE LA INSTITUCION Detainee Name: mmni7q in - A-Number: Date: I I [Ct iiZ Alleged Disciplinary 3,3 Date of Offense: i 13:] You are being referred to the Institution Disciplinary Panel for the above-mentioned charge(s). Le estan re?riendo el panel disciplinario de la institucic'in para las cargas. The hearing will be held on the next available business dav within rescribed ti 5 . at 0730? 1600 hours (time) at the following location The GEO Grou Inc. I.C.E. Proc La audiencia ser? llevada a cabo enrel dia Iaboral disponible pr?xiino prescritas), en 0730-1600 horas (tiempo) en la localizacion siguien Proceso del centro. ntro cle ?pocas os GEO Group, Inc. You are entitled to have a full time staff member epres you at the hearing. Please indicate audiencia. Indique por favor abajo si uste esea tener una ayuda del miembro del personal usted= si es asi su nombre. I (do) wish to have a staff representative. If so, the staff representativ 5 name is: You also have the rig to call witnesses at the hearing ant to present documentary evidence on your behalf; provi d, that calling your witnesses will not jeopardize facility security. Names of witnesses you ,'sh to call should be listed below. State below what each proposed witness would bye/to testify to (be speci?c) Usted bi?n tiene la derecha de llamar testigos en la ?audiencia de presentar certi?cado just/'cggii/o en su favor; con tal que, eso que llama sus testigos no comprometa seguridad de facilidad. Los nombres de testigos que usted desea llamar se deben enumerar abajo. El estado debajo de cual podri'a cada testigo propuesto atestiguar (sea especi?co): Name: A-Number: Can testify to: Name: A-Number: Can testify to: Name: - A-Number; can testify/to: The chairperson of the Institution Disciplinary Panel willsca?l listed above as witnesses (staff or detainee) who are reasonably available, and who are detennin chairperson to be necessary for an appreciation of all the circumstances surrounding the charge(s). Rep ntative witnesses need not be called. Unavailable witnesses may be asked to submit written statem 5. If additional Space is required, use the reverse side of this form. El presidente de] panel disciplinari la instituci?n llamara esos enumerados arriba como testigos (personal 0 detainee) que est?n razonable nte diSponibles, que son detenninados por el presidente para ser necesarios para un aprecio de todas 's circunstancias que rodean las cargas. Los testigos repetidorcs no necesitan ser llamados. Los testi inasequibles se pueden someter declaraciones escritas. Si se requicre el cspacio adicional, utili el dorso de est. DETAIEE RIGHTS AT THE INSTITUTIONAL DICIPLINARY PANEL HEARING EL DETAINEE ENDEREZA EN LA AUDIENCIA DISCIPLINARIA INSTITUCIONAL del PANEL (IDP) The right to have a written c0py of the charge(s) against you at least 24 hours prior to appearing before the IDP. The right to have a full time member of staff who is reasonably available to assist you before the IDP. The right to call witnesses and present documentary evidence in your behalf, provided institutional safety would not be jeOpardized. The right to remain silent. Your silence may be used to draw an adverse inference against you. However, your silence alone may not be used to support a ?nding that you committed a prohibited act. The right to be present throughout the IDP decision, except during committee deliberations and where institutional safety would be jeOpardized. The right to be advised of the DP decision in writing and the facts supporting the panel?s decision, except where institutional safety would be jeopardized. The right to appeal the decision of the IDP- by means of the Detainee Grievance Procedure to the Facility Administrator within 15 days of the notice of the panel?s decision and disposition. Como un detainee cargo con un acto prohibido, usted se ha refcrido el panel disciplinario de la institucion para la disposici?n. Mientras que en la audiencia de IDP, usted tiene las derechas siguientes: 1. DJ derecho de tener una copia escri ta de las cargas contra usted por lo menos 24 horas antes de aparecer antes del IDP. El derecho de tener un miembro a tiempo completo del personal que esta' razonablemente disponible 'para asistirle antes_del derecho de llamar testigos de presentar certificado justificativo en su favor, con tal que la seguridad institucional no fuera comprometida. El derecho de seguir siendo silencioso. Su silencio se puede utilizar para dibujar una inferencia adversa contra usted. Sin embargo, su silencio solamente no se puede utilizar para apoyar encontrar que usted cometi? un acto prohibido. El derecho de estar presente a trav?s de la decision de IDP, excepto durante deliberaciones del comit? donde estan'a la seguridad institucional en peligro. derecho de ser aconsejado de la decision de en la escritura de los hechos que apoyan la decision del panel, a menos que cuando sea institucional la seguridad fucra comprometida. El derecho de abrogar 1a decision del IDP por medio del procedimiento del agravio del Detainee a1 administrador de la facilidad en el plazo de 15 dias del aviso de la decision de la disposici?n-del panel. I hereby acknowledge that I have been advised of and understand the rights afforded me at the Institution Disciplinary Panel Hearing. Reconozco que me han aconsejado de entiendo por este medio que las derechas me produjeron en la audiencia disCiplinaria del panel de la instituci?n. SignedJ/ 3% Notice of Rights given to detainee by: Date: A i Z. Refusal to Sign I have personally advised of the rights afforded detainees at the Institution Disciplinary Panel hearing. The detainee refused to sign the acknowledgement. I Staff Member and Date: Vi? aiver of 24 hoursNotice I have been advised that I have at least a 24-hour notice pn'or to appearing before the IDP. At this timeI wish to waive this right and proceed with the IDP hearing. Me han aconsejado qu'e tenga por lo menos 24 avisos de la hora antes de aparecer antes del IDP. En este tiempo deseo renunciar a esta derecha proceder con la audiencia de IDP. Detainee Si gnature/Date and Time: UNIT DISCIPLINARY COMMITTEE REPORT OF FINDINGS AND ACTIONS Detainee Name: Mandza. Evalin-Ali A-Number Date of Incident: 01/1 8/2012 Incident Location: A-3 Housing Unit Prohibited Code(s): 307. 314 Committee Action: Comments to Committee from Detainee regarding the above Incident: Interviewed Detainee Mandza stated under his own admittance that he refused to move unless he spoke with the lieutenant. It is the Finding of the Unit Disciplinary Committee that: . You committed the Prohibited Ac as Charged: Code(s): 307. 314 . You committed the following Prohibited Act: Code(s): 307. 3 I 4 . . You did not commit a Prohibited Act as charged: Committee Findings are based on the Following lnformation (witnesses. con?dential information. etc. NOT of?cer?s reports): Detainee Mandza was found guilty ofthe above codes and given a warning. Committee Action: Refer to Date Time: January 19. 2012/ 1310 Loss ofPrivileges Loss of Job I: Housing Changes Restrict to Dorm Remove from Program Reprimand Warning Con?scate Contraband lmpound Personal Property Comments: Detainee Mandza was found guilty and given a warning and to bc-moved back to the housing unit. UDC Chair-person's Signature Date/Ti me: 01/1 9/2012/1330 Date/ ime: 1 80VX UDC Member's Signature: Copy delivered to detainee Rev. 3/05 .unmn. . . a? MANDZA EVALIN ?ical a? ?mu. Inc. mm NAME DOB: 1215l1965 Nation: GABON 1012412011 17:05 110- Arrival Date i I NO mm: ?001.90): 4201 RESP: 4'42 0m: @7523 CIRCLE APPROPRIATE RESPONSE l. Headadze/Dlzziness Year (5'01 DETAINEE SYSTEM SECONDAK. .SSESSMENT FORM Name: In (Q) Mam/L DateofBirth: ?309/b( Counu'yofCitizenship: - GHG Date; DETAINEE SYSTEM ASSESSMENT FORM (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) Medical Request . Solicated De Asistencia Medica Date Of request: 2/ I LII I Z. (Please check one) Medical Complain Dental Complaint Fecha de Solicitud Por favor marque uno) Oueja medica ueja Dental I ii print/z aloha Hamlets; A3400 Letra - Molde Inmates Name Number Housing Location Job Assignment Duty Hours Nombre del Preso Numero Sitio de Vivienda Asignacion de Trabajo Horas de Trabajo . (7 - Briefly state the reason for your request; you will receive a response to your request. Please allow several days for your request to be submitted, answered, and returned. A copy of your: request will be ?led in your records. . Explique brevemente la razon de su solicitud. Permita varies dias para que su soiocitud sea procesada. Una copra de su solicitud sear archivada en sus reocrds. Prisioneros de habla hi5parEa pueden solicitar dicha assistencia enespanol. PROBLEM :2 mm will, i 5 I i Inmate's Signature] Firma del Preso NOT WRITE BELOW THIS NO 5502135 DEBAJO DE ESTA Date Received: (Stamp Date) Date Reviewed: g] Written Response (see ?elow) El Seen in Medical I ACTION TAKEN: . I - tanf 3:65 {it/I?th Placed on Sick Call List Date of Appointment: Placed on Dental List Date of Appointment: El Other (Explain) .0 . The GEO Group, Inc. Consent to Dental Procedures Inmate Name: mania Inmate Number. DateofBirth; I hereby authorize The GEO Group, Inc. and treat me as is necessary in her judgment. . The prdcedure(s). ?l'Db J74 - {Laymmx 's tenns) necessary to treat my condition has been fully explained understand the nature of, and risks associated with, this pmcedure(s). Brie?y stated, they are: (BMW) Possible Risks: . A. Infection, discomfort, or swelling a?er tooth removal. 33. Heavy bleeding that may be prolonged. C. Injury or tenderness of adjacent teeth. D. Stretching of the corners of the mouth with resultant and/or bruising. E. Limited or painful opening of the mouth for several days or weeks. F. Decision to leave 'a small piece of root in the jaw when its removal would require extensive surgery. G. Breakage of the jaw. H. to the nerve underlying the teeth resulting in numbness or tingling of the lip, chin, gums, cheek, teeth, and/or tongue on the Operated side; this may persist for several weeks, months, or in remote instances, pennanently. I. Opening of the sinus (a normal cavity situated above the upper teeth), to the mouth requiring As. .1. umut". Gee Medical Request! The GEO Group. Inc. Solicated De Asistencia Medica Date of request: 3 l? I Z. (P1easc check one) Medical Complaint Dental Complaint Fecha de Solicitud (Por favor marque uno) Oucja medica Oueja Dental even mm Lena-Molde Inmates Name! Number/ Housing Location! Job Assignment/. Duty Hours/ Nimiero SitiodeVrvierrla AsignadmdeTmbajo HorasdeTrabajo Brie?y state the reason for your request; you will receive a response to your request. Please allow several days for your request to be-submitted, answered, and returned. A copy of your request Will be ?led in your records. Explique brevemente la razon de su solicitud. Permita varios dias para que su solicitud sea procesada. Una copia de su solicitud sera archivada en sus records. Prisioneros de habla hispana pueden solicitar dicha assistencia en espanol. Frown}: burning [the Inmate?s Signature/Firms del Preso NOT WRITE BELOW THIS ESCRIBA DEBAJO DE ESTA Date Received: (Stamp Date) Date Reviewed: 5] 9- Written Response (see below) Seen in Medical ACTIONTAKEN: ?ax/an nor/IL nf? Magmia. Owl?29049 morbca? 1?1? ?5 u, \?30 r51 0.) 0 QPlaced on sick call list Date of Appointment: ?5 CD I 9 El Placed on Dental list Date of Appointment: Other (Explain): Medical Stafl'Si ature Date I 1 7 GEO 6mm- lm NURSING ASSESSMENT PROTOCOLS . cmcommnm - -on atonset: ormaroon, Scale 1-10: 0 mild nouo at onshessre?efmeam ?ber MANDZA, EVALIN 008:121511965 Nation: GABON - . Arrival Date: 10:24:20" 17:05 .. U. A. (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) ee? Medical Request/ The can Group, Inc. Solicated De Asistencia Medica Date of request; (please check one) Medical Complaint 7 Dental Complaint Fecha de Solicitud (Por favor marque 11110) Oueja medica Oueja Dental print]; uo Letra-Molde Inmates Name! Number/ Housing Location/ Job Assignment! Duty Hours] NonheddPreso Nmnao SitiodeVivienda AsigaimdeTmhajo Brie?y state the reason for your request; you will receive a response to your request. Please allow several days for your request to be submitted; answered, and returned. copy of your request will be ?led in your records. Explique brevemente la razon de su solicitud. Permita varios dias para que su solicitud sea procesada. Una copia de su solicitud sera archivada en sus records. Prisioneros de habla hispana pueden solicitar dicha assistencia en espahol. bar" Mame which?): bumy?. Sinatra asam Mqucl'Zq Inmate?s Signature/Erma del Preso NOT WRITE BELOW THIS ESCRIBA DEBAJO DE ESTA Date Received: (Stamp Date) Date Reviewed: '0 Written Response (see below) ?ew in Mediealv ACTIONTAKEN: M?e/f #40 With/M. Zoe/4.419 [4ng AW JD Placed on sick call list . Date of Appointment: Placed on Dental list Date of Appointment: . Other. (Explain): Date (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) ee? Medical Request/ The GEO Group, Inc. Solicated De Asistencia Medica a Date of request: 37 3 I 2. (Please check one) MBdiCal Complaint Dental Complaint Fecha de Solicitud (Por favor - ue uno) mOueja medica Oueja Dental . Housing Location! Si?Oderimda Wendel. Haasth pm?: quim Mom. Lena-Molds Inmates Name! Mnhed'dPreso Nlnmo . - 0 1 .1 Em! Mm?zq . Inmate?s Signature/Firma del Preso Date Received: - Date Reviewed: Written Response (See below) ?eet: in Medical ACTIONTAKEN: MS lg: A pm @110 0Q MM c. 79.7 may \r I Placed all sick call list Date of Appointment: I Placed on Dental list Date of Appointment: I Other (Exinlain): - I mealStaffSignature Date .I U'Wguigwom nun nau- . . B: . . Mixture-I a . A . 'hnu: w. - . gar If?tawabodin?muo 'meats . . . .. . -- . .- mammathnJa v?v-rv' . i . 'bpw . -- .(W6), Jlfy?l? If, . (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) sh ..Mv._ju . . .l1 . m. ?k1o? WA 3 ..I :Iil I .. . .ge, Hue lm-r.. .M . \xEm? rmg? 1- awkl.zlulaalx liar.: MJ a i 1% ?31 RINKI Il1l L1 zillill .- \u ?v ,3 nil . jr?; ALL: :14. ?1?34? (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) (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) (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) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) .65/14/_2812 14:56 4666663675 RURAL PAGE 61/66 CD Flefd Medical Coordlnotar- Denver Field twice 12445 E. CaleyAvenue Centennfal, C080111 720-8 a?'lce) 202-321 BB) 8-66-31 -- 7 - 1'0: It:qu FROM: FAN: PAGE: 2 PHONE: magma GATE: 511m Mandza, EvaIIn-All mm? Urgent For Review I: Please Comment .Please Reply Please Reach: Comm: Please provide cop! of the ambulance report. Transport took place 4/12/2012. Thanks 35/14/2812 14:56 4805053675 RURAL METHJ PAGE 82/86 nmuumnv: canny: runs-u rum: OF CNTRI. COLORADO EVELYN pomzen WWII 8W 5 AZ 85252-2812 8611189 10091268 9 4/12/1 2?33: momma 'ro'm?mTf mum-ram $1,316.31 $.00 81,316.31 "mme Rum/mm or cm comma m? 0 BOX 52202 FROM: 3130 OAKLAND 8T simmers PHOENIX AZ 85072-2202 To: AURORA SOUTH CAMPUB 808611189 EVALIN WM 1419 DETROIT ST APT 24 DENVER CO 80206-2441 Federal Employer 11) TOFI NOTE: P87 81' CREDIT CARD. 383 NOTIGE (INTI-IE BACK FLEASE KEEP ms mm Fan mun mes PATIENT my?. my!" INVOICE DATE: 5/14/12 808611189 INV: 0001009126869 an mm. an --: -. ghee: AURORA FIRE DEPARTMENT no. mo: MOFCALL Na 3130 OAKLAND 81' 10091268 9 4/12/1 6:23:32 100930997 70? AURORA SOUTH CAMPUS f. - manna - mount . 4/12/12 ALS BERGENCY 1 947.619 947.6? 4/12/12 - MILEAGE '7 17.51 122.57 4/12/12 INFECTION CONTROL SUPPLIB 1 13.95 13.95 0/12/12 OXYGEN SUPPLIES 1 105.88! 105.88 4/12/12 KG 5: CARDIAC SUPPLIES 1 111.72 111.72 4/12/12 PULSE OXIHETBR PROBE 1 14.52 14.52 mm mm $.00 $1,316.31 mm Or .m Pedaral Employer ID mu as: mm m: mama nun nun-mm mum on such: (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) 55/14/2812 14:55 48868535735 PIEGE Emma FINAL Patient Care Report Rum-1m Multan? 33;"ng Aurcm. Printout 51m:- WS-lm Ava Run Numhu: 3253 Banal-Bani?: Fulani Nan-u: Emlin Mann gm?. Trinqn Tag 8: 353 471.1? I-n- Hc?I-I-w-j?nuq Inhn?mum?l In "HI-I?upnm ll Im?mmI-? un?l? 51mm Dear-Hall!? - In?. gm [5mm mm m: Hit-Hun. 171?: ll?'l Hum-Mm Pun-t aura-tr: Nov-rail law-Ham cut-Mutton to: llOruEMA I?th?dLIluhHu9_ I. 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(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) sassat- FIRE DEPT nausea pm. 05-03-2012 I i! lnoldentNumher 00001-2012-011559-00 1 EMS Patient Care Report Patient Name Mandza, Evailn D'P'mm'? Incident Loeatlon 3130 Oakland Street {80011) Incident Date O4f12i?O12 Time of Call 08:21:46 Shift BShiit Patient iniormation Age 46Yeara Gender Male Ethnicity Black. non-Hispanic History Bounce Patient Patient Weight 150 Pounds (Approx) Current Medications The patient denies taking any medications currently. Allergies The patient denies having any known aliarglee. Medical Hletory The patient has a history ot Barriers to Patient Care None Advance DIreetlvee None Alcohol I Drug Use Indicators None No Claeeitioation Medical Cardiac Arrest 2Hours tat Patient Contact 06:23 Provider'e impression Chest pain and Heartburn indigestion - mnpoglttan Transported by FluraLiMetro. Initial Condition Green {Good} Printed on comm 2 at 15:00:49 Page 1 of a 30333 FIRE DEFT 03: 19:49 pm. 05-08-2012 4 IO Incident umber meet-zois-oiisse-oo EMS Patient care Report Petient Number 1 Patient Neme station. Evalln Pi" Tienepomd By Floral/Metre 'l'ilneported To TMGA (The Medical Center oi Aurora) Benoit Diversion Deetinetion condition Unknown Suiting Miiee I Ending Mites Assessments 'l'ime mebnents It Assessments 08:29 Position: Supine; Blood Pressure: 135185; Pulse: so (Regular); Fiespiratlons: 20 (increased. not labored): Perceived Pein: one: Pulse Oximeiry: 100 (On Oxygen); Movement of Exirernitiee: x4: Level oi Concieuenem: 15 (MEI-6): EKG interpretation: Normal sinus rhyihm ??atten by automated device: 43:80 l?cttiluenm b; ~Eml'ie.iisil candle: Response: No change: minimization: Protocol (standing order): administered '3 0 0W9 06:82 12 Lead Gordisc Monitor; Authorization: Protocol (standing order); psrionned by COMMENT: no ST segment elevation. no ectopic beats observed I. (W6), HIPM information l-iiPM inie'rrnetion given to patient Inicnn alien we: Bigneture obteinerl No titet eigneture was not obtained - Patient transported by other agency 1'reneier oi cm cere ?i?reneierred To eignetureweonot obtained . - no We at the Immigration detention facility. we located the Pt in an examination room lying supine on an examination table. Scene scans. Pi is a 46 y/o male who is conscious and alert. Pt states a CC of mldiine chest pain. Eo- Pt states medical hit. no current medications and nkde's. Pt states he hasn't had it bowel movement in the past four days. Pt states he ate a bowl of soup last night. that contained a large A smountofliot chili peppers. 0- bours?sgo, Pt woke up from sleep with cement pain. P- polo is repioducibieupoomovement. enriches: wellpaipation. Q-Ptstetss it is abumingsensetion. states the burning travels from hie-uppersbd, to his esophagusdenies nausea/vomiting. Pt states no diephoie'sis. .A- Gerrerei Impression: Pt is conscious _and i3 ?0 verb?! ?mm Pt is was no. smears 30m. FIRE DEPT 03:20:11p.m. as?ca-am 'mmu";w"m EMS Patient Care Report Patient mute Manda. Evalln mm" h- r? gamma at 15:60:49 signs of pain or respiratory distress. open/patent, increased/unassisted. skin warm and dry, radial pulse strong and regular. heent clear. chest wall stable rise and fall equal. breath sounds clear and equal bilateral. abd soft non-tender. pelvis stable. mcex4. gcs=15. vitals as recorded. Pt was placed onto ?pm 02 prior to our arrival by facility nurse. [2 lead ECG revealed a Sinus no 81? segtnent elevation or ectopic beats observed. Pt was packaged onto the pram and removed from the facility. Pt was secured into RM 101 for non- emergent transport to TMCA South due to AIP diversion. Immigration detention of?cer accompanied RM 101. Pt states no ?uther complaints. Rn See Treatment. Tu See Encounter. Upon release of care Pt's condition had remained unchanged. drive or STATEMENT-- Submittedby: a? we 016: cm Report completed by: on educate a; h" . - . - (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) 5/4/2012 11:39 HM FROM: Port 15 TO: 9,18663110973 PAGE: 002 OF 318 THE MEDICAL CENTER OF AURORA South Campus North Campus Centennial Medical Plaza 1501 South Potomac 700 Potomac 14200 East Arapahoe Road Aurora, CO 80012 Aurora, CO 80011 Englewood, CO 80112 PATIENT NAME: ACCT 340000734489 MR LOCATION: E.SURGIN ATTENDING PHY: ADMITTING PHY: CARDIAC CATH LAB Case No.: 42299 ADMISSION DATE: 06/12/2012 PROCEDURE DATE: 04/12/2012 CARDIOLOGIST: MD PROCEDURE: Coronary catheter insertion, coronary cineangiogram, drug?eluting stent to the left main coronary artery and PTCR of the left anterior descending artery. INDICATION: Acute anterior myocardial infarction. Procedure as an emergency. DESCRIPTION OF PROCEDURE: The patient was brought to the cardiac catheterization laboratory and quickly prepped and draped in the usual sterile fashion. A 6-French sheath was placed in the right femoral artery, a 6?French XB 3.5 guiding catheter was positioned. A Prowater flex guidewire was positioned down the left anterior descending artery. A 2.5 12 mm TREK angioplasty catheter was positioned across the total occlusion and inflated to 12 atmospheres for 10 seconds. The angioplasty catheter was then removed. The patient then went into ventricular tachycardia and then a arrest. ACLS protocol was begun, including CPR cardioversion. Of note is that the patient had received an Angiomax bolus and infusion prior to the balloon inflation. The patient received 3 mg of epinephrine IV. The guiding catheter was pulled back. The patient then developed a blood pressure of close to 200 and a heart rate of at least 140. This was transient. The guiding catheter was then removed and a 6?French JL4 guiding catheter was positioned in an effort to try and not have the guiding catheter into the left main as it was realized this was the source of the embolus to the left anterior descending artery and there was a severe stenosis there. We were not able to visualize the left main with this catheter and this had to be removed. An aortic root shot injection was performed which still did not show any filling into the left coronary artery. This guiding catheter was then removed and an KB 3.5, 6?French guiding catheter was then repositioned. During this time, the patient received continued CPR. He required multiple defibrillations at 360 joules in an attempt to revive him. PATIENT NAME: ACCOUNT ?zE40000734489 Denver Qatient Care Inquiry (PCI: OE Database COCAA) Run: 05/04/12?llz35 page 1 of 3 5/4/2012 11:39 AM FROM: Port 15 TO: 9,18663110973 PAGE: 003 OF 018 Also of note is that a 7?French sheath was placed in the left femoral vein in an attempt to access the artery and place a balloon pump. The artery was never able to be accessed on that side and the balloon pump was unable to be placed. A temporary pacemaker wire was positioned. A second 6-French XB 3.5 guiding catheter was then positioned to replace the Judkins catheter, and the Prowater flex guidewire was positioned down the left anterior descending artery, and a Runthrough guidewire was positioned down the circumflex artery which now also had an embolus in it, presumed from the left main ostium. A Xience 3.5 12 mm stent was positioned across the ostium with restoration of patency; however, by this point the distal arteries had at best TIMI 1 flow and ultimately had TIMI 0 flow. No further interventional maneuvers were then able to be performed. The patient received a final defibrillation of 360 joules but had no electrical activity. Because of the embolization into 2 arteries and now the TIMI 0 flow throughout the whole left coronary system despite a patent left main coronary artery, it was felt he had microvascular thrombosis and there was no hope for resuscitation. The patient was then pronounced dead at 8:38 am on 04/12/2012. Procedure time: 52 minutes Fluoro time: 11.5 minutes Contrast: 100 mL Isovue Fluids: 1000 mL normal saline MEDICATIONS ADMINISIERED: Fentanyl 50 IV versed 1 mg IV Benadryl 25 mg PO Epinephrine 1 mg IV 36 Angiomax bolus 11 mL, plus drip 250 mg/50 mL NS 26 mL/hr Solium Bicarbonate mEq x2 Calcium Chloride 1 mg IV Amiodarone 150 mg IV FINAL DIAGNOSES: . 1. Successful stent placement to the left main coronary artery. 2. Unsuccessful percutaneous intervention of the left anterior descending artery, which was felt to have been occluded from an embolization from . the left main. 3. Unsuccessful resuscitation of the patient due to no flow into the entire left coronary circulation due to a combination of embolization from the left main and thrombosis of the microcirculation due to no flow and prolonged CPR. WXEJWUXQ D: l4/l 012 08:25:48 T: 04/13/2012 09:08:32 uob 761752/509640304 PATIENT NAME: ACCOUNT Denver Patient Care Inquiry (PCI: OE Database COCAA) Run: Page 2 Of 3 5/4/2012 11:39 AM FROM: Port 15 T0: 9,18663110973 PAGE: 004 OF 018 Electronically Signed 05/02/12 at 1439 PATIENT NAME: ACCOUNT Denver Patient Care Inquiry (PCI: CE Database COCAA) Run: 05/04/12?llz35 by ammxmaxq Page 3 of 3 5/4/2012 11:39 AM FROM: Port 15 TO: 9,18663110973 PAGE: 005 OF 018 THE MEDICAL CENTER OF AURORA South Campus North Campus Centennial Medical Plaza 1501 South Potomac 700 Potomac . 14200 East Arapahoe Road Aurora, CO 80012 Aurora, CO 80011 Englewood, CO 80112 PATIENT NAME: ACCT E40000734489 MR E001113503 LOCATION: E.ERHOLD ATTENDING PHY: ADMITTING PHY: HISTORY PHYSICAL REPORT ADMISSION DATE: 04/12/2012 REASON FOR ADMISSION: Acute anterior MI. HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old gentleman whose history was limited as the patient was in severe pain and not very communicative. He apparently had chest pain starting at 4 o'clock this morning while he was in the detention center. The pain was obviously severe and an EKG was eventually done there at 5:45. He was transported here because of ongoing pain. Upon arrival here, he was found to have evidence of an acute anterior MI and a cardiac alert was called. The patient's history again is very limited. He denies having similar chest pain or any heart problems. He denies any medical problems. MEDICATIONS: He takes no medications. ALLERGIES: NONE. REVIEW OF SYSTEMS: Cannot be done. PHYSICAL EXAMINATION: GENERAL: He is a well-nourished gentleman. He is in extreme chest pain. VITAL SIGNS: 149/97, pulse is 53 plus metoprolol. HEENT: Normal. SKIN: Warm and dry. JVP is 5. CHEST: Clear to auscultation. CARDIAC EXAM: Revealed a 4th heart sound, without murmurs or gallops. ABDOMINAL: With no masses, tenderness or organomegaly. NEURO: Good pulses in his feet, groin and hands. They were all equal. PATIENT NAME: ACCOUNT Denver Patient Care Inquiry (PCI: OE Database COCAA) Run: by Page 1 of 2 5/4/2012 11:39 AM FROM: Port 15 T0: 9,18663110973 PAGE: 006 OF 018 LABORATORIES: Potassium of 3, BUN of 7, creatinine 1. IMPRESSION: The patient is a 46?year?old gentleman with no apparent risk factors. He is having an acute anterior myocardial infarction. He will report to the Cath Lab. We will treat it with beta blockers, aspirin, statin and a platelet inhibitor. CONDITION AT THE TIME OF ADMISSION: Guarded. D: I4 1 '12 07:40:04 T: 04/12/2012 08:19:23 Job 863240/509465129 Electronically Signed by on 04/20/12 at 0655 PATIENT NAME: . ACCOUNT #:340000734489 Denver Patient Care Inquiry (PCI: CE Database COCAA) 5/4/2012 11:39 AM FROM: Port 15 T0: 9,13663110973 PAGE: 007 OF 018 THE MEDICAL CENTER OF AURORA South Campus North Campus Centennial Medical Plaza 1501 South Potomac 700 Potomac 14200 East Arapahoe Road Aurora, CO 80012 Aurora, CO 80011 Englewood, CO 80112 PATIENT NAME: ACCT 340000734489 MR E001113503 LOCATION: E.SURGIN ATTENDING PHY: PHY: ED DOCUMENTATION Patient: MANDZA, EVALIN Clinical Report - Physicians/Mid Levels MRN: E001113503 The Medical Center of Aurora VisitID: E40000734489 1501 South Potomac St., Aurora, CO 80012 303-695-2628 46y, Arrival Date/Time: 04/12/2012 6:58 DOB: 12/05/1965 Arrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESS CHEST PAIN. This started 4:00 and is still present. It was abrupt in onset. Onset during light activity. It is described as "pain" and it is described as located in the central chest area. No radiation. At its maximum, severity described as 10 10. When seen in the E.D., severity described as 10 10. Modifying factors? Not worsened by anything. Not relieved by anything. He has had difficulty breathing. No nausea, vomiting or diaphoresis. Similar previously: None. Recent medical care: Not recently seen/assessed. REVIEW OF SYSTEMS No chills, fever, decreased vision, hearing loss or nasal congestion. No runny nose, sore throat, calf pain, chest pain or cough. PAST HISTORY Negative. Denies the following risk factors for heart disease hypertension, smoking, diabetes, elevated cholesterol and family history of heart disease. Denies the following risk factors for - history of DVT and pulmonary embolism and recent surgery. Medications: None.. Allergies: No Known DrUg Allergy.. PATIENT NAME: ACCOUNT Denver Patient Care Inquiry (PCI: OE Database COCAA) Run: Page 1 of 6 5/4/2012 11:39 AM FROM: Port 15 TO: 9,18663110973 PAGE: 003 OF 018 SOCIAL HISTORY Never smoked. No alcohol use or drug use. ADDITIONAL NOTES The nursing notes have been reviewed. Weight: 79.3 kg estimated. Height: 72 inches Estimated. BMI: 23.7. PHYSICAL EXAM Appearance: Alert. Appears to be in pain. Eyes: Pupils equal, round and reactive to light. ENT: Pharynx normal. Neck: Neck supple. CVS: Normal heart rate and Heart sounds normal. Respiratory: No respiratory distress. Breath sounds normal. Abdomen: Soft and nontender. Back: Normal external inspection. Skin: Skin warm and dry. Normal skin color. Extremities: Extremities exhibit normal ROM. Neuro: Oriented 3. No motor deficit. No sensory deficit. LABS, X-RAYS, AND EKG EKG: EKG time Rate: 96. (Normal waves. Normal QRS complex. ST elevation in lead V2, V3, V4 and V5. The study has been interpreted contemporaneously by me. The study has been independently viewed by me. The EKG appears to be a good tracing. Laboratory Tests: (COLL: 04/12/2012 07:21) 04/12/2012 07:34) Final results Laboratory Test Value POINT OF CARE TROPONIN I 0.03 (COLL: 04/12/2012 07:26) 04/12/2012 07:29) Final results Laboratory Test Value POC TOTAL CARBON DIOXIDE 20 POINT OF CARE SODIUM 142 POINT OF CARE POTASSIUM 3.0 POINT OF CARE CHLORIDE 107 POINT OF CARE BUN 7 POINT OF CARE IONIZED CALCIUM 1.13 POINT OF CARE CREATININE 1.0 POINT OF CARE ANION GAP 19 POINT OF CARE HGB 15.6 POINT OF CARE HEMATOCRIT 46 POINT OF CARE GLUCOSE 170 GFR AFRICAN AMERICAN PATIENT >60 GFR NON-AFRICAN AMER. PATIENT >60 (COLL: 04/12/2012 07:15) 04/12/2012 07:42) Final results Laboratory Test Value PATIENT NAME: ACCOUNT Denver Patient Care Inquiry (PCI: OE Database COCAA) Run: Page 2 Of 6 5/4/2012 11:39 AM FROM: Port 15 T0: 9,18663110973 PAGE: 009 OF 018 PROTHROMBIN TIME PATIENT 10.9 INTERNATIONAL NORMAL RATIO 1.0 PARTIAL THROMBOPLASTIN TIME 22 (COLL: 04/12/2012 07:15) 04/12/2012 07:28) Final results Laboratory Test Value SPECIMENS ORDERS PROGRESS AND PROCEDURES Course of Care: Pt arrived by EMS as abdominal pain, neg EKG in ICE detention. EKG done at facility reported as neg.. 7:11 EKG shown to me by Nursing staff. I immediately go to the bedside. Pt is not answeing questions. Is writhing in pain, pointing to his chest. After several minutes of questions pt is still not asnsering questions. There are no language Cardiac aler called by me at 7:17. Pt is finally answering questions after I told him that he is having a heart attack, and I need him to anser my questions in order for me to help him. At this time pt is prividijq min mal My. Pt has received ASA and metoprolol. Discussed with Dr. One of his partners will see PI in ER. Dr.mm4max.at bedside. i-stat noted,not hyperkalemic. Pt to cath lab.. Critical care performed (35 minutes). Time is exclusive of separately billable procedures. Time includes: direct patient care, patient reassessment, interpretation of data (chest xrays), review of patient's medical records, medical consultation and documentation of patient care- see progress notes. Clinical Review This patient definitively has Acute Coronary ECG interpretation documented. Antiplatelet medications administered. Reperfusion therapy initiated. Consultation obtained from cardiologist. Chest pain precautions provided to patient. Disposition: Admitted. CLINICAL IMPRESSION Acute myocardial infarction with ST elevation (STEMI). Aspirin administered in ED. - PATIENT NAME: ACCOUNT Denver Patient Care Inquiry (PCI: OE Database COCAA) Run: by Page 3 of 6 (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) 5/4/2012 11:39 AM FROM: Port 15 T0: 9,18663110973 PAGE: 013 OF 018 THE MEDICAL CENTER OF AURORA South Campus North Campus Centennial Medical Plaza 1501 South Potomac 700 Potomac 14200 East Arapahoe Road Aurora, CO 80012 Aurora; CO 80011 Englewood, CO 80112 PATIENT NAME: ACCT E40000734489 MR E001113503 LOCATION: E.SURGIN ATTENDING PHY: ADMITTING PHY: ELECTROCARDIOGRAM Test Reason 28 Blood Pressure vent. Rate 096 BPM Atrial Rate 096 BPM PP-R-T Axes 081 052 071 degrees Int 477 ms Normal sinus Right atrial enlargement ST elevation consider anterolateral injury or acute infarct ST elevation consider inferior injury or acute infarct 'k 'k Abnormal ECG No previous ECGs available Confirmed by(121) on 4/13/2012 7:44:11 AM Referred By: SELF REFERRED Overread By: MD PATIENT NAME: ACCOUNT Denver Patient Care Inquiry (PCI: OE Database COCAA) Run: by Page 1 of 1 (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) 5/4/2012 11:39 AM FROM: Port 15 T0: 9,18663110973 PAGE: 015 OF 018 RUN DATE: 05/04/12 The Medical Center-Aurora LAB PAGE 1 RUN TIME: 1136 Specimen Inquiry RUN USER: PCI User: Lab Database: LAB.COCAA yum '95 :1 u' Specimen: Collected: 04/12/12-0718 Status: COMP Req#: 05215267 Received: 04/12/12-0846 Sub DI: (bxs), Verified: 04/12/12-0846 Patient Id: Ordered: ABGPOC POC P02 TCOZPOC .1 SAT . POC - POINT OF CARE TESTING . . . . . . . . . . . . . . . . . . . . . . . 5/4/2012 11:39 AM FROM: Port 15 T0: 9,18663110973 PAGE: 016 OF 018 RUN DATE: 05/04/12 'The Medical Center-Aurora LAB PAGE 1 RUN TIME: 1136 S-ecimen Inquiry RUN USER: PCI User: Lab Database: LAB.COCAA Specimen: Collected: 04/12/12-0721 Status: COMP Req#: 05215191 Received: 04/12/12-0734 Sub Dr: Carepoint,Physician Verified: 04/12/12-0734 Patient Id: Ordered: IROPONIN ISTAI LigETfef? .n . pf thej?ye?al? ?linidai picture; ?7 clinical history, and other indicat?yg?H..?.h. we? fsv?wiwi?ivLH POC - POINT OF CARE TESTING 5/4/2012 11:39 AM FROM: Port 15 TO: 9,18663110973 PAGE: 017 OF 018 RUN DATE: 05/04/12 The Medical Center-Aurora LAB PAGE 1 RUN TIME: 1136 Specimen Inquiry RUN USER: PCI Userz? (mwxw?nm) Lab Database: LAB.COCAA . ii . . 3 3? max Specimen: Collected: 04/12/12-0715 Status: COMP Ra?s: 05215186 Received: 04/12/12-0730 Sub Dr: wmequq Verified: 04/12/12-0741 Patient Id: Ordered: PT, PTI Comments: Campus: 5 DISCHARGE PT PATIENT 10.9 9.5-12.0 SEC AR 235??INai?g?i?iigg??n . FDR . ARTERIAL THROMBOSIS HEART VALVE PROPHYLAXIS: 2.5f3.5 .. 525272;;a. 1.1? .. . .1. ABWA 6/27/2011heparin, as measured by the which roughly corresponds as measured by the activated factor assay. If the the monitoring of_?h? antieoagu?tione consider.m?asvring the.H? NH. PATIENTS AR - THE MED CTR OF AURORA, SOUTH CAMPUS 1501 S. POTOMAC, AURORA, CO. 80012 . . . 5/4/2012 11:39 AM FROM: Port 15 T0: 9,18663110973 PAGE: 018 OF 018 RUN DATE: 05/04/12 The Medical Center-Aurora LAB PAGE 1 RUN TIME: 1136 Specimen Inquiry User: Lab Dat abase: . Specimen: Collected: 04/12/12-0715 Received: 04/12/12-0730 Verified: 04/12/12?0742 Patient Id: Ordered: CBC DIFF Comments: Campus: 3 DISCHARGE 3.4-11.2 10*3uL AR M.V .A317718r3Hg/gp . 1 . 1 ..AR 1* 79.0-9810*3/uL AR 9 4 1 lea/91AURORA, SOUTH CAMPUS 1501 S. POTOMAC, AURORA, CO. 80012 if i i 7 7 (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) U.S. IMMIGRATION AND CUSTOMS ENFORCEMENT DIRECTIVE TITLE: NOTIFICATION AND REPORTING OF DETAINEE DEATHS INDIVIDUAL INCIDENT CHECKLIST *3 Provide written noti?cation to the Of?ce of Public Affairs via a Director's Note. oM?rovide written noti?cation to the Of?ce of Congressional Relations via a Director?s Note. Provide written noti?cation to the Of?ce of WA ICE Policy, via a Director?s Note. 0) Within 48 hours of the death of a detainee, the Executive Associate Director of ERO shall: Ensure that copies 0t all available medical reports are provided to the DHS Of?ce of Iealth Affairs (OI-IA) in order to provide OI-IA the ability to initiate a proper mortality review. (All other relevant documents shall be provided to OHA in accordance with section 8.) NOTE: All noti?cations provided in accordance with this section. alone with an acknowledgment that the notification was received (ifpossibleL shall be documented and maintained in the decedent?s alien ?le (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) U.S. IMMIGRATION AND CUSTOMS ENFORCEMENT DIRECTIVE TITLE: NOTIFICATION AND REPORTING OF DETAINEE DEATHS INDIVIDUAL INCIDENT CHECKLIST 7.3. Noti?cation to Congress, the Media and Nongovernmental Organizations. a) Within 24 hours of the death of a detainee, the ICE Office of Congressional Relations shall provide e-mail noti?cation to the Chair and Ranking member of the following Committees: Time Person making Status: Date: Time: Zone: Notification: Person Notified: Manner: Those House and Senate members who have jurisdiction over where the death occurred Senate Judiciary Committee. ??House Judiciary Committee. 'I'Senate Judiciaty Committee. Subcommittee on Immigration. Refugees and Border Security. ':?House Judiciary Committee. Subcommittee on immigration. Citizenship. Refugees. Border Security and International Law. Senate Homeland Security and Governmental Affairs Committee. House Homeland Security Committee. :1?Senate ApprOpriations Committee. House Appropriations Committee. NOTE: OCR shall coordinate with the ICE Of?ce ofthe Chief Financial Officer before sending noti?cations to House and Senate Appropriations Committee staff. ICOMMENTS: >The Of?ce of Public Affairs shall provide a media release to the local press and the Associated Press. and post the media release on Internet website. (After notification of the next-of-kin. or when the next-of-kin cannot be located but reasonable efforts have been made by DRO (in coordination with the consulate) to locate the next-of-kin.) U.S. IMMIGRATION AND CUSTOMS ENFORCEMENT DIRECTIVE TITLE: NOTIFICATION AND REPORTING OF DETAINEE DEATHS INDIVIDUAL INCIDENT CHECKLIST FThe ICE Office of Policy shall provide a copy of the media release to nongovernmental organizations (NGOS) via the working group co-chairs. I In instances where the consulate has been notified of a detainee?s death but the next-of?kin have not been located yel 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. 8 ONGOING REPORTING REQUIREMENTS. 8.2. Status: Detention Management Division. Upon the death of a detainee in a detention facility, the ERO Assistant Director for Management (ADM) shall require: Date: Time: Time Zone: Person making Notification: Person Notified: Manner: ?2?In coordination with OPR. an internal review of all facility inspection records for the detention facility at which the death occurred. review ofall contract documentation for the detention facility where the death occurred. ?i?lf the death occurs at a medical facility or while the detainee is in transita 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 ofthe detainee to: Time Person making status: Date: Time: Zone: Notification: Person Notified: Manner: senior management OPR OHA for inclusion in mortality review CRCL OIG (ifthe investigation is being conducted MA by the OIG). c) [he ADM shall prov1de 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: Date: Time: Zone: Notification: Person Notified: Manner: OHA for inclusion in mortality review CRC OIG (ifthe investigation is being conducted MA by the Detainee Death Review Medical Record Review MANDZA, Evalin Ali, A # (b)(6), (b)(7)(c) Denver Contract Detention Facility, Denver, CO Section 1: Medical Compliance Review As requested by the ICE Office of Professional Responsibility, Office of Detention Oversight, Creative Corrections (CC) participated in a review of detainee Evalin Ali MANDZA’s death at the Denver Contract Detention Facility (DCDF) in Denver, CO. CC accompanied Special (b)(6), (b)(7)(c) Agents and (b)(6), (b)(7)(c) on a site visit May 21-23, 2012, and participated in interviews of ICE, correctional and medical staff. Additionally, CC reviewed the medical record of detainee MANDZA, and relevant policies and procedures. CC’s participation was requested to determine compliance with the ICE Performance Based National Detention Standards governing medical services. The following chronicles detainee MANDZA’s period of detention at DCDF based on documented and reported information. CC’s observations and compliance findings appear in commentary. Medical terminology is defined in parentheses and brackets. Medical Encounters Timeline October 17, 2011 Record of Deportable/Inadmissible Alien Form I 213 completed by Immigration Enforcement Officer (b)(6), (b)(7)(c) documents detainee MANDZA, 46 years old, was arrested and charged with resisting an officer and detained at the Aurora County Jail. The form further documents the detainee “states he is in good health and is taking no medications;” further, “appears to be in good health.” He was subsequently transferred to the Denver Enforcement & Removal Operations (ERO) Field Office for processing. October 24, 2011 5:05 pm The detainee arrived at the DCDF. The Order to Detain listed his nationality as Gabon, a country in west central Africa. 6:45 pm (b)(6), (b)(7)(c) Intake Screening was conducted by , Licensed Practical Nurse (LPN). Vital signs (VS) were documented as follows: pulse (P) 81, blood pressure (BP) 101/62, respirations (R) 14, temperature (T) 97.1, all within normal limits (WNL). No chronic care issues were identified, and the form documented negative responses to all health history questions. His placement recommendation was recorded as “General Population.” A consent for treatment form was signed and dated. On interview LPN (b)(6), (b)(7)(c) stated she always asks more questions than listed on the form and seeks to identify possible signs or symptoms of anything abnormal. She stated she found “nothing out of the ordinary.” DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 1 The Nursing Incoming Screen Progress Note form documents no medications were ordered, no special treatments or follow-up referrals, no work limitations, and no housing or bunk limitations. CC was informed this form is designed to focus on chronic conditions requiring follow up and/or medications. (b)(6), (b)(7)(c) , MD reviewed and signed the form on October 27, 2011. The Mental Health Intake Screen completed by LPN (b)(6), (b)(7)(c) documents negative responses for all items. The form was signed by(b)(6), (b)(7)(c) MD on the same date. The detainee refused syphilis testing and signed a refusal form. A chest x-ray was performed with the results documented as “Negative except for calcified granuloma [small area of inflammation of benign calcification] less than 2 cm.” October 25, 2011 Detainee MANDZA submitted a sick call request stating he had “bad movement.” October 26, 2011 6:00 pm A physical examination and health appraisal was performed by (b)(6), (b)(7)(c) Adult Nurse Practitioner (ANP). Height: 5 feet 8 inches; weight: 141 pounds. VS: T 98.6, P 78, R 18, BP 104/64, and all WNL. All history and systems items were documented as normal. Dr. (b)(6), (b)(7)(c) signed the physical examination on October 27, 2011. Progress Note by (b)(6), (b)(7)(c) , Registered Nurse (RN) documents detainee MANDZA was seen for sick call complaining of not having a bowel movement in three to four days. He was instructed to increase his fluid intake. The detainee verbalized understanding and was given Ducolax and Milk of Magnesia (MOM) (laxatives to relieve constipation) in accordance with GEO nursing protocols. October 31, 2011 Detainee MANDZA submitted a sick call request for “constipation movement.” He was placed on the sick call list to be seen by Dr. (b)(6), (b)(7)(c) on November 3, 2011. During site visit, CC learned Detainee MANDZA’s name was crossed off Dr. (b)(6), (b)(7)(c) sick call list with a crayon. Acting HSA RN (b)(6), (b)(7)(c) stated names are crossed off sick call lists with crayons to signify the medical record has been pulled for the appointment. There was no corresponding Progress Note or other documentation supporting detainee MANDZA was seen by Dr. (b)(6), (b)(7)(c) on November 3, 2011; in fact, he was not seen by a physician until December 2, 2011. RN (b)(6), (b)(7)(c) could not explain why the sick call appointment was missed. COMMENT: CC cites non-compliance with ICE PBNDS, Medical Care, section (II)(2), requiring that health care needs be met in a timely and efficient manner. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 2 November 8, 2011 Detainee MANDZA submitted a sick call request for, “bumps shaving, need medical.” November 9, 2011 The medical record documents the sick call request was reviewed and the detainee was seen by LPN (b)(6), (b)(7)(c) . Per GEO nursing protocol, he was given TAO (triple antibiotic cream) to be applied daily for seven days. November 10, 2011 Detainee MANDZA submitted a sick call request for “constipation movement.” November 11, 2011 The medical record documents the sick call request was reviewed by LPN GEO nursing protocol he was given Ducolax again and fiber was added. Per (b)(6), (b)(7)(c) November 17, 2011 Detainee MANDZA submitted a sick call request for “dental hurt, couldn’t go to sleep.” RN (b)(6), (b)(7)(c) gave him Tylenol (for pain) and scheduled him to see the dentist on November 21, 2011. He was instructed on proper dental hygiene and advised to return to the clinic if symptoms persisted or worsened. November 21, 2011 Detainee MANDZA was seen by (b)(6), (b)(7)(c) DDS. Per Progress Note, detainee complained of lower level toothache. “The tooth has deep cavities and needs to be extracted. The detainee has court tomorrow, so will reschedule the extraction.” COMMENT: The record includes no documentation the extraction was rescheduled. November 27, 2011 Detainee MANDZA submitted a sick call request for “constipation movement with shaving bumps.” November 28, 2011 RN(b)(6), (b)(7)(c)gave detainee MANDZA MOM, Ducolax, and fiber for the constipation and TAO for razor burn rash. RN(b)(6), (b)(7)(c)documented he was instructed to “drink a lot of water, don’t use TAO around the eyes, and return to medical if symptoms persist or worsen.” December 2, 2011 Dr. (b)(6), (b)(7)(c) evaluated detainee MANDZA for constipation and folliculitis (inflammation of hair follicles). He prescribed glycerin suppositories, increased fiber, and Colace for the constipation, and a triple antibiotic cream for his neck rash. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 3 December 11, 2011 Detainee MANDZA submitted a sick call request for “dental complaint, need to be cleaned but not to take out.” December 12, 2011 Detainee MANDZA was seen by RN (b)(6), (b)(7)(c) and was given Ibuprofen per GEO nursing protocol. A dental appointment was scheduled for December 20, 2011. December 14, 2011 Detainee MANDZA submitted a sick call request stating “I fall from top bed hurt my foot.” December 15, 2011 Dr.(b)(6), (b)(7)(c)documented he evaluated detainee MANDZA; no new orders were issued. December 20, 2011 Dr. (b)(6), (b)(7)(c) (DDS) documented the detainee asked to have his teeth cleaned and complained of pain in his lower level. He refused extraction and was given Ibuprofen. COMMENT: No refusal form was found in the medical record. December 25, 2011 11:40 am Medical Report on Injuries/Non-Injuries documents detainee MANDZA was evaluated due to his involvement in “horseplay” with other detainees. Tiny scratches on his chest and left wrist area were noted by LPN (b)(6), (b)(7)(c) No other apparent injuries. The Pre-Segregation History and Physical by LPN (b)(6), (b)(7)(c) documents clearance for placement in administrative segregation. The form was signed by Dr. (b)(6), (b)(7)(c) on December 27, 2011. December 30, 2011 RN(b)(6), (b)(7)(c)documented detainee “fell playing soccer.” She gave him Ibuprofen and ice packs for his left big toe. January 3, 2012 Dr. (b)(6), (b)(7)(c) documented the detainee complained of a sore foot from striking it against a soccer ball. He was noted to be in no apparent distress with any swelling, tenderness or gross deformity. He was prescribed Ibuprofen and a lower bunk was ordered. January 13, 2012 Detainee MANDZA submitted a sick call request for a “dental problem.” The request was reviewed on January 15, 2011 and an appointment was scheduled for January16, 2012. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 4 January 15, 2012 Detainee MANDZA submitted a sick call request for a “dental problem/I need to keeping taking the constipation suppositories that help. Thanks.” The request was reviewed and LPN (b)(6), (b)(7)(c) saw the detainee. He was reminded of his dental appointment on January 16, 2012. January 16, 2012 RN(b)(6), (b)(7)(c)documented the detainee was seen in medical for his constipation and dental issues. He was scheduled to see the dentist the same day and to see Dr.(b)(6), (b)(7)(c)on January 18, 2012. Per Progress Note by Dr. (b)(6), (b)(7)(c) the detainee again refused the extraction. He was given Amoxicillin (antibiotic) and Tylenol. COMMENT: No refusal form was found in the medical record. January 18, 2012 7:08 am An entry in the Segregation/Special Management Unit (SMU) log book documents detainee MANDZA was “escorted to seg/SMU.” The Pre-Segregation History and Physical completed by RN (b)(6), (b)(7)(c) documents medical clearance for housing in Administrative Segregation. “[N]o physical confrontation just arguing” was noted. The form was signed by(b)(6), (b)(7)(c) MD, but not dated. COMMENT: Per January 16 Progress Note, detainee MANDZA was to be seen by Dr. this date. There is no documentation this appointment occurred. RN(b)(6), (b)(7)(c)could not explain why Dr.(b)(6), (b)(7)(c)did not see the detainee. (b)(6), (b)(7)(c) January 27, 2012 Progress Note by ANP(b)(6), (b)(7)(c)documents the detainee was complaining of constipation and was declining the Colace and fiber. The glycerin suppositories were renewed for three days, and he was counseled on taking the prescribed treatment for constipation. COMMENT: There were no refusal forms for Colace and fiber in the record. CC was informed it is not customary practice to have detainees sign refusal forms for over-thecounter medications. February 9, 2012 Progress Note by RN(b)(6), (b)(7)(c)documented the detainee complained of constipation and had not had a bowel movement since February 3, 2012. His bowel signs were decreased and discomfort was increased. He was given Ducolax and MOM per GEO nursing protocol. February 14, 2012 Detainee MANDZA submitted a sick call request for a “problem with my teeth.” A note (illegible initials) documents he was to see the dentist that day. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 5 DMD (b)(6), (b)(7)(c) extracted tooth number 18. A consent form was signed and dated. March 1, 2012 The detainee submitted a sick call request complaining of burning eyes and constipation. RN (b)(6), (b)(7)(c)reviewed the request, saw the detainee and gave him Ducolax, MOM and artificial tears per GEO nursing protocol. He was to return to medical if symptoms persisted or worsened. He was placed on the physician sick call list for March 5, 2012. March 5, 2012 Physician Assistant (PA) (b)(6), (b)(7)(c) documented the detainee presented with complaints of constipation; “no dumping (when food passes too rapidly from the stomach into the upper intestine), H2O, on meds.” Observations: “Lungs clear, heart-no [illegible], abdomen soft, visceromegaly[abnormal enlargement of the soft internal organs];” Assessment: “Constipation, no water;” Plan: “Increase fiber, increase water, increase exercise.” March 21, 2012 Detainee MANDZA submitted a sick call request for “bad move problems/bumps shaver problems.” LPN(b)(6), (b)(7)(c)documents he was seen in medical and given MOM, Ducolax and was scheduled for a medical review. Progress Note by Dr. (b)(6), (b)(7)(c) documents the detainee has a history of constipation and a stress fracture; Colace ordered again. March 25, 2012 Progress Note by Dr. (b)(6), (b)(7)(c) documents medications are working well, no nausea, vomiting, diarrhea; no complaints; vital signs stable; continue medications. Detainee to submit a sick call request if problems. March 31, 2012 Detainee MANDZA submitted a sick call request for “no movement all week.” April 1, 2012 LPN (b)(6), (b)(7)(c) documents the detainee was seen in medical and given Ducolax and MOM per GEO nursing protocol. April 12, 2012 5:24 am Per Medical Correctional Log book, “Code Blue in A-4.” 5:25 am Per A-4 Log book, “Code Blue A-4 110/2, Mandza Evalin-Ali complaining of chest pains.” DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 6 (b)(6), (b)(7)(c) Per General Incident Report authored by Detention Officer (DO), “I D/O (b)(6), (b)(7)(c) while he was making rounds on unit A-4 when the other (b)(6), (b)(7)(c) was talking with Lt. detainees got my attention that detainee Mandza Evalin-Ali needed help. When I arrived at A110, Ali was complaining of chest pains. I instructed Lt. (b)(6), (b)(7)(c) to call Code Blue.” DO (b)(6), (b)(7)(c) documented on the report Code Blue was called at 05:25, Medical arrived at 05:28, “Stand down from Code Blue” at 05:33, “Medical departs with detainee Mandza” at 05:34. On interview, DO (b)(6), (b)(7)(c)stated he normally makes rounds every 30 minutes and that during his 5:00 a.m. round, “everything was fine.” When he was summoned by the other detainees and went over to detainee MANDZA’s bed, he found the detainee “rocking and rolling” in bed with his hands on his chest complaining of chest pain. He also stated nursing staff who responded had a wheelchair, crash bag (containing ammonia, a manual breathing bag, gloves, spill kit), and a pulse oximeter (measures the oxygen level in the blood). He did not remember an AED automated external defibrillator (AED) being brought to the housing unit. (b)(6), (b)(7)(c) Per GEO Serious Incident Report, Incident Description, written by Lt , he called a Code Blue due to the detainee “complaining of chest pains.” On interview, Lt. (b)(6), (b)(7)(c) stated he found the detainee in a “fetal position grasping his chest and groaning.” He called the “Code Blue” over the radio and proceeded to open the side door to expedite medical staff’s arrival. He stated nursing staff brought with them a wheelchair, crash bag, and oxygen tank, but no AED. Medical record Progress Note by RN (b)(6), (b)(7)(c) documented, “Responded to Code Blue at housing unit 4A. Found detainee lying on back (in bed) touching left chest area. Detainee alert and oriented, answers all questions appropriately. Skin w/d [warm/dry], color adequate, no respiratory distress noted. Reports chest pain 8-9/10 [8-9 on a pain scale of 0 to 10, with 10 being worst], pain worse with inspiration, pulse ox: [level of oxygen in the blood] on RA [room air] 94%. Assisted to wheelchair for transfer to medical unit.” (b)(6), (b)(7)(c) COMMENT: RN did not utilize the assessment criteria in the GEO nursing protocol for chest pain. Though she documented “color adequate,” she did not note whether or he was pale or cyanotic (bluish discoloration of the skin indicating lack of oxygen). In addition, she did not address the presence of diaphoresis (perspiring) or quality of his respirations, i.e., whether they were shallow or labored. Although she noted the intensity of the pain and that it was worse with inspiration, she failed to inquire as to the duration of the pain. The only vital sign taken was a pulse oximetry reading. As noted, she recorded the encounter in a Progress Note, only. There was no completed “Chest Pain Protocol” form in the medical record. (b)(6), (b)(7)(c) RN stated during interview she responded immediately to the Code Blue, taking with her the wheelchair, oxygen tank, crash bag and the AED. LPN(b)(6), (b)(7)(c)did not document in the medical (b)(6), (b)(7)(c) record, however, on interview, she stated she responded with RN to the “Code Blue” with a wheelchair, crash bag, oxygen tank and AED. As noted, DO(b)(6), (b)(7)(c) and Lt. (b)(6), (b)(7)(c) reported that they did not observe an AED. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 7 COMMENT: Whether an AED was brought to the scene cannot be confirmed. While use of an AED on detainee MANDZA would not have been appropriate because he was found alert, responsive, breathing and with a pulse, code blue response equipment should always include an AED in the event it is needed. COMMENT: CC verified current CPR certification for all responding correctional and medical staff. 5:28 am (b)(6), (b)(7)(c) Per Progress Note by RN “Transfer to trauma room. VS 154/84 -68-18; On assessment skin (warm and dry) color adequate, bilateral breath sounds clear to auscultation. All peripheral [areas of the arm, wrist, legs and feet] pulses palpable. O2 [oxygen] placed at 4 L[liters], pulse ox 92-94%, abdomen soft, flat with hypoactive bowel sounds [normal during sleep, but can also indicate constipation]. Reports last [bowel movement] was on 4-8. Chest pain remains unchanged. BP 144/85, 71[pulse] rr [regular rhythm] 18 [respirations]. 3 lead EKG [electrocardiogram] done.” COMMENT: VS were not documented again until 6:20 am. Per GEO nursing protocol for chest pain, VS are to be taken every five minutes. The GEO nursing protocol for chest pain requires a 12-lead EKG. During site visit, CC learned DCDF has two 12-lead EKG machines made by different manufacturers: a Welch Allen EKG (b)(6), (b)(7)(c) machine and a Schiller AT-102. RN chose the Schiller AT-102 and proceeded to attempt a three-lead rather than 12-lead EKG. A three-lead EKG monitors only two areas of the heart; a (b)(6), (b)(7)(c) 12-lead EKG provides detailed monitoring of all three areas of the heart. On interview RN stated she chose to perform a three-lead EKG because she had not performed a 12-lead EKG “in (b)(6), (b)(7)(c) years.” She further stated she had no formal training in the use of either machine. When RN completed hooking detainee MANDZA up to the Schiller AT-102 EKG machine, she realized the memory was full and requested LPN(b)(6), (b)(7)(c)assistance. LPN(b)(6), (b)(7)(c)was unsuccessful in erasing the memory, therefore, the Schiller AT-102 was detached and the Welch Allyn machine (b)(6), (b)(7)(c) was used. RN stated she was unable to interpret the EKG results and relied on her “gut instinct” to ultimately send the detainee to the hospital. (b)(6), (b)(7)(c) and LPN(b)(6), (b)(7)(c)stated they had not received formal training in During interviews, both RN reading EKGs. They stated in the past, results from the Schiller AT-102 machine were faxed to the on-call physician or a cardiology practice for interpretation; however, faxing results from the Welch Allyn machine was not possible because the machine has not been programmed the same (b)(6), (b)(7)(c) way as the Schiller AT-102. Asked about maintenance of the EKG machines, RN indicated she had previously reported the Schiller AT-102 memory issue to Acting HSA (b)(6), (b)(7)(c). According to LPN(b)(6), (b)(7)(c), the EKG machines are checked daily for operability, though the memory is not always checked. HSA (b)(6), (b)(7)(c) was able to produce documentation of checks for the clinic’s other emergency equipment, including oxygen tank, oxygen mask and tubing, AmbuBag, pulse oximeter, and AED; however, there was no record documenting EKGs are checked. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 8 COMMENT: ODO cites non-compliance with ICE PBNDS, Medical Care, section (V)(O) requiring that medical and safety equipment be available and maintained, and that staff be trained in proper use of the equipment. . (b)(6), (b)(7)(c) Per interview with DCDF’s new physician, Doctor of Osteopathy he supports (b)(6), (b)(7)(c) documentation by RN . However, after reviewing the GEO nursing protocol for chest pain, he stated it is flawed because the EKG should not be used as an “acute tool” in this setting; further, that this may have delayed sending the detainee to the hospital up to “ten minutes.” He would like to see the protocol revised to call for an immediate 911/EMS response to chest pain along with the administration of aspirin. He stated, “We are putting the facility at risk” by not sending detainees to the hospital in this situation. He further stated he does not need to be contacted for an order to do so. (b)(6), (b)(7)(c) instructed her to “get the paperwork started” when During interview, LPN(b)(6), (b)(7)(c)stated RN detainee MANDZA was in the trauma room. She stated this instruction meant the physician was to be called for an order, the HSA was to be notified, and the Shift Commander (Lt (b)(6), (b)(7)(c) was to be contacted for an “order for transport.” She indicated she was under the impression the detainee would be transported by GEO transport van rather than ambulance because she thought at the time the detainee “wasn’t in dire distress.” 5:50 am (b)(6), (b)(7)(c)“Dr. (b)(6), (b)(7)(c) notified of detainee status. Orders Per medical record documentation by RN received.” A verbal order was given to “transfer the detainee to hospital for chest pain (b)(6), (b)(7)(c) evaluation.” On interview, RN stated it was her understanding a doctor’s order was required to send a detainee to an outside hospital. However, RN (b)(6), (b)(7)(c) stated during interview she would use her “nursing discretion” to send a detainee to an outside hospital if needed and notify the physician later. In addition, as noted, Dr. (b)(6), (b)(7)(c) stated it was not necessary to obtain a physician’s order in this situation. CC notes that according to GEO policy “Emergency Services,” 4-Triage,(a), Immediate Life Threatening Emergency, dated 6/13/2011, “If the Response Team Leader determines a life threatening emergency exists, Emergency Medical Services (EMS) will be summoned immediately.” COMMENT: CC cites non-compliance with ICE PBNDS, Medical Care, section (II)(7) requiring that detainees who need health care beyond facility resources to be transferred in a timely manner to an appropriate facility where care is available. (b)(6), (b)(7)(c) stated she instructed LPN(b)(6), (b)(7)(c)to call EMS, however, she did not document this RN instruction. It is further noted Lt. (b)(6), (b)(7)(c) Supervisor’s Report and the Aurora Fire Department EMS Patient Care Report (see below) document the time as 6:20 am and 6:21am, respectively. During interview, LPN(b)(6), (b)(7)(c)stated that she was still under the impression detainee MANDZA would be going to the hospital via GEO transport van. In her General Incident Report, LPN(b)(6), (b)(7)(c)writes “orders received per Dr. (b)(6), (b)(7)(c) to send to hosp. At this time I Nurse (b)(6), (b)(7)(c)completed transfer form and notified watch commander (b)(6), (b)(7)(c) of transfer to hosp per MD orders.” DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 9 Per GEO Serious Incident Report authored by Lt. (b)(6), (b)(7)(c) LPN(b)(6), (b)(7)(c)“advised the detainee needed to be transported to the Aurora South Hospital for further medical examination.” 6:00 am (b)(6), (b)(7)(c) Per Progress Note authored by RN , “Ms. (b)(6), (b)(7)(c) notified of detainee status.” 6:20 am Per Serious Incident Report by LPN(b)(6), (b)(7)(c), detainee Evalin Ali MANDZA “VS-[BP] 139/81, [P] 67, pulse ox 100% on 4 liters.” Per Supervisor Report by Lt. (b)(6), (b)(7)(c) , “At 0620 hours medical informed that 911 needed to be call in order to have detainee taken to Aurora South Hospital ER for additional treatment.” On interview, he stated this direction was given when he called the nursing station to get a status update on the transport of detainee MANDZA to the ER. He stated he spoke with LPN(b)(6), (b)(7)(c) who instructed him to call 911. This was 30 minutes after an order was obtained from Dr. (b)(6), (b)(7)(c) to send the detainee to the emergency room and approximately 50 minutes after the detainee arrived in the trauma room. Lt. (b)(6), (b)(7)(c) stated in retrospect it “bothered” him it took so long to send the detainee out. Per GEO Serious Incident Report, Immediate Action Taken, by Lt. (b)(6), (b)(7)(c) , “Upon arrival in (b)(6), (b)(7)(c) the medical department an assessment by RN and LPN(b)(6), (b)(7)(c)was conducted. The determination to call 911 (ambulance) was requested and detainee was taken to the Aurora South Hospital ER for additional treatment.” The report by Lt. (b)(6), (b)(7)(c) does not state who made the determination to call 911, when 911 was called, nor by whom. COMMENT: The decision to call EMS versus transport the detainee by van is not documented in the medical record. Interviews with staff point to poor communication resulting in a delay in getting him to the ER. CC cites a second deficiency in the ICE PBNDS, Medical Care, section (II)(7) requiring timely transfer to off-site care facilities. 6:21 am Per the Aurora Fire Department EMS Patient Care Report, a call came in from DCDF for emergency response. 6:25 am Per GEO Serious Incident Report by Lt. (b)(6), (b)(7)(c) “EMS arrived on site about 0625 hours.” The Aurora Fire Department EMS Patient Care Report confirms this time. 6:29 am Per the Aurora Fire Department EMS Patient Care Report, VS were “BP 135/85, P 80-regular, R 20-increased but not labored, perceived pain 9/10, O2 level 100 %, movement of extremities X 4[is able to move all four extremities], level of consciousness 15 [out of 15], EKG interpretation –normal sinus rhythm taken by automated device.” DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 10 6:30 am Per the Transport/Escort Log, “EKG done by EMT.” Aurora Fire Department EMS Patient Care Report documents impression as “Chest pain and Heartburn/Indigestion;” Cardiac Arrest was answered as “No.” “The patient is conscious and alert” and complains of “midline chest pain.” The EMS report further documents: “History: Pt [patient] states no medical history, no current medications, no nkdas[no known drug allergies]. Pt states he hasn’t had a bowel movement in the last 4 days. Pt states he ate a bowl of soup last night that contained a large amount of hot chili peppers. Onset: Two hours ago pt awoke with current pain. Provocation [Does anything make the pain worse?]: Pain is reproduce able upon movement and chest wall palpitation. Quality of Pain: Pt states it is a burning sensation. Region and radiation: Pt states the pain travels from his upper abdomen to his esophagus. Severity: 9/10; pt denies nausea and vomiting; pt states no diaphoresis. Assessment: General Impression-Pt is conscious and is responding to verbal questioning. Pt is showing no signs of pain or respiratory distress. ABC’s [airway, breathing, circulation] open/patent, increased/unassisted, skin warm and dry, radial pulse strong and regular, heent [head, ears, eyes, nose, throat]clear, chest wall stable rise and fall equal, breath sounds clear and equal bilateral, abd [abdomen]soft non-tender, pelvis stable, vitals as recorded. Pt was placed onto 4 L O2 prior to our arrival by facility nurse. 12 lead ECG revealed a Sinus Rhythm, no ST segment elevation or ectopic beats observed [indications of an abnormal EKG].” Pt was packaged onto the pram and removed from the facility. Pt was secured into RM 101 for non-emergent transport to TMCA South. Pt states no further complaints. Upon release of care pt’s condition remained unchanged.” 6:35 am Per the Transport/Escort Log, Commander Warden(b)(6), (b)(7)(c)notified. (b)(6), (b)(7)(c) (Immigration Health Services Corps) and 6:43 am Per Control Emergency Log book, EMT offsite. 6:57 am General Incident Report authored by (b)(6), (b)(7)(c) , DCDF Medical Transport Officer, documents arrival at Aurora South Medical Center. Officer (b)(6), (b)(7)(c) accompanied the ambulance to the ER. COMMENT: The detainee was transported as a non-emergent case, therefore, it took 14 minutes to get to the hospital. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 11 Per Aurora H&P [history and physical], “The patient is a 46 year old gentleman with no apparent risk factors. He is having an acute anterior myocardial infarction. He will report to the Cath Lab. Condition at time of admission: guarded” 7:35 am Per General Incident Report detainee moved to the “Cath Lab for Cardiac Catheterization.” Per Aurora Hospital Cardiac Catheterization Report “Ventricular tachycardia [fast heart rhythm that originates in the ventricles of the heart] and PEA arrest (pulseless electrical activity), [there is electrical activity, but the heart does not contract. The heart rhythm observed on EKG looks like the heart is producing a pulse, but is not]; CPR cardioversion [procedure to restore normal heart rhythm]; continued CPR and multiple defibrillations.” 7:55 am Per General Incident Report “[hospital] medical staff started giving Mandza chest compressions with negative results.” COMMENT: On interview with Transport Officer (b)(6), (b)(7)(c) who remained with the detainee at the hospital, “The whole cardio department was here to try to save his life.” 8:38 am Per the Cardiac Catheterization Report Detainee Evalin Ali MANDZA expired due to “unsuccessful resuscitation of the patient.” 12:49 pm GEO Serious Incident Report transmitted by Warden (b)(6), (b)(7)(c) 1:00 pm ICE Removal proceeding hearing scheduled. (b)(6), (b)(7)(c) , Warden, “In compliance with current Per Serious Incident Report authored by ICE standards the onsite staff is handling the details of the autopsy.” May 24, 2012 Per the Death Certificate, Immediate Cause of Death was listed as “Anterior MI [myocardial infarction or heart attack] due to or as a consequence of “Severe left main coronary artery stenosis [abnormal narrowing]. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 12 MEDICAL COMPLIANCE REVIEW CONCLUSIONS The ICE PBNDS, Medical Care, requires that detainees have access to emergent, urgent, or nonemergent medical care so that their health care needs are met in a timely and efficient manner. . As discussed in the above timeline, deficiencies were found in the following: • ICE PBNDS Medical Care, section (II)(2) requiring detainees to have healthcare needs met in a timely and efficient manner. o There was no documentation to support Dr. (b)(6), (b)(7)(c) evaluated the detainee for his complaint of constipation as scheduled on November 3, 2011. He was not seen by the physician until December 2, 2011. • ICE PBNDS Medical Care, section (II)(7) requiring a detainee who needs health care beyond facility resources will be transferred in a timely manner to an appropriate facility where care is available. o A total of 56 minutes elapsed between the Code Blue emergency and activation of 911. Thirty minutes elapsed after Dr. (b)(6), (b)(7)(c) ordered transfer to the ER. • ICE PBNDS Medical Care, section (V)(O) requiring medical and safety equipment to be available and maintained and staff to be trained in proper use of the equipment. o There was no documentation EKG machines were checked daily to determine if they were in working order and for memory capacity. (b)(6), (b)(7)(c) o Neither RN nor LPN(b)(6), (b)(7)(c)had documented formal training on the EKG machines used at DCDF medical clinic, or in recognizing lethal rhythms. Submitted: (b)(6), (b)(7)(c) Creative Corrections, LLC DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 13 DETAINEE DEATH REVIEW: Evalin Ali MANDZA Medical Compliance Summary Creative Corrections, LLC Page 14 U.S. Immigration and Customs Enforcement ADDENDUM IHSC MEDICAL RECORD REVIEWHNVESTIGATION Detainee: MANDZA, Evalin-Ali Alien Number: DOB: 12-05?1965 EXECUTIVE SUMMARY On 04-12-2012, US. Immigration and Customs Enforcement (ICE), Health Service Corps (IHSC) received notification er the death of Evalin-Ali MANDZA, an individual in the custody of ICE at the Denver Contract Detention Facility, Aurora. Colorado. The Assistant Director for requested a review of medical records to determine the appropriateness oi?the medical care he received while in ICE custody. Cause of Death: Anterior myocardial infarction Severe left main coronary artery stenosis Conclusion: This additional information does alter the initial observations, conclusions and recommendations that appeared in the 05-09-2012 report. MANDZA did not have access to appropriate medical care while detained in the Denver Contract Detention Facility (DCDF). On 04-! 2-2012 he received appropriate emergent medical care at the however, there was an approximate 30 minute delay from when the physician ordered MANDZA transferred to the hospital for evaluation of chest pain, to when EMS received a call to respond to the Facility. At present, has not received a death certi?cate; however, based upon a review of the hospital records, MANDZA apparently had an acute myocardial infarction (heart attack) and expired as a result of an inherent potential complication of a lifesaving procedure called emergency angioplasty. Prior to the morning 01?04-12?2012, MANDZA did not have a history of any significant medical problems. nor did he complain of any that demonstrated an increased risk for cardiac problems. DETAILS OF INQUIRY Page 2 of 5 On 04-12-2012, US. Immigration and Customs Enforcement (ICE), Health Service Carps (IHSC) received noti?cation of the death of Evalin-Ali MANDZA, an individual in the custody of ICE at the Denver Contract Detention Facility, Aurora, Colorado. The Assistant Director for IHSC requested a review of MAN medical records to determine the appropriateness of the medical care he received while in ICE custody. PURPOSE Review medical records and prepare a formal statement regarding the standard of health care he received while in ICE custody. BACKGROUND MANDZA was a 46 year old male from Gabon, on the date he expired. ICE Custody Histog - 10-24-2011 to 04-12-2012 Denver Contract Detention Facility, CO 04-] 2-201 2 Expired Medical and Mental Health Conditions: 0 No medical diagnoses Irreversible pulpitis tooth #18 extracted 0 Acute anterior myocardial infarction ADDITIONAL INFORMATION RECEIVED Aurora Fire Department (04-12-2012) U/a at the immigration detention facility, we located the Pt in an examination room lying supine on an examination table. Scene secure. Pt is a 46 y/o male who is conscious and alert. Pt states a CC of midline chest pain. states medical hx, no current medications and nkda?s. Pt states he hasn?t had a bowel movement in the past four days. Pt states he ate a bowl of soup last night, that contained a large amount of hot chili peppers. O?Two hours ago, Pt woke up from sleep with current pain. P- pain is reproducible upon movement, and chest wall palpation. Q- Pt states it is a burning sensation. R- Pt states the burning travels from his upper abd, to his esophagusdenies nausea/vomiting. Pt states no diaphoresis. A- General Impression: Pt is conscious and is responsive to verbal questioning. Pt is showing no signs of pain or respiratory distress. open/patent, increased/unassisted, skin warm and dry, radial pulse strong and regular, heent clear, chest wall stable rise and fall equal, breth sounds clear and equal bilateral, abd soft non-tender, pelvis stable, moex4, gcs=15, Vitals as recorded. Pt was placed onto 41pm 02 prior to our arrival by facility nurse. 12 lead ECG revealed a Sinus Wise-911W Page 3 of5 no ST segment elevation or ectopic beats observed. Pt was packaged onto the pram and removed from the facility. Pt was secured into RM 101 for non-emergent transport to TMCA South due to AIP diversion. Immigration detention officer accompanied RM 101. Pt states no further complaints. R- See Treatment T- See Encounter. Upon release of care Pt?s condition had remained unchanged.? 0621 Time call received. 0628 Patient contact. 0629 (Paramedic) ?Position: Supine; Blood Pressure: 135/85; Pulse: 80 (Regular); Respirations: 20(lncreased, not labored); Perceived Pain: 9/10; Pulse Oximetry: 100 (On Oxygen); Movement of Extremities: x4; Level of Consciousness: 15 EKG Interpretation: Normal Sinus Taken by automated device.? ~0630 ?Oxygen, 4 l/m nasal cannula; Response: No change; Authorization: Protocol (standing order); administered by Rural/Metro Employee? 0632 ?12 Lead Cardiac Monitor; Authorization: Protocol (standing order); performed by [paramedic] COMMENT: NSR, no ST segment elevation, no ectopic beats observed? Rural Metro Ambulance (04-12-2012) Crew: #1 Paramedic, #2 EMT ?DiSpatch to chest pain. UA pt found lying supine on exam table in facility clinic. Pt CC chest pain. Pt states he awoke the pain this moming. Pt describes that pain as a burning sensation that travels from his upper abd through his chest and up into his throat. Pt state that he did eat soup hot peppers last night. Pt denies any recent trauma or illness. Pt denies any drug or alcohol use. Pt (person, place, time, event). Breath sounds clear and equal bilaterally. Chest wall intact. Increased pain on palpation of chest. No n'auma noted. HEENT clear and intact. PUpils 4, PEARL. Skin WPD. Abd non distended or rigid, increased pain on palpation of bilateral upper quadrants. No tramna noted. Pt placed on 3L via NC. monitor applied, 12 lead acquired sinus artifact. Pt scooted to pram by own power. Pt secured to pram with straps. Pt began hyperventilating en route. Pt would not talk crew but appeared as if the pain had become worse. Pt given 324mg ASA PO. Pt would not follow directions to chew the pills so they sat in his mouth for a few minutes. Pt would not cooperate to get a third set of vitals en route. Pt vomited UA to ED. ASA pills present in vomit. Pt care transferred to nurse at receiving facility.? Page4 of5 0627 At patient. 0630 02 3L nasal cannula applied by Aurora Fire Department (AF D) 0631 Cardiac monitor and 12 lead EKG performed by Rural Metro Paramedic; interpreted by AFD as sinus with ectopy and artifact. 0631 Sp02 monitor applied by Rural Metro Paramedic. 0643 Transport to ED. 0647 Four 81mg chewable ASA administered by Rural Metro Paramedic. 0655 Cardiac monitor and 12 lead interpreted by Rural Metro Paramedic as sinus with ectopy and artifact. 0700 Arrived ED and transferred care. Death Certi?cate Cause of Death: Anterior myocardial infarction Severe left main coronary artery stenosis Autopsy Coroner did not perform an autopsy. OBSERVATIONS The Denver Contract Detention Facility nurse received a physician?s order at 0550 to transfer MANDZA to the hospital for evaluation of chest pain. The Aurora County Fire Department did not receive a call until 062]. CONCLUSIONS This additional information does alter the initial observations, conclusions and recommendations that appeared in the 05-09-2012 report. MANDZA did not have access to appropriate medical care while detained in the Denver Contract Detention Facility (DCDF). On 04-12-2012 he received appr0priate emergent medical care at the however, there was an approximate 30 minute delay ?'om when the physician ordered MANDZA transferred to the hospital for evaluation of chest pain, to when EMS received a call to respond to the facility. At present, II-ISC has not received a death certi?cate; however, based upon a review of the hospital records, MANDZA apparently had an acute myocardial infarction (heart attack) and expired as a result of an inherent potential complication of a lifesaving procedure called emergency angioplasty. Prior to the morning of 04-] 2-2012, Page 5 of 5 MANDZA did not have a history of any signi?cant medical problems, nor did he complain of any that demonstrated an increased risk for cardiac problems. RECOMMENDATIONS The ?ndings of this review should be forwarded to the DCDF Health Authority for review, comment and corrective action plan(s) as indicated. 0 During the next scheduled review of the DCDF, the reviewers should focus on the length of time it takes the facility to arrange for emergent transport of detainees. NOTE: recommendations applicable to staffed facilities will be shared with the facility by the appropriate Field Of?ce. Follow-up on implementation of the recommendations will be conducted by the appropriate IHSC Field Medical Coordinator. RECORDS REVIEWED Other Information Received/Reviewed: 0 04-12-2012 Aurora Fire Department EMS report 04-12-2012 Rural Metro Ambulance report 0 State of Colorado Certi?cate of Death Note: The information and conclusions conveyed in this report are based upon the medical records and other sources of information made available to the reviewers as of 05-14-2012. Date of Report: 05-24-2012 End of report Reviewers: MD. CAPT, USPHS Deputy Assistant Director Clinical Services/Medical Director (A) ICE Health Service Corps 500 12 ST SW, Room 11079 Washington, DC 20536 M- CAPT, USPHS Compliance Program Administrator Medical Quality Management Branch ICE Health Service Corps 300 N. Los Angeles St., Room 7631 Los Angeles, CA 90012 Detainee Death Review Medical Record Review (b)(6), (b)(7)(c) MANDZA, EVALIN ALI A Denver Contract Detention Facility, Denver, CO Section 2: Mortality Review (b)(6), (b)(7)(c) This mortality review was prepared by MD, Creative Corrections’ Chief Medical Officer, based on medical records from the Denver Contract Detention Facility (DCDF) and information obtained during on-site interviews by , RN, Health Care Subject (b)(6), (b)(7)(c) Matter Expert. AUTOPSY FINDINGS None. Autopsy not conducted. CHRONOLOGICAL SUMMARY October 17, 2011 Patient was processed at the Denver Field Office and Form 1213 documents the patient “states he is in good health and is taking no medication” and “appears to be in good health.” He was 46 years old. October 24, 2011 Patient arrived at the Denver Contract Detention Facility (DCDF) and listed his nationality as Gabon, a country in west central Africa. (b)(6), (b)(7)(c) Intake screening was conducted by Licensed Practical Nurse (LPN). Vital signs were all within normal limits. Patient denied having any chronic care problems and it was documented he was not currently taking any prescribed medication. Spanish was documented as his primary language, as circled on the Receiving Screening Form, Line # 24. It was not documented whether he spoke and understood English. Patient was recommended to be placed in the general population. (b)(6), (b)(7)(c) MD reviewed and signed the form on October 27, 2011. Patient had no significant mental health problems/issues as documented by LPN (b)(6), (b)(7)(c) Document was signed by(b)(6), (b)(7)(c) MD on this date. A chest x-ray was performed with the results documented as “Negative except for calcified granuloma (small area of inflammation that has calcified) less than 2cm.” The location of the granuloma in the lungs was not documented by the radiologist. October 25, 2011 Patient complained of having “bad movement,” which could be referred to as difficulty with movement of his bowels. October 26, 2011 (b)(6), (b)(7)(c) Physical examination was performed by , Adult Nurse Practitioner (ANP). The progress note documented physical examination was completed, however, it did not confirm if DETAINEE DEATH REVIEW: Evalin Ali MANDZA Section 2 – Mortality Review Creative Corrections LLC Page 1 there were any significant findings on exam. Patient complained of having difficulty with movement of his bowels for several days in duration as stated on the progress note. Patient was prescribed Milk of Magnesia (MOM, laxative to relieve constipation) and was instructed to increase his fluid intake. Patient was also given Ducolax (a stool softener). This was the patient’s second complaint for having difficulty with movement of his bowels. The patient initially complained of difficulty with movement of his bowels on October 25, 2011. October 31, 2011 Patient submitted a Sick Call Request complaining of constipation. This was patient’s third complaint of constipation. Patient was scheduled to be seen by Dr. (b)(6), (b)(7)(c) on November 3, 2011. However, the appointment did not occur. Patient was not evaluated by Dr. (b)(6), (b)(7)(c) until December 2, 2011 for this complaint of constipation. Patient should have been scheduled to be evaluated earlier by a physician for this complaint. November 8, 2011 Patient submitted a Sick Call Request complaint requesting to be seen with a complaint of bumps (on his face, secondary to shaving). Patient was given topical antibiotic ointment to be applied to his face daily for seven days. November 10, 2011 Patient submitted a Sick Call Request continuing to complain of constipation. This was the (b)(6), (b)(7)(c) fourth complaint for this malady. Patient was evaluated by , LPN, for this complaint. Patient was given Ducolax and recommended to add fiber to his diet. Patient should have been evaluated by a physician since this has been a persistent complaint. November 17, 2011 Patient submitted a Sick Call Request, complaining of dental pain. Patient was scheduled to be seen by the dentist on November 21, 2011 and was instructed to take Tylenol as needed for pain. November 21, 2011 Patient was evaluated by the dentist who recommended a tooth extraction. November 27, 2011 Patient continued to complain of having constipation. This was the fifth complaint for this ongoing problem. Despite the recommendations given by the nurses, there was no improvement in his condition. November 28, 2011 Patient was evaluated by an RN (medical staff’s signature was illegible) and was given MOM, Ducolax and fiber. Patient had been given these same recommendations in the past, without an effective resolution. Patient was also instructed to return to health services if his symptoms worsened. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Section 2 – Mortality Review Creative Corrections LLC Page 2 December 2, 2011 Patient was evaluated by Dr. (b)(6), (b)(7)(c) for constipation, as well as having a rash involving his neck. Physical examination was deferred by Dr. (b)(6), (b)(7)(c). Dr. (b)(6), (b)(7)(c) recommended the following for treatment: (1) adult glycerin suppositories (medication used to stimulate the bowels) to be administered rectally twice a day for 3 days. (2) add fiber to his diet twice a day for 90 days (60 cc) (3) Colace (stool softener) twice a day for 90 days. Stool softener and fiber had been previously recommended by other clinical providers. This treatment had proven to be ineffective. (4) Triple antibiotic ointment cream to the neck area twice a day for 90 days. Dr. (b)(6), (b)(7)(c) progress note documented the patient was having abdominal pain. The examination of the abdomen was deferred by Dr. (b)(6), (b)(7)(c). The physician should have ordered abdominal xrays, labs, and performed an abdominal exam, as well as rectal exam for this chronic complaint. December 11, 2011 Patient submitted a Sick Call Request with a complaint of having dental pain. December 12, 2011 Patient was seen by RN (b)(6), (b)(7)(c) for this dental complaint, and was given Ibuprofen and scheduled to be evaluated by the dentist on December 20, 2011. December 14, 2011 Patient submitted a Sick Call Request complaining of pain involving his right great toe secondary to falling off the top bunk. December 15, 2011 Patient was evaluated by Dr.(b)(6), (b)(7)(c); however, his progress note did not indicate a physical examination was performed for an injury involving his right great toe. In addition, no x-rays of his right great toe were ordered. No recommendations and/or orders were given by the physician. December 20, 2011 Patient was seen by Dr. (b)(6), (b)(7)(c) (dentist) and it was recommended to extract the tooth. Patient refused the extraction; however, there was no refusal form documented in patient’s medical record. The provider should always complete a refusal form if the patient refuses the recommended treatment. December 25, 2011 (b)(6), (b)(7)(c) An injury report was completed by LPN, for evaluation of abrasions on the patient’s chest and left wrist due to a physical altercation described as “horseplay” with other detainees. Patient was cleared to be placed in administrative segregation. The History and Physical exam performed by LPN (b)(6), (b)(7)(c) was signed by Dr. (b)(6), (b)(7)(c) on December 27, 2011. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Section 2 – Mortality Review Creative Corrections LLC Page 3 December 30, 2011 Patient was evaluated by RN(b)(6), (b)(7)(c), with a complaint of an injury involving his right great toe. Patient stated he “fell playing soccer.” The health assessment performed by RN(b)(6), (b)(7)(c)indicated injury to his right great toe. Ice packs and Ibuprofen were recommended. January 3, 2012 Patient was examined for injury to his right great toe (secondary to playing soccer). Author’s signature on progress note was illegible. The physical exam was negative. Patient was prescribed Ibuprofen as well as authorized to have a lower bunk. The duration of patient requiring to have a lower bunk was not documented by author. In addition, a diagnosis of the injury was not documented by the author. During site visit for this review, the author was determined to be Dr. (b)(6), (b)(7)(c) January 13, 2012 A Sick Call Request was submitted for complaint of a “dental problem.” Patient was scheduled to be seen by the dentist on January 16, 2012. January 15, 2012 Patient submitted a Sick Call Request, continuing to complain of constipation. This was the sixth complaint of patient informing health services of this problem. Per patient, the suppositories were helping with this condition. Patient also continues to complain of dental problem and as previously advised his appointment for the dentist was scheduled for January 16, 2012. January 16, 2012 Patient was seen by Dr. (b)(6), (b)(7)(c) (dentist) and was prescribed Amoxicillin (antibiotic) and Tylenol. Dr. (b)(6), (b)(7)(c) recommended an extraction of the involved tooth; however, patient refused. No refusal form was found in the patient’s health record. Patient was scheduled to be evaluated by Dr.(b)(6), (b)(7)(c)on January 18, 2012 to discuss the use of glycerin suppositories. January 18, 2012 Patient was “escorted to seg/SMU.” History and Physical form was completed by RN (b)(6), (b)(7)(c) which cleared the patient to be admitted in Administrative Segregation. Patient voiced having no physical complaints to RN (b)(6), (b)(7)(c). Physical examination was performed by RN (b)(6), (b)(7)(c) was unremarkable. It was signed by (b)(6), (b)(7)(c) MD., but not dated. The date of the signature should have been documented by the Practitioner. The patient was scheduled to be seen by Dr.(b)(6), (b)(7)(c) however, this appointment did not occur. January 27, 2012 Patient continued to complain of constipation and refused to take Colace and fiber. This was the (b)(6), (b)(7)(c) patient’s seventh complaint of this issue. ANP renewed patient’s treatment of Glycerin suppositories for three days and the patient was counseled to take the previously prescribed treatment for constipation. According to the progress note, (b)(6), (b)(7)(c) documented that the patient was noncompliant with the full prescribed treatment for constipation. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Section 2 – Mortality Review Creative Corrections LLC Page 4 February 9, 2012 Progress note by RN (b)(6), (b)(7)(c) documented the eighth complaint of patient complaining of constipation. Patient stated his last bowel movement was on January 23, 2012. Patient also had generalized abdominal discomfort associated with decreased bowel sounds. Decreased bowel sounds upon examination could have indicated a bowel obstruction was ensuing and could have necessitated a medical emergency. Patient was given a Ducolax and MOM, 30cc, one dose. It was imperative that the patient be seen immediately by a physician. February 14, 2012 Patient submitted a Sick Call Request complaining of dental pain. Patient was seen by (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) , DMD (doctor of medical dentistry) and tooth # 18 was extracted. March 1, 2012 A Sick Call Request was submitted by the patient with his ninth complaint of constipation. Patient also complained of his eyes burning. March 3, 2012 RN(b)(6), (b)(7)(c)reviewed the request and gave Ducolax and artificial tears. Patient was placed on the physician’s sick call list for March 5, 2012. Patient was instructed to “return if symptoms persisted/worsened.” March 5, 2012 Patient was evaluated by (b)(6), (b)(7)(c) PA (physician’s assistant) with his tenth complaint of having constipation. The progress note was written by (b)(6), (b)(7)(c) (penmanship was illegible). The PA documented on examination visceromegaly (abnormal enlargement of the soft internal organs). It was difficult to ascertain which internal organs were enlarged, by the provider’s progress note. The provider documented “no water.” Increased water consumption is recommended for a patient who complains of being constipated. Again, the patient should have been scheduled to be evaluated by a physician for this chronic complaint. In addition, due to the chronicity of this complaint, a gastroenterology consult should have been considered for evaluation of this condition with appropriate treatment. March 7, 2012 Patient was seen by a provider; however, the note was illegible. March 21, 2012 Patient submitted a Sick Call Request complaining of “bad move problems/bumps shaver problems.” This was the patient’s eleventh complaint of being constipated. Patient denied having abdominal pain. RN(b)(6), (b)(7)(c)reiterated to the patient that he needed to continue the same treatment as previously prescribed. It was quite obvious that this treatment was ineffective. At this time, the patient should have been scheduled to be evaluated by the physician and/or a referral submitted for a gastroenterology consult. Topical antibiotic ointment was prescribed to be applied twice a day for seven days to the facial area for his rash. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Section 2 – Mortality Review Creative Corrections LLC Page 5 (b)(6), (b)(7)(c) A progress note by (LPN) documented the patient had a stress fracture. The progress note did not indicate location of fracture, or how the diagnosis was determined. In addition, there was no evidence that x-rays were taken of the involved area. March 25, 2012 The author (illegible signature) of the progress note stated previously prescribed medications for treatment of constipation was working. Patient stated he had normal bowel movements. Patient was instructed to continue prescribed treatment for constipation as needed. During site visit for this review, the author was determined to be Dr. (b)(6), (b)(7)(c). March 31, 2012 A Sick Call Request was submitted by the patient for “no movement all week.” This was the patient’s twelfth complaint of constipation. Ducolax was prescribed one dose twice a day and MOM was prescribed, one dose per day as needed for constipation. Signature of provider was not documented on the Sick Call Request. April 1, 2012 The patient was evaluated by LPN (b)(6), (b)(7)(c) and was given Ducolax and MOM. April 12, 2012 Detention Officer (DO), was making rounds on the A-4 Unit at 05:25 and was informed by other detainees that Evalin Mandza Ali was complaining of chest pains. (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (DO) instructed Lt. to “call Code Blue.” The Code Blue was called at (b)(6), (b)(7)(c) 05:25. stated the patient was “rocking and rolling” in bed with his hands on his chest (b)(6), (b)(7)(c) complaining of chest pain. The nurses on duty, RN and LPN (b)(6), (b)(7)(c) , responded with a wheelchair, and a crash bag, which contained various medical equipment. It was unclear whether an AED (automated external defibrillator) was brought to the housing unit by the nurse. An AED should be taken to the housing unit when the patient is complaining of chest pain, because a cardiac arrest (abnormal rhythm of the heart muscle) may ensue. This equipment is necessary in an attempt to restore the normal function of the heart muscle. (b)(6), (b)(7)(c) Patient rated his chest pain, on a scale of 1 to 10, as an 8-9/10. Blood pressure was mildly elevated with remaining vital signs within normal limits. Patient also stated chest pain worsened (b)(6), (b)(7)(c) upon inspiration (increase pain with breathing). RN recommended the patient be transferred to the institution’s trauma room for further evaluation. Patient was transferred to the trauma room within the institution at 05:28. At this point, no medications were administered to the patient in an attempt to relieve his chest discomfort. It is standard protocol to administer Nitroglycerin (medication given to relieve chest discomfort) and Aspirin (medication used to dilate the heart arteries). EMS (Emergency Medical Services) should have been activated immediately when nurses became aware that the patient was complaining of chest pain. RN(b)(6), (b)(7)(c) attempted to perform an EKG using the Schiller AT-102 machine (an EKG is used as a standard assessment to determine if there is any injury to the patient’s heart muscle); however she realized the memory of the machine was full, thus the machine was inoperable. There should be a log book in the trauma room which documents that the EKG machine has been checked on a daily DETAINEE DEATH REVIEW: Evalin Ali MANDZA Section 2 – Mortality Review Creative Corrections LLC Page 6 basis by clinical staff which insures the equipment is functional. Also, the memory should be cleared after each use. (b)(6), (b)(7)(c) stated she had not performed a “12 lead EKG in years;” therefore, a 3 lead EKG was RN performed using the Welch Allyn EKG machine. A 3 lead EKG monitors only two areas of the heart. A 12 lead EKG assesses the entire function of the patient’s heart to determine if there was any direct injury to the heart muscle, which could cause a myocardial infarction (death of the heart muscle, hence a heart attack). RN(b)(6), (b)(7)(c) also stated she had not had any formal training from the institution on the use of the two EKG machines available in the trauma unit. This is not medically acceptable, especially since she is a clinical health services provider. (b)(6), (b)(7)(c) stated she could not interpret the findings on the EKG performed on the Welch Allyn RN machine. Clinical health services staff should be able to interpret any abnormalities on the tracing of the EKG which could identify a patient was having an acute heart attack. RN(b)(6), (b)(7)(c) also stated in the past the EKG could be faxed to the institution’s physician on call and/or a (b)(6), (b)(7)(c) cardiologist for interpretation of the EKG. RN stated that presently no provision had been (b)(6), (b)(7)(c) made to proceed with this process of faxing the EKG. Therefore, RN stated she just relied (b)(6), (b)(7)(c) on her “gut instinct” to send the patient to the hospital. Dr. DO (doctor of osteopathic medicine) stated he would like to revise “Chest Pain Protocol” to reflect an immediate EMS response to chest pain along with administration of Aspirin. This is a very good recommendation made by Dr (b)(6), (b)(7)(c) to revise the “Chest Pain Protocol.” At 05:50, Dr. (b)(6), (b)(7)(c) was notified that the patient was complaining of chest pain. Dr. (b)(6), (b)(7)(c) recommended the patient be transferred to the local community hospital for further evaluation. It is also noted that LPN(b)(6), (b)(7)(c)stated the patient “wasn’t in dire distress,” and they didn’t “need to rush” (unclear who LPN(b)(6), (b)(7)(c)was referring to as “they”). LPN(b)(6), (b)(7)(c)recommended the patient be transported to the local community hospital by GEO van. A complaint of chest pain from a patient requires emergent evaluation and if necessary immediate transport to a higher level medical facility for evaluation and treatment. This transport to this higher level medical facility should occur expeditiously, by an ambulance. The decision to transport a patient via institutional van with a complaint of having severe chest pain was medically inappropriate. failed to follow the institution’s “Chest Pain Protocol.” Vital signs were It is so noted RN(b)(6), (b)(7)(c) taken twice during this encounter and not documented between 5:50 and 06:20 am. Per Institution’s “Chest Pain Protocol,” vital signs are to be taken every five minutes. In addition, no completed Chest Pain Protocol Form was located in the patient’s health record. (b)(6), (b)(7)(c) instructed LPN(b)(6), (b)(7)(c)to “get the paper work started.” When an emergency exists within RN the detention center, there should be a protocol whereby having to notify various staff should not cause a delay in transporting the patient to a hospital. LPN(b)(6), (b)(7)(c)advised Lt. (b)(6), (b)(7)(c) that “the Patient needed to be transported to Aurora South Hospital for further medical examination.” There was confusion as to who activated the EMS (Emergency Medical Services). The staff designated in orchestrating the emergency should be the individual notifying the custodial staff in charge of activating EMS. EMS was activated at 06:21. EMS arrived at the institution at 06:30. Patient continued to complain of chest discomfort, rating pain as 9 out of 10. A 12 lead DETAINEE DEATH REVIEW: Evalin Ali MANDZA Section 2 – Mortality Review Creative Corrections LLC Page 7 EKG was performed by EMS, which revealed the patient had “normal sinus rhythm taken by automated device.” Normal sinus rhythm means the patient’s heart beat was beating at a normal rate. There were no acute findings seen on the EKG tracing which indicated the patient was having an acute heart attack. Upon departure from the institution, patient continued to rate his chest pain as a 9 out of 10. At 06:57, patient arrived at Aurora South Medical Center. Per Aurora H & P (history and physical), “The patient is a 46 year old gentleman with no apparent cardiac risk factors. He is having acute anterior myocardial infarction. He will report to the Catherization Lab. Condition at time of admission was “guarded.” Patient was diagnosed with having an acute heart attack. During the cardiac catheterization (a procedure used to identify if there was blockage of the heart arteries), patient went into cardiac arrest (no contraction of the heart muscles). Advanced Cardiac Life Support Measures (medication used in an attempt to restore function of the heart) was unsuccessful. Patient expired at 08:38 on April 12, 2012. May 24, 2012 Per the Death Certificate, Immediate Cause of Death was listed as “Anterior MI (myocardial infarction or heart attack) due to or as a consequence of “Severe left main coronary artery stenosis (abnormal narrowing).” FINDINGS Based on documentation in the medical record as summarized above, the reviewer finds the following: Timeliness of Care A. Evaluation of chest pain It took approximately 50 minutes from the onset of the patient’s complaint of chest pain for the patient to be transferred to a higher level facility for further evaluation. A complaint of chest pain requires emergent evaluation and immediate transport to a hospital. This delay in deciding to transport patient to a higher level care facility can be deleterious to patient’s condition. EMS should have been activated immediately when medical staff was notified that the patient was having chest pain. The institution’s “Chest Pain Protocol” should be revised to include the immediate administration of Nitroglycerin and Aspirin provided patient has no contraindications for these medications. B. Notification of appropriate staff There was a delay in transporting the patient to the hospital because various staff, as well as signatures had to be obtained. The clinical staff should be familiar with the protocol for “Emergency Services,” which mandates which staff should be notified in a medical emergency. DETAINEE DEATH REVIEW: Evalin Ali MANDZA Section 2 – Mortality Review Creative Corrections LLC Page 8 D. Scheduling of patients Frequently there were instances wherein the patient was not scheduled for the physician and/or dentist due to the lack of proper scheduling procedures. Procedures should be in place for scheduling patients to be seen by the clinical staff in a timely manner. E. Persistent complaint of constipation Patient submitted numerous Sick Call Requests for being constipated. The same treatment was offered repeatedly without an effective resolution. Patient was seen by the physician; however, no physical examination was performed for this ongoing complaint. In addition, there were no labs, x-rays or documentation of consideration for a specialty consult (gastroenterology) to be placed for further evaluation for this condition. Patient also complained of having abdominal pain and decreased bowel sounds were detected. This could have indicated an obstruction of his intestinal tract. Quality of Care A. Use of medical equipment The two nurses on duty at the time of the medical emergency were unable to operate the EKG machine. Medical staff should be comfortable and knowledge in the operation of various medical equipment, i.e. EKG machines. Training should be performed with documentation that the clinical staff are familiar with the use of the medical equipment. B. Chest Pain Protocol Nitroglycerin and Aspirin is standard medical practice to be administered immediately to any patient when the chest pain appears to be cardiac in origin. Dr. (b)(6), (b)(7)(c) stated that the “Chest Pain Protocol” would need to be revised to include this measure. Also, chest pain should necessitate emergent transport outside the institution if the pain appears to be cardiac in nature. C. Legibility of progress notes It was difficult to read the progress notes due to poor penmanship of the providers. The date and signature of the provider should be legible. D. In house training It was quite evident with this patient that the nurses were not trained properly to understand the nature and seriousness of this medical emergency. Interpretation and recognition of an acute myocardial infarction (heart attack) on an EKG tracing should be recognizable to the clinical staff. Continuing medical education should be a consideration in educating the clinical staff on the latest updates in the assessment and treatment of medical emergencies. Training by the staff physicians should be conducted on a regular basis to familiarize the medical staff in dealing appropriately with medical emergencies. E. Diagnostic Screening A drug screen should have been considered by the physician(s) in determining a possible cause for patient’s persistent complaint of constipation. For example, if the patient had DETAINEE DEATH REVIEW: Evalin Ali MANDZA Section 2 – Mortality Review Creative Corrections LLC Page 9 been taking non-prescribed narcotics/substances, this could have been a cause for his being constipated. CONCLUSION It was obvious the medical staff was unfamiliar with the institution’s “Chest Pain Protocol.” Appropriate cardiac medication was not administered to this patient. This medication was critical in reducing the workload of the heart as well as preventing the death of the muscle of the heart (hence a heart attack). Also, time was of the essence in transporting the patient to a higher level care facility for prevention of further destruction of the heart wall muscle which could have contributed to the patient’s demise. An autopsy was not ordered; reasons not documented. An autopsy would have been helpful to ascertain the pathology (abnormality) of the patient’s heart arteries. Toxicology was not ordered, which would have been beneficial in determining if the patient was taking any illicit/ recreational drugs which could have also contributed to his demise. Submitted: MD Creative Corrections, LLC (b)(6), (b)(7)(c) DETAINEE DEATH REVIEW: Evalin Ali MANDZA Section 2 – Mortality Review Creative Corrections LLC Page 10